Thurs., 10/4/12 Hip Fractures, PAPER #31, 3:49 pm OTA-2012
Short Versus Long Intramedullary Nails for Intertrochanteric Femur Fractures
Kelly Carlberg, MD; Christopher Boone, MD; Denise Koueiter, MS; Kevin Baker, PhD;
Jason Sadowsi, MD; Patrick Wiater, MD; Gregory Nowinski, MD; Kevin Grant, MD;
Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, Michigan, USA
Purpose: The use of intramedullary (IM) nails for intertrochanteric (IT) femur fractures has become a well-accepted and common procedure among orthopaedic surgeons. The patient population is typically older with several medical comorbidities and fixation can lead to difficult complications such as periprosthetic fracture (PPF). While short IM nails (SIMN) have been historically more common, surgeons at our institution have trended towards the use of long IM nails (LIMN) that extend to the distal metaphysis. The rationale for this is that IT fractures in the elderly are often the result of osteopenia/osteoporosis, a metabolic bone disease, and therefore these fractures can be considered pathologic. The standard of care for pathologic long-bone fractures is to protect the entire bone with the use of long IM implants. However, the use of longer nails may increase operative time and estimated blood loss (EBL), leading to more systemic complications. The purpose of this study was to compare EBL and operative times associated with long versus short IM nails for IT fracture fixation, as well as refracture rate around the site of the nail.
Methods: A retrospective analysis was conducted of IT fractures treated with IM nails from one manufacturer at our Level I trauma center between January 2001 and December 2011 by four fellowship-trained orthopaedic traumatologists. Only extra-articular fractures in the trochanteric area of AO classification 31A were included. Mechanism of injury was limited to low-energy injuries, including a fall or twist. Exclusions were minors, patients who sustained another lower extremity fracture at initial presentation, and patients with a diagnosed metabolic bone disorder other than osteoporosis. Medical records were reviewed for age, gender, EBL, operative time, length of stay (LOS), and PPF. Data were statistically analyzed by comparing these variables between long and short IM nails using a Mann-Whitney rank sum test, with statistical significance at P <0.05.
Results: 225 qualifying patients (60 males, 165 females) were reviewed, with 1 bilateral IM treatment, for a total of 226 nails, of which 86 were SIMN and 140 nails were LIMN. Average age was 82.1 ± 9.6 years (range, 45-101). The average EBL for LIMN (135.7 ± 92.1 mL) was found to be significantly greater (P = 0.002) than EBL for SIMN (99.1 ± 69.5 mL). Average operative time was also found to be significantly greater (P = 0.001) for LIMN procedures (64.4 ± 25.4 minutes) than SIMN procedures (44.3 ± 13.4 minutes). The overall incidence of refracture was 0.013% (3 total, 1 with SIMN and 2 with LIMN). EBL and operative time did not significantly vary as a function of surgeon, gender, or side.
Conclusion: The EBL and operative times were significantly lower for SIMN, indicating shorter nails could be a better option for patients with more severe medical comorbidities. The incidence of PPF was very low, and the LIMN did not reduce refracture rate. Other questions still remain, including the difference in morbidity with regard to revision surgery after PPF around short versus long implants.
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• 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.