A preliminary experience with the Russell-Taylor reconstruction nail for complex femoral fractures.

Eleven cases of complex femoral fractures were seen from November 1987 to November 1989; five ipsilateral femoral neck and shaft fractures and six comminuted subtrochanteric fractures. High-energy accidents accounted for most of these injuries. There were numerous associated injuries, many requiring operative procedures. All of the fractures were treated with Russell-Taylor reconstruction nails. All fractures united, but there were two delayed unions. There was no delay in diagnosis of the femoral neck fractures, and all healed without avascular necrosis. Malalignment occurred in one case, shortening of the femur occurred in two cases, and in two cases only one screw could be placed in the femoral head. In three patients technical errors related to nail insertion led to fracture complications. The use of the Russell-Taylor reconstruction nail is technically demanding. However, we conclude that in complex femoral fractures, this device offers superior stabilization over other currently used methods of internal fixation.     

Initial experience with a second generation locking femoral nail: the Russell-Taylor reconstruction nail

A series of 36 patients with 20 subtrochanteric fractures, 12 ipsilateral neck/shaft fractures, and five intertrochanteric fractures with shaft extension underwent closed intramedullary nailing with the Russell-Taylor reconstruction (RECON) nail. The average Injury Severity Score was 16, and seven of the fractures were open. All fractures were acute injuries, and all but one were treated within 24 hours of admission. Follow-up was obtained at three, six, nine, 12, and 24 months or until the fracture healed. The range of follow-up was one to three years. Complete follow-up was obtained in 33 of 36 patients. Union was achieved in all acute fractures. Shortening occurred in two cases and chondrolysis and avascular necrosis occurred in another patient. Excellent hip and knee range of motion were obtained except in a few cases of ipsilateral limb injuries. While many complex femoral shaft fractures can be treated successfully with first generation locking nails, this study demonstrates that second generation locking nails, such as the RECON nail, offer the added strength and design features necessary for more effective treatment of complex proximal and ipsilateral femoral neck/shaft fractures.     

Treatment of ipsilateral femoral neck and shaft fractures with the Russell-Taylor reconstructive nail.

Twenty-seven ipsilateral femoral neck and shaft fractures were treated with the Russell-Taylor reconstructive nail. Follow-up ranged from 6-48 months (average: 23.6 months). Femoral neck fractures healed within an average of 3.7 months and femoral shaft fractures healed within an average of 4.8 months. Complications included one case of avascular necrosis of the femoral head, a varus healing of one femoral neck fracture, and a rotational malalignment of the femoral shaft in another case. There were no cases of hardware failure. The Russell-Taylor reconstructive nail allows concomitant hip and shaft fractures to be fixed with a single implant.     

Intramedullary osteosynthesis of complex proximal femoral fractures with the Targon PF nail

We evaluated the performance of the Targon PF nailing system in the treatment of complex proximal femoral fractures with a retrospective analysis of prospectively collected data for 94 patients with a complex proximal femoral fracture (subtrochanteric fracture or fracture with reversed fracture line pattern) treated with a Targon PF nail. There were no intra-operative femoral fractures. Late complications requiring reoperation were one femoral fracture and one fracture around the nail secondary to tumour. Seven nails had to be dynamised and a further six 'self-dynamised' at the site of the distal locking screw. One patient required revision of the distal locking. Only one other patient required secondary surgery for a wound haematoma. There were no cases of implant cut-out or non-union. The Targon PF nail represents a progressive development in the design of intramedullary nails for proximal femoral fractures and the results compare favourably with other intramedullary systems used to treat complex proximal femoral fractures.     

股骨粗隆下骨折手术治疗进展

股骨粗隆下区骨折是髋关节周围骨折中最难处理的一种骨折类型,多由高能量创伤所致的粉碎性骨折。非手术治疗有较高的畸形愈合、不愈合以及其他并发症发生率,因而,粗隆下骨折多主张手术治疗。Russell-Taylor分类方法临床较常用,有利于指导内固定方法的选择。对于小粗隆以下平面的骨折,采用标准的交锁髓内钉较理想。骨折波及到小粗隆但梨状窝未累及时,选用头髓钉或95°角钢板可取得满意效果。对于大粗隆骨折并累及梨状窝时,采用滑行钉器械固定较好。DHS器械不适宜用于粗隆下骨折的治疗。     

Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing.

