ORIGINAL ARTICLE
Short Versus Long Intramedullary Nails for Treatment of Intertrochanteric Femur Fractures (OTA 31-A1 and A2) Christopher Boone, MD,* Kelly N. Carlberg, MD,* Denise M. Koueiter, MS,† Kevin C. Baker, PhD,† Jason Sadowski, MD,* Patrick J. Wiater, MD,* Gregory P. Nowinski, MD,* and Kevin D. Grant, MD*
Objectives: The purpose of this study was to compare blood loss
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
and operative times associated with long versus short intramedullary nails for intertrochanteric fracture fixation and rate of periprosthetic fracture.
(J Orthop Trauma 2014;28:e96–e100)
Design: A retrospective study. Setting: Level 1 trauma center. Patients: One hundred ninety-four patients with an intertrochanteric fracture (AO/OTA class 31-A1 and A2) and low-energy mechanism of injury treated by 1 of 4 fellowship-trained orthopaedic traumatologists. Intervention: Short versus long intramedullary nail. Methods: Medical records were reviewed for age, gender, estimated blood loss (EBL), transfusion rate, operative time, length of stay, and incidence of periprosthetic fracture. Variables were statistically compared between long and short intramedullary nails, with statistical significance at P , 0.05.
Results: The average EBL (135.5 6 91.9 mL) and transfusion rate (57.1%) for long nails were found to be significantly greater (P = 0.002) than the EBL (92.6 6 47.2 mL) and transfusion rate (40.2%) for short nails. Average operative time was also found to be significantly greater (P , 0.001) for long (56.8 6 19.4 minutes) than for short (44.0 6 10.7 minutes) intramedullary nail procedures. The overall incidence of periprosthetic fracture was 0.5%, one patient with initial treatment of a long intramedullary nail.
Conclusions: Statistically significant lower operative time, EBL, and transfusion rate were found in this study for short intramedullary nails. There were no differences seen in length of stay or periprosthetic fracture. The incidence of periprosthetic fracture was very low in both cohorts. Further study with greater statistical power is needed. Key Words: intertrochanteric fracture, intramedullary femoral nail, long intramedullary nail, short intramedullary nail, periprosthetic fracture, retrospective review Accepted for publication July 26, 2013. From the Departments of *Orthopaedic Surgery, and †Orthopaedic Research, William Beaumont Hospital, Royal Oak, MI. Presented in part as a podium presentation at the Annual Meeting of the Orthopaedic Trauma Association, October 4, 2012, Minneapolis, MN. The authors report no funding or conflicts of interest. This study was conducted with IRB approval: HIC#2011-017. Reprints: Kevin D. Grant, MD, Department of Orthopaedic Surgery, William Beaumont Hospital, Woodward Avenue, Royal Oak, MI 48073 (e-mail: [email protected]). Copyright © 2013 by Lippincott Williams & Wilkins
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INTRODUCTION Proximal intertrochanteric femur fractures in the elderly population have become increasingly common in developed nations and have recently become a major health concern.1 With the majority of fractures occurring in the elderly population, they often lead to significant morbidity, mortality, and compromise in quality of life.1,2 Postoperative mortality has been reported to be as high as 20%–30% in the first 6–12 months after surgical fixation of these fractures.1–3 The overall number of proximal intertrochanteric femur fractures is expected to continue to increase secondary to increased life expectancy and overall increase in the elderly population.1 In the past several years, the intramedullary nail has become the implant of choice for intertrochanteric fractures among many US-based orthopaedic surgeons.4,5 With the intramedullary nail being a well-accepted treatment option for the common intertrochanteric fracture, some controversy has developed regarding the length of the nail itself. Short nails have shown good biomechanical stability and acceptable clinical outcomes for the treatment of these fractures.6–17 However, some evidence exists that the use of short intramedullary nails leads to a stress riser at the tip of the nail, thus predisposing patients to periprosthetic fractures.12,18–21 An argument can be made that intertrochanteric fractures in the elderly population are the result of pathologic osteoporotic or osteopenic bone, thus requiring the full protection afforded by the use of longer intramedullary devices. Therefore, any added morbidity because of increased operative time, technical difficulty, and blood loss would theoretically be offset by decreased postoperative periprosthetic fractures. However, to date, the actual difference in blood loss and operative time between long and short nails has not been reported. The purpose of this study is to quantify operative time and blood loss associated with the use of short versus long intramedullary nails in the treatment of intertrochanteric femur fractures. Furthermore, this study aims to determine if there is a significant decrease in the number of periprosthetic fractures when intertrochanteric femur fractures are treated with long intramedullary implants. J Orthop Trauma Volume 28, Number 5, May 2014
J Orthop Trauma Volume 28, Number 5, May 2014
