zy zyx 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 zyxwv z I91 0009-921X-78-0300-0191-0060 @ J . B. Lippincctt Company zy zyxwvutsr zyxwvut zyxwvutsrqp 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 . zy 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. zyxwvu 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 zyxw zy zy zyxw 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 zyxw 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. zyxwvuts SUMMARY Fifty-four cases of nonpathologic subtrochanteric fractures of the femur were treated 194 zyxwvutsrq zyxwvutsr zyx zyxwvut 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. zyxw