Ninety-five subtrochanteric femoral fractures were treated with an interlocking nail. There were 69 closed and 26 open fractures. This injury was the result of high-energy trauma in 77% of the cases. The average time to healing was 25 weeks. There were three delayed unions, one nonunion, and six malunions. Essentially all nonpathologic, subtrochanteric femur fractures can be stabilized by interlocking nailing, regardless of the fracture pattern or degree of comminution. Favorable mechanical characteristics of interlocking nails have eliminated the requirement of surgically reconstituting the medial femoral cortex. Closed interlocking nailing is the preferred treatment for subtrochanteric fractures of the femur resulting from trauma.     

股骨近端防旋髓内钉治疗Russell-TaylorⅡ型股骨转子下骨折

目的探讨股骨近端防旋髓内钉(PFNA)治疗Russell-TaylorⅡ型股骨转子下骨折的手术方法及疗效。方法对17例Russell-TaylorⅡ型股骨转子下骨折患者牵引复位后均行PFNA内固定治疗。结果手术时间60~90 min,术中出血量150~400 ml。17例均获随访,时间10~24个月。骨折均达骨性愈合。按Harris标准进行髋关节功能评价:优10例,良6例,可1例。结论 PFNA治疗Russell-TaylorⅡ型股骨转子下骨折操作简单,创伤小,疗效满意。     

A comparison of the Brooker-Wills and Russell-Taylor nails for treatment of patients who have fractures of the femoral shaft

Seventy-three fractures of the femoral shaft (seventy patients) were randomized to treatment with interlocked nailing with either the Brooker-Wills femoral nail (thirty-nine fractures) or the Russell-Taylor femoral nail (thirty-four fractures). Sixty-one patients (sixty-four fractures) were prospectively followed from admission until healing of the fracture. Specific attention was paid to recording operative details, including technical difficulties associated with insertion of the nails. Technical difficulties were encountered in insertion of the proximal screw, distal screw, and nail, and in deployment of the fins. Insertion of the Russell-Taylor nail was associated with less technical difficulty, operative time, and estimated loss of blood. The two nails differ in their biomechanical properties, methods of fixation, and instrumentation. These differences did not affect the clinical outcome; the fractures in both groups of patients healed with excellent functional results.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Summary Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.      

Intramedullary nailing of the femoral shaft: a prospective, randomized study.

We conducted a prospective, randomized study on 84 consecutive patients with 88 acute, traumatic femoral shaft fractures using 32 Grosse-Kempf nails, 29 Russell-Taylor nails, and 27 Synthes nails. Although total operative times and proximal and distal locking times were similar for the three groups, the procedure was faster with the Grosse-Kempf nail. Three proximal fractures could not be locked with the Synthes nail. At first follow-up, we found no significant difference in terms of pain, limp, range of motion, or time to union; however, we removed fewer Synthes nails to resolve patient complaints of pain. Three delayed unions were attributed to fracture distraction. We conclude that all three nails are suitable for the treatment of almost all femoral shaft fractures. A careful analysis of intraoperative technique and instrumentation indicates that all three nails can be used safely and easily once experience is gained. Clinical outcome is similar regardless of the nail chosen.     

Subtrochanteric fractures treated with interlocking nailing

In a prospective study of 31 subtrochanteric fractures treated with Grosse-Kempf interlocking nails with a followup period of at least 1 year, there was a 87.1% (27/31) union rate, and a union period of 4.2 +/- 1.8 months. Knee range of motion in 28 acute traumatic cases was on average 127.5 +/- 23.0 degrees. The significant complications included: nail breakage, 3.2% (1/31); nonunion without nail breakage, 9.7% (3/31); neglected femoral fracture with malunion, 3.2% (1/31). The interlocking nailing has the advantages of: a) closed method, b) weight-sharing principle, c) shortening prevention, d) non-rigid fixation. From the theoretical and clinical comparison among the various implants, we conclude that closed interlocking nailing is one of the better instruments for subtrochanteric fracture treatment, and moreover, the most reasonable of all. However, for the higher level subtrochanteric fractures, reconstruction-style locking nails should be chosen.     