PATIENTS AND METHODS A retrospective analysis was conducted using our institutional trauma database for intertrochanteric fractures treated at our level 1 trauma center between January 2008 and December 2011 by 1 of 4 fellowship-trained orthopaedic traumatologists. All preoperative radiographs were reviewed by a senior orthopaedic resident and the attending orthopaedic traumatologist. Only patients with fractures in the trochanteric area with AO classification 31-A1 or 31-A2 that were treated with a Stryker Gamma 3 system (Stryker Orthopaedics, Mawah, NJ) were included in this study.22 The use of an intramedullary device as opposed to a sliding hip screw was based on surgeon preference at our institution. The mechanism of injury was limited to low-energy falls or twists. Patients excluded were minors, patients who sustained another lower extremity fracture at initial presentation, and patients with a diagnosed metabolic bone disorder other than osteoporosis or with evidence of malignancy. Only patients with medical records available for a minimum of 1 year before the date of surgery were included. Operative notes were reviewed for estimated blood loss (EBL) and skin to skin operative time as recorded in the operating room. Medical charts were reviewed for age at implantation, gender, hospital length of stay (LOS), and incidence of periprosthetic fracture. Preoperative hemoglobin levels and incidence of transfusion postoperatively were also collected. A total of 347 patients were reviewed. Within 1 year of the date of surgery, 41 patients deceased and 112 were lost to follow-up. Overall, 194 patients met all inclusion criteria, with 7-staged bilateral intertrochanteric fractures with intramedullary nail treatment, for a total of 201 nails. There were 54 men (27.8%) and 140 women (72.2%), and the average age was 81.1 6 9.2 years (range 45–98 years). There were 82 (40.8%) fractures that received a short Gamma nail and 119 (59.2%) fractures that received a long Gamma nail (Fig. 1). Of
Short Versus Long Nail for Intertrochanteric Fracture
the 7 bilateral patients, 2 patients had a long nail in both femurs, 2 had a short nail in both femurs, and 3 had 1 long and 1 short nail. The average follow-up was 2.1 years (range 1–4.5 years). All procedures were performed with the patient in the supine position on a fracture table with fluoroscopic-guided imaging. Closed reduction to near anatomical position was performed before incision while the patient was anesthetized. Use of short versus long implant was determined by the attending surgeon based on surgeon preference. Femurs were reamed by hand, and a guide wire was used for all procedures. All nails had placement of distal interlocking screws as per surgeon preference, either through the nail guide for short nails or by intraoperative perfect circle fluoroscopic technique for long nails. There were no intraoperative complications. Patients were weight bearing as tolerated postoperatively. All data were statistically compared for the short and long nail cohorts. Data were analyzed for normality using the Shapiro–Wilk test and were statistically analyzed using a Mann–Whitney rank sum test or x2 test. For all tests, statistical significance was at P , 0.05. Statistical analyses were performed by graduate-trained research engineers with the aid of a statistical software package (SPSS v.20, IBM Inc).
RESULTS There was no significant difference in the gender of patients with long nails versus short nails (Table 1). However, patients with a short nail were significantly older, and patients with a fracture type AO 31-A2 were more likely to be fixed with a long nail. The preoperative hemoglobin was not significantly different between the short (10.72 6 1.43) and the long (10.79 6 1.56) nail cohorts (P = 0.323). The incidence of postoperative transfusion was significantly higher for the long
FIGURE 1. Anteroposterior and oblique views of short Gamma nail fixation (A, B) and long Gamma nail fixation (C, D) of an intertrochanteric fracture. Ó 2013 Lippincott Williams & Wilkins
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TABLE 1. Patient Demographics Comparing Fractures Fixed With Long and Short Nails
Long nail Short nail Comparison (P)
Sample Size
Age (y 6 SD)
Gender (M/F)
Fracture Class (31-A1/31-A2)
119 82 —
79.6 6 9.6 83.3 6 8.0 0.005
32/87 25/57 0.578
28/91 31/51 0.029
DISCUSSION
(57.1%) than for the short (40.2%) nail cohort (P = 0.022) by 17%. The EBL for long Gamma nails (135.5 6 91.9 mL) was found to be significantly greater (P = 0.002) than the EBL for short Gamma nails (92.6 6 47.2 mL) (Table 2). Operative time was significantly greater (P , 0.001) for long (56.8 6 19.4 minutes) than for short (44.0 6 10.7 minutes) Gamma nail procedures. The LOS for patients who received a long nail was not significantly different (P = 0.393) than for patients who received a short nail (Table 2). When comparing the 31-A1 and 31-A2 fractures (regardless of nail length), there were no significant differences in EBL (P = 0.355), incidence of transfusion (P = 0.412), operative time (P = 0.430), or LOS (P = 0.453). There were also no differences within the individual long nail cohort or short nail cohort for 31-A1 versus 31-A2 fractures in EBL (long P = 0.754, short P = 0.420), incidence of transfusion (long P = 