Session V - Femur
Cephalomedullary Nails in the Treatment of High Energy Proximal Femur Fractures in Young Patients: A Prospective Randomized Trial
Purpose: This study is intended to (1) assess results of management of high-energy proximal femur fractures in young patients treated with cephalomedullary nails and (2) compare a nail using a piriformis fossa starting point to one using a trochanteric starting point in treatment of these injuries.
Methods: 34 consecutive patients between the ages of 18 and 50 years with a proximal femur fracture (subtrochanteric, intertrochanteric, or ipsilateral neck/shaft fractures) due to high-energy injury were randomized to receive a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Patients were followed for at least 1 year. Quality of reduction, fracture union, work status, and hip function were assessed.
Results: There were 17 patients in each group. The groups did not differ with regard to age, sex, body mass index, injury mechanism, Injury Severity Score, percentage of patients requiring concurrent surgery, fracture pattern, or the number of open fractures. The two groups did not differ with regard to incision length, estimated blood loss, duration of surgery, ease of use of the device, or surgeon assessment of reduction. Varus malalignment was defined as >5° of varus when compared to the uninjured hip. One patient in the recon nail group met criteria for varus malreduction; four patients in the long gamma nail group did (P=0.34). One obese patient developed a wound infection. There were no other postoperative complications. Six patients were lost to follow-upone immediately after discharge,and five others after 1, 3, 3, 6, and 9 months of follow-up. Four of these patients had progressed to fracture union; three had returned to work. The 28 remaining patients (82%) were followed for 18 months, on average (range, 12 to 29 months). In this group, all fractures healed. Average Harris Hip Scores in the recon nail and long gamma nail groups were 86 and 84, respectively. At latest follow-up, 12 of 15 patients in the recon nail group had returned to work, while 12 of 13 patients in the long gamma nail group had.
Conclusion: We could find no meaningful differences between the two devices.
Significance: Intramedullary devices yield predictably good results in these difficult fractures. The choice of starting point should depend on the surgeon's preference.