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Subtrochanteric Fractures of the Femur Treated
with Nail-Plate Devices:
A Retrospective Study
GREGORY
w. HANSON,M.D.*
Subtrochanteric fractures of the femur are
difficult both to achieve stabilization and subsequently union. The muscular forces acting
across the proximal femur result in characteristic abduction, flexion and external rotation
of the proximal fracture fragment, and adduction of the distal fragment.5 Fractures in this
region are often comminuted, leading to instability and difficulty with stabilization.
Many attempts at classifying subtrochanteric fractures and relating the classification
to prognosis have been made. Boyd and
Griffin', were the first to classify trochanteric
fractures. Watson, Campbell and Wade8 devised a complicated system based on the site
of the fracture, its length, and the amount of
comminution. They concluded that long and
comminuted fractures are prone to delayed
union; however the more transverse fracture
is more likely to progress to non-union.
Fielding, Cochran and Zickel4 defined the
subtrochanteric area as the 3 inches of the
femur beginning at the proximal border of the
* Resident, Division of Orthopedic Surgery,
Baylor Affiliated Hospitals, 6535 Fannin, Houston,
Texas 77030.
** Associate Professor and Head, Division of
Orthopedic Surgery, Baylor College of Medicine,
6535 Fannin, Houston, Texas 77030.
Received: May 20, 1977.
AND
HUGHs. TULLOS,M.D.**
lesser trochanter and extending 2 inches below it. They divided this area into 3 one inch
segments and concluded that the higher, or
more proximal the fracture, the better the
prognosis.
More recently, Zickelg devised a classification system utilizing 6 categories based on
obliquity and comminution. He found no
correlation between the typc of fracture and
prognosis. This may be explained by his low
non-union rate.
Review of the recent literature reveals a
variety of modes of internal fixation with
varying success rates. Nail-plate devices have
been most widely used. Watson, Campbell
and Wade8 reported a series of subtrochanteric fractures treated with a variety of appliances. They reported a 10% non-union rate.
The Jewett nail was felt to be the treatment
of choice.
Frominsons reported 21 comminuted subtrochanteric fractures and their experience
with heavy Jewett nails. One non-union was
present. They recommended the heavy J m e t t
nail for these fractures.
Fielding, Cochran and Zickel4 reviewed
46 subtrochanteric fractures all treated with
Jewett nails. They reported a 26% nonunion rate and offered a preliminary report
on a larger series of subtrochanteric fractures
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0009-921X-78-0300-0191-0060 @ J . B. Lippincctt Company
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192
Clinical Orthopaedics
and Related Research
Hanson and Tullos
treated with an alternate appliance (Zickel
nail). An improved non-union rate was
noted.
In 1976, Zicke19 again reported the results
of 84 subtrochanteric fractures treated with
his appliance. A single non-union occurred.
(1 %).
Due to these high non-union rates utilizing
Jewett or similar nail-plate combinations,
these devices have become unpopular. Appliance failure secondary to non-union has
led manufacturers to cease recommending
their use in subtrochanteric fractures.l1. l 2
At this center we felt that our results using
nail-plate devices was not as dismal as the
literature would lead one to believe. For that
reason, this study was undertaken.
MATERIALS AND METHODS
The records of all patients with proximal
femoral fractures treated at the Ben Taub General Hospital since 1972, the Veteran’s Administration Hospital since 1968, and The Methodist Hospital since 1970 were reviewed. A
series of 54 nonpathologic subtrochanteric
femoral fractures treated by nail-plate devices
were accumulated. The hospital charts, clinic
charts and X-rays of all cases were reviewed
with respect to age, mechanism of injury, anatomic type of fracture, method of internal fixation, and postoperative ambulatory regimen.
Of the 54 cases, 5 were lost to follow-up and
one patient died one month after surgery. The
6 n a l results of treatment in 48 cases are known.
TABLE 1 .
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Fielding Classification
Number of Patients
Mixed
35
Smith+Petersen nails and Thorton side plate,
6 with compression screws and plates and
37 were treated with Jewett nail-plates. Accessory fixation (cortical screws) was used in
several cases. There was one case requiring
reoperation and bone grafting due to a bent
plate sustained in a fall one week after the
initial operation.
Forty-two fractures united successfully
after a single operative procedure, at an average of 7.8 months. All patients were mobilized 72 hours postoperatively on crutches;
partial weight bearing was begun by the third
postoperative month and full weight bearing
by the sixth postoperative month. The criteria for full weight bearing was X-ray evidence of solid union. Six fractures, 12.5%
of the entire series, progressed to non-union.
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TABLE 2.
Number o f
Patients Non-Unions
RESULTS
The average age in this series was 51.5
years. Total follow-up averaged 13.2
months. Using Fielding’s clas~ification,~
the
results are seen in Table 1. Using Zickel’s
classification9 there were 16 comminuted
short oblique fractures, 2 long oblique, 17
comminuted long oblique and 4 high transverse fractures (Table 2).
All fractures were stabilized by nail-plate
devices. Five patients were treated with
Zickel Classification
Short Oblique
0
0
Long Oblique
2
0
Comminuted Short
Oblique
16
1
Comminuted Long
Oblique
17
1
High Transverse
4
2
Low Transverse
0
0
TABLE 3.