0.662, short P = 0.825), operative time (long P = 0.983, short P = 0.926), or LOS (long P = 0.420, short P = 0.931). There was 1 patient overall who presented with periprosthetic fracture who met inclusion criteria, yielding an overall incidence of 0.5% in the reviewed population. This patient was initially treated with a long intramedullary nail with periprosthetic fracture occurring at the medial femoral condyle 8.4 months postoperatively (Fig. 2). Mechanism of this new injury was fall when getting up from a chair, and the patient also presented with a tibial plateau fracture and right proximal humerus fracture at that time. The periprosthetic fracture was treated with a distal femoral plate and the tibial plateau fracture with a tibial locking plate. One patient presented with a lag screw cutout and an impending periprosthetic fracture around a short nail, treated by conversion to a total hip arthroplasty. Other complications related to intramedullary (IM) nailing requiring reoperation included infection (n = 2), nonunion (n = 1), avascular necrosis of the femoral head (n = 2), and hardware failure (n = 2) with 1 screw cutout and
TABLE 2. Difference in Preoperative Hemoglobin, EBL, Transfusion Rate, Operative Time, and LOS for Long Versus Short Nails
Preoperative hemoglobin (g/dL) EBL (mL) Transfusion required (n) Operative time (min) LOS (days)
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Long Gamma Nail
Short Gamma Nail
10.79 6 1.56
10.72 6 1.43
0.323
135.5 6 91.9 68 (57.1%) 56.8 6 19.4 8.0 6 4.5
92.6 6 47.2 33 (40.2%) 44.0 6 10.7 7.7 6 4.1
0.002 0.022 ,0.001 0.393
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1 superior screw migration (Table 3). The incidence of complication leading to reoperation was 2.4% in the short nail cohort and 4.2% in the long nail cohort and was not significantly different between cohorts (P = 0.503). The overall rate of reoperation was 3.5%.
P
To our knowledge, this is the first reported series on the use of short versus long intramedullary nails for treatment of intertrochanteric femur fractures with use of the Stryker Gamma nail. Our results showed that use of a short nail significantly decreased operative time, EBL, and incidence of transfusion. It could be argued that the approximate 43-mL decrease in blood loss and increase in operative time of approximately 13 minutes with the implantation of short versus long Gamma nails may not be clinically significant. However, the 17% greater incidence of blood transfusion could be considered significant in an elderly patient population who are more susceptible to fluid overload. The difference between the LOS was not significant between the long and the short nail cohorts. There was no significant difference between rate of reoperation related to surgical complications between the long nail and the short nail cohorts. Our current data also suggest that the periprosthetic fracture rate around these implants is extremely low (0.5% in our reviewed population) and that the use of a long nail does not completely dispose of this complication as previously hypothesized. Postoperative periprosthetic fracture is one of the most devastating and discussed complications regarding the use of intramedullary femoral nails. Previous literature has found periprosthetic fracture rates of new implants to range from 0.6% to 1.7%.5,10,23,24 The rate of periprosthetic fracture for short intramedullary nails has been shown to range from 0% to 20%.7,10,14,19,21,25–30 However, a review of the literature does show the rate of fracture distal to short intramedullary nails has decreased significantly with new generations of implants.10,24 Long nails used to treat a variety of femur fractures have been reported with most showing low, though not absent, rates of fracture around or distal to these implants.24,25,31 Norris et al24 found that fractures around longer implants trended toward a lower risk compared with short implants, although this finding was not statistically significant. There currently exists a plethora of literature supporting the use of long and short intramedullary nails for the treatment of intertrochanteric fractures. However, significant concern exists regarding implant heterogeneity. Multiple companies have similar intramedullary devices each with their own subtleties in composition and design, making it impossible to accurately compare implants based on long or short designs. It was the intention of our study to compare short versus long intramedullary implants for the treatment of intertrochanteric fractures using the same device and to thus determine if operative outcomes of EBL, operative time, length of hospital stay, and risk of periprosthetic fracture were solely a function of nail length. We also aimed to limit surgeon variability by selecting only those patients treated by fellowship-trained orthopaedic traumatologists to help limit outlying surgeons who may only rarely perform this procedure. Ó 2013 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 5, May 2014
Short Versus Long Nail for Intertrochanteric Fracture
FIGURE 2. Immediate postoperative radiograph of initial fixation of intertrochanteric fracture with a long intramedullary nail (A, B) and periprosthetic fracture approximately 8 months after initial fixation (C, D).
