OTA 2012 Posters

Scientific Poster #32 Hip/Femur OTA-2012

Ipsilateral Femoral Neck and Shaft Fractures: Results of Treatment With Hip Screws and a Retrograde Intramedullary Nail

Robert F. Ostrum, MD1; Paul Tornetta, III, MD2; J. Tracy Watson, MD3;
Anthony Christiano2; Emily Vafek, MD4;
1Cooper University Hospital, Camden, New Jersey, USA
2Boston University Medical Center, Boston, Massachusetts, USA;
3Saint Louis University, Saint Louis, Missouri, USA;
4Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA

Purpose: Ipsilateral femoral neck and shaft fractures are not common injuries but can be a difficult entity to treat. Currently, sliding hip screw or multiple cannulated screw fixation of the proximal femoral fracture followed by retrograde intramedullary nailing is considered the treatment of choice. This study reviews our experience using this technique.

Methods: This is a consecutive series, retrospective review from February 2003 to April 2011 of all ipsilateral femoral neck and shaft fractures treated at three Level I trauma centers. They were all treated with a sliding hip screw (SHS), 95° hip screw (DCS), or cannulated screws (CS) proximally followed by retrograde intramedullary nailing. Patients were followed until clinical union and complications, range of motion, and secondary procedures were examined.

Results: There were 68 patients identified; 3 were lost to follow-up, leaving 65 patients in the cohort. There were 17 females, 48 males, 30 left, and 35 right femoral fractures. The average age was 37.3 years and follow-up ranged from 16 weeks to 52 months. The proximal fractures (OTA 31A,B) included: 1 subtrochanteric, 12 intertrochanteric, 35 basicervical, 15 transcervical, and 2 subcapital. There were 2 DCS and 38 SHS implants, and 25 patients had CS as their treatment. 17 shaft fractures were open. Three patients were polytraumatized and had open reduction and internal fixation of their hip fracture with external fixation of the femoral shaft fracture, followed later by retrograde intramedullary nailing. 15 patients had isolated femur fractures and 50 patients had other associated injuries. 60 fractures were identified by plain radiograph and CT scan prior to going to the operating room. Two patients had the proximal femur fracture identified in the operating, one in the post anesthesia care unit, and one morbidly obese patient had a basicervical fracture identified in the trauma ICU following retrograde intramedullary nailing. One patient demonstrated a displaced femoral neck fracture after antegrade intramedullary nailing and was converted to screws plus a retrograde intramedullary nail. There were 25 communited (OTA 32C), 17 with a butterfly (OTA 32B), 22 transverse (OTA 32A) and 1 distal one-third (OTA 33A) fractures. Two open, comminuted fractures went on to nonunion, one healing after exchange nailing and the other after plating. One patient required dynamization for a shaft delayed union and one required nail removal and antibiotic beads for infection after an open fracture. One patient with a body mass index>40 had thigh pain, no broken hardware, and a lucency that was called a delayed union and was successfully treated with autogenous bone graft. Two patients were nailed 1 cm short. One patient treated for an ipsilateral subtrochanteric fracture with a DCS implant healed in 5° of varus. One patient with a displaced femoral neck fracture developed osteonecrosis. An asymptomatic nonunion of a nondisplaced femoral neck fracture occurred in one patient. One femur was nailed in varus and one femoral neck treated with an SHS drifted into varus. 9 patients had knee pain (6 had screw removal), 2 had hip pain, and 1 had hip and knee pain. There was no difference in results when comparing CS to SHS for proximal fractures and the amount of overlap of the retrograde intramedullary nail and the SHS had no influence on union.

Conclusions: The treatment of ipsilateral femoral neck fractures with hip screw fixation and a retrograde nail demonstrated good clinical results with 96.7% union for the shaft and 96.7% union for the femoral neck fractures. There was one displacement of a femoral neck fracture and the two delayed unions and one infection of the femoral shaft fractures were successfully treated. There was one predictable case of osteonecrosis after a displaced fracture of the femoral neck. There was no difference in femoral neck union or alignment when comparing CS to an SHS.

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.