Name
Age
C.G.
77
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Subtrochanteric Fractures
March-April,
Number
131 1978
Fracture
Type
Non-unions
First
Procedure
Second
Procedure
Total
FOIIOW-UP
Jewett 12/68
Jewett 7/69
36 Months
Union
Jewett 5/74
Jewett 11/74
25 Months
Union
28 Months
Union
Jewett 3/73
Jewett 4/74
W.E.
Comminuted
High Transverse
56 Comminuted Short
Oblique
60 Comminuted
High Transverse
56 Comminuted
Jewett 9/74
R.D.
85
Comminuted
Jewett 4/73
Compression
Screw
Schneider Rod
M.E.
M.B.
74
Comminuted Long
Oblique
Jewett 9/74
DISCUSSION
All 6 cases of non-union were initially
treated with Jewett nails and all were comminuted (Table 3). The average age of these
patients was 68 years as compared to 51.5
years for the total series. The average time
to initial weight bearing was the same as in
those that united. Every non-union was associated with failure of the Jewett appliance
either at the nail or the nail-plate junction.
Three of the patients with non-unions were
treated by renailing with a second Jewett
nail and healed. One was treated with a
compression screw and did not heal. Two
were treated with intramedullary rods and do
not have a final result. Each non-union was
grafted using autogenous iliac bone.
We were unable to define any causative
factors in the management of those patients
whose fractures progressed to non-union.
These patients were an average of 20 years
older and age may have been a contributing
factor. It is our belief, as well as others,'+,6
that appliance failure is the result of the nonunion and not the cause.
Our results parallel those of the other
authors.5** Ten per cent, not 26%, appears
Final
Result
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38 Months
Non-Union
8 Months
Not Known
Schneider Rod 38 Months
Not Known
9/ 73
N.S.
I93
9/76
to be the expected non-union rate with the
use of nail-plate devices in subtrochanteric
fractures.3. 4 Although the non-union rate
with use of the Zickel nail is approximately
1%, it is a demanding operative proced ~ r e .l o~ , Reported technical complications
with its use include intraoperative trochanteric comminution, rotation of the femoral
shaft, excessive anteversion or retroversion
of the rod, perforation of the femoral head,
and rod failure.7. The Zickel nail and other
intramedullary devices appear to be best
suited for use in the more transverse and
noncomminuted subtrochanteric fractures.
Whcn comminution extends into the trochanteric area or when the fracture is long and
highly comminuted, the Jewett nail or similar
device remains an acceptable appliance.
There are instances in which nail or screwplate devices are the only possible, and sometimes, the only available method of fixation.
Primary bone grafting as adjunctive treatment should be considered.
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SUMMARY
Fifty-four cases of nonpathologic subtrochanteric fractures of the femur were treated
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Hanson and Tullos
by fixation with nail-plate devices. Of the
48 final cases, 42 patients (88%) united successfully after a single operative procedure.
Six patients (12.5 %) developed a non-union
and required further surgery, an experience
similar to that of other authors. Ten per cent
appears to be the expected non-union rate
with nail-plate devices. At this time the
Jewett nail and the compression screw
should be regarded as part of the orthopedist’s armamentarium in the treatment of
comminuted subtrochanteric fractures of the
femur.
REFERENCES
1. Boyd, H. D. and Anderson, L. D.: Manage-
ment of unstable trochanteric fractures, Surg.
Gynecol. Obstet. 112:633, 1961.
2. - and Griffin, L. L.: Classification
and treatment of trochanteric fractures, Arch.
Surg. 58:853, 1949.
3. Fielding, J. W. and Magliato, H. J.: Subtrochanteric fractures, Surg. Gynecol. Obstet.
122:555, 1966.
Clinical Orthopaedics
and Related Research
4. _ _ , Cochran, G. V. and Zickel, R. E.:
Biomechanical characteristics and surgical
management of subtrochanteric fractures,
Orthop. Clin. North Am. 5:629, 1974.
5. Frominson, A. I.: Treatment of comminuted
subtrochanteric fractures of the femur, Surg.
Gynecol. Obstet. 131:465, 1970.
6. Holt, E. P.: Hip fractures in the trochanteric
region, J. Bone Joint Surg. 45A:687, 1963.
7. Michelson, M. R. and Bonfiglio, M.: Pathologic fractures of the proximal femur treated
by Zickel-Nail fixation, J. Bone Joint Surg.
58A: 1067, 1976.
8. Watson, K., Campbell, R. D., Jr. and Wade,
P. A. : Classification, treatment, complication
of the adult subtrochanteric fracture, J.
Trauma 4:457, 1964.
9. Zickel, R. E.: An intramedullary fixation device for the proximal part of the femur.
Nine year’s experience, J. Bone Joint Surg.
58A:866, 1976.
10. -.
. A new fixation device for subtrochanteric fractures of the femur. Clin.
Orthop. 54: 115, 1967.
1 1 . Zimmer: Product Description, Jewett Nail,
1973.
12. -.
. Product Description, Hip Compression Screw, 1975.
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