However, this study is limited by its retrospective nature and relatively short follow-up period. Also the use of EBL is extremely subjective, so an analysis of transfusion rate was also included. An assessment of the preoperative and postoperative hemoglobin was also felt to be misleading. Many of these patients are dehydrated and under-resuscitated preoperatively and will have a falsely elevated preoperative hemoglobin, making definitive analysis difficult. Additionally, surgeon bias in nail length selection may affect the results. Ó 2013 Lippincott Williams & Wilkins
Overall, our results are consistent with the literature, which seems to support a decreasing and clinically acceptable rate of periprosthetic fracture with regard to femoral intramedullary nails. With comparable results found in both patient populations, treatment for individual patients can be tailored to anatomic variables. The anterior bow in some osteoporotic patients can make placement of a longer device more difficult. The results of our study suggest that a shorter implant does not have a great clinical impact on the rate of periprosthetic fracture and also that the use of long intramedullary devices www.jorthotrauma.com |
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TABLE 3. Number of Patients Requiring Reoperation Because of Complication in the Long and Short Nail Cohorts Infection Avascular necrosis Nonunion Hardware failure
Long Nail
Short Nail
2 (1.7%) 2 (1.7%) 0 1 (0.8%)
0 0 1 (1.2%) 1 (1.2%)
does not completely mitigate distal fractures, and thus, the previously held ideology of protecting the entire bone may not hold true. However, further evaluation with a greater number of patients would be needed before any definitive recommendations regarding periprosthetic fractures can be made. Another question that still remains is the difference in morbidity with regard to revision surgery after periprosthetic fracture around short versus long implants. The treatment of these fractures is different depending on the initial implant used. A fracture around a short nail usually requires removal of the original device and revision to a longer intramedullary nail, whereas a fracture around a long nail can be treated with a lateral plate and does not require removal of the original implant. Therefore, initial treatment may also be based on which revision periprosthetic surgery is less difficult to perform and results in less morbidity for the patient. We feel that the treatment of intertrochanteric fractures with an intramedullary device in the elderly population provides good clinical results. Furthermore, both use of long and short implants are acceptable options and should be tailored to the patient and the surgeon’s ability to perform either procedure in a safe manner. Further studies with greater statistical power and longer term follow-up are needed to evaluate the significance of nail length on the rate of periprosthetic fracture. REFERENCES 1. Brauer CA, Coca-Perraillon M, Cutler DM, et al. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573–1579. 2. Tosteson AN, Gottlieb DJ, Radley DC, et al. Excess mortality following hip fracture: the role of underlying health status. Osteoporos Int. 2007; 18:1463–1472. 3. Melton LJ III, Gabriel SE, Crowson CS, et al. Cost-equivalence of different osteoporotic fractures. Osteoporos Int. 2003;14:383–388. 4. Radcliff TA, Regan E, Cowper Ripley DC, et al. Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study. J Bone Joint Surg Am. 2012;94:833–840. 5. Kokoroghiannis C, Aktselis I, Deligeorgis A, et al. Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures— a review. Injury. 2012;43:686–693. 6. Bellabarba C, Herscovici D Jr, Ricci WM. Percutaneous treatment of peritrochanteric fractures using the gamma nail. J Orthop Trauma. 2003;17:S38–S50. 7. Bellabarba C, Herscovici D Jr, Ricci WM. Percutaneous treatment of peritrochanteric fractures using the Gamma nail. Clin Orthop Relat Res. 2000;375:30–42. 8. Calvert PT. The Gamma nail—a significant advance or a passing fashion? J Bone Joint Surg Br. 1992;74:329–331. 9. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop. 2006;30:69–78.
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10. Bojan AJ, Beimel C, Speitling A, et al. 3066 consecutive Gamma nails. 12 years experience at a single centre. BMC Musculoskelet Disord. 2010; 11:133. 11. Lavini F, Renzi-Brivio L, Aulisa R, et al. The treatment of stable and unstable proximal femoral fractures with a new trochanteric nail: results of a multicentre study with the Veronail. Strategies Trauma Limb Reconstr. 2008;3:15–22. 12. Valverde JA, Alonso MG, Porro JG, et al. Use of the gamma nail in the treatment of fractures of the proximal femur. 1998. J Orthop Trauma. 2003;17:S51–S56. 13. Kukla C, Heinz T, Gaebler C, et al. The standard Gamma nail: a critical analysis of 1,000 cases. J Trauma. 2001;51:77–83. 14. Lindsey RW, Teal P, Probe RA, et al. Early experience with the gamma interlocking nail for peritrochanteric fractures of the proximal femur. J Trauma. 1991;31:1649–1658. 15. Gadegone WM, Salphale YS. Short proximal femoral nail fixation for trochanteric fractures. J Orthop Surg (Hong Kong). 2010;18:39–44. 16. Gadegone WM, Salphale YS. Proximal femoral nail—an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop. 2007;31:403–408. 17. Chevalley F, Gamba D. Gamma nailing of pertrochanteric and subtrochanteric fractures: clinical results of a series of 63 consecutive cases. J Orthop Trauma. 1997;11:412–415. 18. Lorich DG, Geller DS, Nielson JH. Osteoporotic pertrochanteric hip fractures: management and current controversies. Instr Course Lect. 2004;53:441–454. 19. Hesse B, Gachter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg. 2004; 124:692–698. 20. Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br. 1993;75:789–793. 21. Bridle SH, Patel AD, Bircher M, et al. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991; 73:330–334. 22. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(suppl 10):S1–S133. 23. Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res. 2005;439:221–227. 24. Norris R, Bhattacharjee D, Parker MJ. Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: a systematic review of 13,568 patients. Injury. 2012;43:706–711. 25. Bhandari M, Schemitsch E, Jonsson A, et al. Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis. J Orthop Trauma. 2009;23:460–464. 26. Madsen JE, Naess L, Aune AK, et al. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma. 1998;12:241–248. 27. Butt MS, Krikler SJ, Nafie S, et al. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury. 1995;26:615–618. 28. Leung KS, So WS, Shen WY, et al. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br. 1992;74:345–351. 29. Ahrengart L, Tornkvist H, Fornander P, et al. A randomized study of the compression hip screw and Gamma nail in 426 fractures. Clin Orthop Relat Res. 2002;401:209–222. 30. Schipper IB, Steyerberg EW, Castelein RM, et al. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br. 2004;86: 86–94. 31. Pervez H, Parker MJ. Results of the long Gamma nail for complex proximal femoral fractures. Injury. 2001;32:704–707.
Ó 2013 Lippincott Williams & Wilkins
Short Versus Long Intramedullary Nails for Treatment of Intertrochanteric Femur Fractures (OTA 31-A1 and A2) Christopher Boone, MD,* Kelly N. Carlberg, MD,* Denise M. Koueiter, MS,† Kevin C. Baker, PhD,† Jason Sadowski, MD,* Patrick J. Wiater, MD,* Gregory P. Nowinski, MD,* and Kevin D. Grant, MD*
Objectives: The purpose of this study was to compare blood loss
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
and operative times associated with long versus short intramedullary nails for intertrochanteric fracture fixation and rate of periprosthetic fracture.
(J Orthop Trauma 2014;28:e96–e100)
Design: A retrospective study. Setting: Level 1 trauma center. Patients: One hundred ninety-four patients with an intertrochanteric fracture (AO/OTA class 31-A1 and A2) and low-energy mechanism of injury treated by 1 of 4 fellowship-trained orthopaedic traumatologists. Intervention: Short versus long intramedullary nail. Methods: Medical records were reviewed for age, gender, estimated blood loss (EBL), transfusion rate, operative time, length of stay, and incidence of periprosthetic fracture. Variables were statistically compared between long and short intramedullary nails, with statistical significance at P , 0.05.
Results: The average EBL (135.5 6 91.9 mL) and transfusion rate (57.1%) for long nails were found to be significantly greater (P = 0.002) than the EBL (92.6 6 47.2 mL) and transfusion rate (40.2%) for short nails. Average operative time was also found to be significantly greater (P , 0.001) for long (56.8 6 19.4 minutes) than for short (44.0 6 10.7 minutes) intramedullary nail procedures. The overall incidence of periprosthetic fracture was 0.5%, one patient with initial treatment of a long intramedullary nail.
Conclusions: Statistically significant lower operative time, EBL, and transfusion rate were found in this study for short intramedullary nails. There were no differences seen in length of stay or periprosthetic fracture. The incidence of periprosthetic fracture was very low in both cohorts. Further study with greater statistical power is needed. Key Words: intertrochanteric fracture, intramedullary femoral nail, long intramedullary nail, short intramedullary nail, periprosthetic fracture, retrospective review Accepted for publication July 26, 2013. From the Departments of *Orthopaedic Surgery, and †Orthopaedic Research, William Beaumont Hospital, Royal Oak, MI. Presented in part as a podium presentation at the Annual Meeting of the Orthopaedic Trauma Association, October 4, 2012, Minneapolis, MN. The authors report no funding or conflicts of interest. This study was conducted with IRB approval: HIC#2011-017. Reprints: Kevin D. Grant, MD, Department of Orthopaedic Surgery, William Beaumont Hospital, Woodward Avenue, Royal Oak, MI 48073 (e-mail: [email protected]). Copyright © 2013 by Lippincott Williams & Wilkins
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INTRODUCTION Proximal intertrochanteric femur fractures in the elderly population have become increasingly common in developed nations and have recently become a major health concern.1 With the majority of fractures occurring in the elderly population, they often lead to significant morbidity, mortality, and compromise in quality of life.1,2 Postoperative mortality has been reported to be as high as 20%–30% in the first 6–12 months after surgical fixation of these fractures.1–3 The overall number of proximal intertrochanteric femur fractures is expected to continue to increase secondary to increased life expectancy and overall increase in the elderly population.1 In the past several years, the intramedullary nail has become the implant of choice for intertrochanteric fractures among many US-based orthopaedic surgeons.4,5 With the intramedullary nail being a well-accepted treatment option for the common intertrochanteric fracture, some controversy has developed regarding the length of the nail itself. Short nails have shown good biomechanical stability and acceptable clinical outcomes for the treatment of these fractures.6–17 However, some evidence exists that the use of short intramedullary nails leads to a stress riser at the tip of the nail, thus predisposing patients to periprosthetic fractures.12,18–21 An argument can be made that intertrochanteric fractures in the elderly population are the result of pathologic osteoporotic or osteopenic bone, thus requiring the full protection afforded by the use of longer intramedullary devices. Therefore, any added morbidity because of increased operative time, technical difficulty, and blood loss would theoretically be offset by decreased postoperative periprosthetic fractures. However, to date, the actual difference in blood loss and operative time between long and short nails has not been reported. The purpose of this study is to quantify operative time and blood loss associated with the use of short versus long intramedullary nails in the treatment of intertrochanteric femur fractures. Furthermore, this study aims to determine if there is a significant decrease in the number of periprosthetic fractures when intertrochanteric femur fractures are treated with long intramedullary implants. J Orthop Trauma Volume 28, Number 5, May 2014
J Orthop Trauma Volume 28, Number 5, May 2014
PATIENTS AND METHODS A retrospective analysis was conducted using our institutional trauma database for intertrochanteric fractures treated at our level 1 trauma center between January 2008 and December 2011 by 1 of 4 fellowship-trained orthopaedic traumatologists. All preoperative radiographs were reviewed by a senior orthopaedic resident and the attending orthopaedic traumatologist. Only patients with fractures in the trochanteric area with AO classification 31-A1 or 31-A2 that were treated with a Stryker Gamma 3 system (Stryker Orthopaedics, Mawah, NJ) were included in this study.22 The use of an intramedullary device as opposed to a sliding hip screw was based on surgeon preference at our institution. The mechanism of injury was limited to low-energy falls or twists. Patients excluded were minors, patients who sustained another lower extremity fracture at initial presentation, and patients with a diagnosed metabolic bone disorder other than osteoporosis or with evidence of malignancy. Only patients with medical records available for a minimum of 1 year before the date of surgery were included. Operative notes were reviewed for estimated blood loss (EBL) and skin to skin operative time as recorded in the operating room. Medical charts were reviewed for age at implantation, gender, hospital length of stay (LOS), and incidence of periprosthetic fracture. Preoperative hemoglobin levels and incidence of transfusion postoperatively were also collected. A total of 347 patients were reviewed. Within 1 year of the date of surgery, 41 patients deceased and 112 were lost to follow-up. Overall, 194 patients met all inclusion criteria, with 7-staged bilateral intertrochanteric fractures with intramedullary nail treatment, for a total of 201 nails. There were 54 men (27.8%) and 140 women (72.2%), and the average age was 81.1 6 9.2 years (range 45–98 years). There were 82 (40.8%) fractures that received a short Gamma nail and 119 (59.2%) fractures that received a long Gamma nail (Fig. 1). Of
Short Versus Long Nail for Intertrochanteric Fracture
the 7 bilateral patients, 2 patients had a long nail in both femurs, 2 had a short nail in both femurs, and 3 had 1 long and 1 short nail. The average follow-up was 2.1 years (range 1–4.5 years). All procedures were performed with the patient in the supine position on a fracture table with fluoroscopic-guided imaging. Closed reduction to near anatomical position was performed before incision while the patient was anesthetized. Use of short versus long implant was determined by the attending surgeon based on surgeon preference. Femurs were reamed by hand, and a guide wire was used for all procedures. All nails had placement of distal interlocking screws as per surgeon preference, either through the nail guide for short nails or by intraoperative perfect circle fluoroscopic technique for long nails. There were no intraoperative complications. Patients were weight bearing as tolerated postoperatively. All data were statistically compared for the short and long nail cohorts. Data were analyzed for normality using the Shapiro–Wilk test and were statistically analyzed using a Mann–Whitney rank sum test or x2 test. For all tests, statistical significance was at P , 0.05. Statistical analyses were performed by graduate-trained research engineers with the aid of a statistical software package (SPSS v.20, IBM Inc).
RESULTS There was no significant difference in the gender of patients with long nails versus short nails (Table 1). However, patients with a short nail were significantly older, and patients with a fracture type AO 31-A2 were more likely to be fixed with a long nail. The preoperative hemoglobin was not significantly different between the short (10.72 6 1.43) and the long (10.79 6 1.56) nail cohorts (P = 0.323). The incidence of postoperative transfusion was significantly higher for the long
FIGURE 1. Anteroposterior and oblique views of short Gamma nail fixation (A, B) and long Gamma nail fixation (C, D) of an intertrochanteric fracture. Ó 2013 Lippincott Williams & Wilkins
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TABLE 1. Patient Demographics Comparing Fractures Fixed With Long and Short Nails
Long nail Short nail Comparison (P)
Sample Size
Age (y 6 SD)
Gender (M/F)
Fracture Class (31-A1/31-A2)
119 82 —
79.6 6 9.6 83.3 6 8.0 0.005
32/87 25/57 0.578
28/91 31/51 0.029
DISCUSSION
(57.1%) than for the short (40.2%) nail cohort (P = 0.022) by 17%. The EBL for long Gamma nails (135.5 6 91.9 mL) was found to be significantly greater (P = 0.002) than the EBL for short Gamma nails (92.6 6 47.2 mL) (Table 2). Operative time was significantly greater (P , 0.001) for long (56.8 6 19.4 minutes) than for short (44.0 6 10.7 minutes) Gamma nail procedures. The LOS for patients who received a long nail was not significantly different (P = 0.393) than for patients who received a short nail (Table 2). When comparing the 31-A1 and 31-A2 fractures (regardless of nail length), there were no significant differences in EBL (P = 0.355), incidence of transfusion (P = 0.412), operative time (P = 0.430), or LOS (P = 0.453). There were also no differences within the individual long nail cohort or short nail cohort for 31-A1 versus 31-A2 fractures in EBL (long P = 0.754, short P = 0.420), incidence of transfusion (long P = 0.662, short P = 0.825), operative time (long P = 0.983, short P = 0.926), or LOS (long P = 0.420, short P = 0.931). There was 1 patient overall who presented with periprosthetic fracture who met inclusion criteria, yielding an overall incidence of 0.5% in the reviewed population. This patient was initially treated with a long intramedullary nail with periprosthetic fracture occurring at the medial femoral condyle 8.4 months postoperatively (Fig. 2). Mechanism of this new injury was fall when getting up from a chair, and the patient also presented with a tibial plateau fracture and right proximal humerus fracture at that time. The periprosthetic fracture was treated with a distal femoral plate and the tibial plateau fracture with a tibial locking plate. One patient presented with a lag screw cutout and an impending periprosthetic fracture around a short nail, treated by conversion to a total hip arthroplasty. Other complications related to intramedullary (IM) nailing requiring reoperation included infection (n = 2), nonunion (n = 1), avascular necrosis of the femoral head (n = 2), and hardware failure (n = 2) with 1 screw cutout and
TABLE 2. Difference in Preoperative Hemoglobin, EBL, Transfusion Rate, Operative Time, and LOS for Long Versus Short Nails
Preoperative hemoglobin (g/dL) EBL (mL) Transfusion required (n) Operative time (min) LOS (days)
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Long Gamma Nail
Short Gamma Nail
10.79 6 1.56
10.72 6 1.43
0.323
135.5 6 91.9 68 (57.1%) 56.8 6 19.4 8.0 6 4.5
92.6 6 47.2 33 (40.2%) 44.0 6 10.7 7.7 6 4.1
0.002 0.022 ,0.001 0.393
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1 superior screw migration (Table 3). The incidence of complication leading to reoperation was 2.4% in the short nail cohort and 4.2% in the long nail cohort and was not significantly different between cohorts (P = 0.503). The overall rate of reoperation was 3.5%.
P
To our knowledge, this is the first reported series on the use of short versus long intramedullary nails for treatment of intertrochanteric femur fractures with use of the Stryker Gamma nail. Our results showed that use of a short nail significantly decreased operative time, EBL, and incidence of transfusion. It could be argued that the approximate 43-mL decrease in blood loss and increase in operative time of approximately 13 minutes with the implantation of short versus long Gamma nails may not be clinically significant. However, the 17% greater incidence of blood transfusion could be considered significant in an elderly patient population who are more susceptible to fluid overload. The difference between the LOS was not significant between the long and the short nail cohorts. There was no significant difference between rate of reoperation related to surgical complications between the long nail and the short nail cohorts. Our current data also suggest that the periprosthetic fracture rate around these implants is extremely low (0.5% in our reviewed population) and that the use of a long nail does not completely dispose of this complication as previously hypothesized. Postoperative periprosthetic fracture is one of the most devastating and discussed complications regarding the use of intramedullary femoral nails. Previous literature has found periprosthetic fracture rates of new implants to range from 0.6% to 1.7%.5,10,23,24 The rate of periprosthetic fracture for short intramedullary nails has been shown to range from 0% to 20%.7,10,14,19,21,25–30 However, a review of the literature does show the rate of fracture distal to short intramedullary nails has decreased significantly with new generations of implants.10,24 Long nails used to treat a variety of femur fractures have been reported with most showing low, though not absent, rates of fracture around or distal to these implants.24,25,31 Norris et al24 found that fractures around longer implants trended toward a lower risk compared with short implants, although this finding was not statistically significant. There currently exists a plethora of literature supporting the use of long and short intramedullary nails for the treatment of intertrochanteric fractures. However, significant concern exists regarding implant heterogeneity. Multiple companies have similar intramedullary devices each with their own subtleties in composition and design, making it impossible to accurately compare implants based on long or short designs. It was the intention of our study to compare short versus long intramedullary implants for the treatment of intertrochanteric fractures using the same device and to thus determine if operative outcomes of EBL, operative time, length of hospital stay, and risk of periprosthetic fracture were solely a function of nail length. We also aimed to limit surgeon variability by selecting only those patients treated by fellowship-trained orthopaedic traumatologists to help limit outlying surgeons who may only rarely perform this procedure. Ó 2013 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 5, May 2014
Short Versus Long Nail for Intertrochanteric Fracture
FIGURE 2. Immediate postoperative radiograph of initial fixation of intertrochanteric fracture with a long intramedullary nail (A, B) and periprosthetic fracture approximately 8 months after initial fixation (C, D).
However, this study is limited by its retrospective nature and relatively short follow-up period. Also the use of EBL is extremely subjective, so an analysis of transfusion rate was also included. An assessment of the preoperative and postoperative hemoglobin was also felt to be misleading. Many of these patients are dehydrated and under-resuscitated preoperatively and will have a falsely elevated preoperative hemoglobin, making definitive analysis difficult. Additionally, surgeon bias in nail length selection may affect the results. Ó 2013 Lippincott Williams & Wilkins
Overall, our results are consistent with the literature, which seems to support a decreasing and clinically acceptable rate of periprosthetic fracture with regard to femoral intramedullary nails. With comparable results found in both patient populations, treatment for individual patients can be tailored to anatomic variables. The anterior bow in some osteoporotic patients can make placement of a longer device more difficult. The results of our study suggest that a shorter implant does not have a great clinical impact on the rate of periprosthetic fracture and also that the use of long intramedullary devices www.jorthotrauma.com |
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J Orthop Trauma Volume 28, Number 5, May 2014
Boone et al
TABLE 3. Number of Patients Requiring Reoperation Because of Complication in the Long and Short Nail Cohorts Infection Avascular necrosis Nonunion Hardware failure
Long Nail
Short Nail
2 (1.7%) 2 (1.7%) 0 1 (0.8%)
0 0 1 (1.2%) 1 (1.2%)
does not completely mitigate distal fractures, and thus, the previously held ideology of protecting the entire bone may not hold true. However, further evaluation with a greater number of patients would be needed before any definitive recommendations regarding periprosthetic fractures can be made. Another question that still remains is the difference in morbidity with regard to revision surgery after periprosthetic fracture around short versus long implants. The treatment of these fractures is different depending on the initial implant used. A fracture around a short nail usually requires removal of the original device and revision to a longer intramedullary nail, whereas a fracture around a long nail can be treated with a lateral plate and does not require removal of the original implant. Therefore, initial treatment may also be based on which revision periprosthetic surgery is less difficult to perform and results in less morbidity for the patient. We feel that the treatment of intertrochanteric fractures with an intramedullary device in the elderly population provides good clinical results. Furthermore, both use of long and short implants are acceptable options and should be tailored to the patient and the surgeon’s ability to perform either procedure in a safe manner. Further studies with greater statistical power and longer term follow-up are needed to evaluate the significance of nail length on the rate of periprosthetic fracture. REFERENCES 1. Brauer CA, Coca-Perraillon M, Cutler DM, et al. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573–1579. 2. Tosteson AN, Gottlieb DJ, Radley DC, et al. Excess mortality following hip fracture: the role of underlying health status. Osteoporos Int. 2007; 18:1463–1472. 3. Melton LJ III, Gabriel SE, Crowson CS, et al. Cost-equivalence of different osteoporotic fractures. Osteoporos Int. 2003;14:383–388. 4. Radcliff TA, Regan E, Cowper Ripley DC, et al. Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study. J Bone Joint Surg Am. 2012;94:833–840. 5. Kokoroghiannis C, Aktselis I, Deligeorgis A, et al. Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures— a review. Injury. 2012;43:686–693. 6. Bellabarba C, Herscovici D Jr, Ricci WM. Percutaneous treatment of peritrochanteric fractures using the gamma nail. J Orthop Trauma. 2003;17:S38–S50. 7. Bellabarba C, Herscovici D Jr, Ricci WM. Percutaneous treatment of peritrochanteric fractures using the Gamma nail. Clin Orthop Relat Res. 2000;375:30–42. 8. Calvert PT. The Gamma nail—a significant advance or a passing fashion? J Bone Joint Surg Br. 1992;74:329–331. 9. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop. 2006;30:69–78.
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Ó 2013 Lippincott Williams & Wilkins