A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing

OBJECTIVES: Antegrade femoral intramedullary nailing through a greater trochanteric insertion site has been proposed for the treatment of subtrochanteric fractures. The currently available trochanteric nails have dissimilar characteristics, and the most appropriate insertion site for satisfactory subtrochanteric fracture alignment has not been determined. This study is an analysis of 5 different trochanteric femoral nails and 3 different insertion sites using a cadaveric model of a reverse obliquity subtrochanteric femur fracture to determine the optimal trochanteric entry site. SETTING: OSHA-approved cadaveric laboratory with an OEC 9800 (General Electric Company, Fairfield, CT) fluoroscopic C-arm. METHODS: Twenty-one embalmed human cadaveric femurs were stripped of soft tissues. Three different starting points on the anteroposterior radiograph were used: at the tip of the greater trochanter, and 2 to 3 mm medial and lateral to the tip. A reverse obliquity subtrochanteric fracture was created. The Trochanteric Antegrade Nail (TAN), Gamma nail (2nd and 3rd generations), Trochanteric Fixation Nail (TFN), and the Holland Nail were then inserted. The proximal bend and radius of curvature were calculated for each nail. Varus and valgus angulation as well as lateral gapping were measured on radiographs; also calculated were the mean, range, and standard deviation. Statistical analysis was performed on angulation and gapping at the fracture site by using Fisher least significant differences analysis, based on a 2-way ANOVA test. RESULTS: The Holland nail had a proximal bend of 10 degrees and a radius of 300 cm. TAN was 5 degrees and 350 cm, TFN was 6 degrees and 150 cm, Gamma 2 was 4 degrees and 300 cm, and Gamma 3 was 4 degrees and 200 cm. The tip starting point led to the most neutral alignment regardless of nail. The lateral starting point led to varus with all nails. The medial starting point led to valgus of >6 degrees with the Holland and TFN; Gamma and TAN had better alignment with <4 degrees of valgus. Gapping of the lateral cortex was greatest with a lateral starting point. CONCLUSIONS: An analysis of 5 trochanteric intramedullary nails with different proximal bends and 3 different starting points in the greater trochanter showed that the tip of the trochanter is close to the "universal" starting point. In this cadaveric subtrochanteric fracture model, the tip starting point led to the most neutral alignment regardless of nail used. The lateral starting point led to varus and gapping of the lateral cortex with all nails. CLINICAL RELEVANCE: Subtrochanteric fractures treated with a trochanteric antegrade nail should have an acceptable reduction before nail insertion. The tip of the trochanter, or even slightly medial, on anteroposterior fluoroscopy is recommended as the universal starting point for these nails. However, slight deviations from this point and nail geometry can cause fracture site malalignment. A lateral starting point led to varus alignment and should be avoided.     

Proximal screw failure with reconstruction nail fixation of a subtrochanteric fracture

. The Russell-Taylor intra-medullary nail provides a stable construct for the management of subtrochanteric femoral fractures. Implant failure with this system typically involves the distal locking screws. Proximal screw cut-out and back-out have been reported [2]. Breakage of both proximal locking screws has not previously been described. We present a case of failure of both proximal locking screws in a Russell-Taylor delta reconstruction nail implant. Résumé. L'enclouage centro-médullaire selon Russel-Taylor procure un montage stable pour le traitement des fractures sous-trochantériennes du femur. L'échec du montage est classiquement lié à un éventuel problème du verrouillage distal. Des fractures et des expulsions de la vis de verrouillage proximal ont également été décrites. Une fracture simultanée des deux vis de verrouillage proximales n'a par contre pas été décrite jusqu'à ce jour. Nous rapportons un cas.     

Subtrochanteric Femoral Fracture during Trochanteric Nailing for the Treatment of Femoral Shaft Fracture

We report on three cases of subtrochanteric femoral fractures during trochanteric intramedullary nailing for the treatment of femoral shaft fractures. Trochanteric intramedullary nails, which have a proximal lateral bend, are specifically designed for trochanteric insertion. When combined with the modified insertion technique, trochanteric intramedullary nails reduce iatrogenic fracture comminution and varus malalignment. We herein describe technical aspects of trochanteric intramedullary nailing for femoral shaft fractures to improve its application and prevent implant-derived complications.     

Should early weightbearing be allowed after intramedullary fixation of trochanteric femur fractures? A finite element study

BackgroundThis study aims to investigate the effects of early weightbearing after intramedullary fixation of trochanteric fractures.MethodsFemurs with different types of trochanteric fractures were modeled according to AO/OTA classification. Fractures were ideally reduced with one mm gap between fragments and fixed with intramedullary nails. Forces were applied simulating single- (Body weight: 60 kg, joint reaction force: 1999.2 N, abductor muscle force:1558.8 N) and double-leg standing positions (Joint reaction force: 196 N). In another model, a 500 Nm rotational force was applied as a simulation of a fall.ResultsA higher level of stress was determined at the calcar femorale, the fracture site, the holes for the lag screws, and the hole for the proximal locking screw on the nail, the threadless parts of the lag screws, and the mid-portion of the nail. During the single-leg stance, up to 3 mm displacement was observed with the reverse oblique type of fractures. In the simulation of the fall, 1.5 mm displacement occurred at the fracture site. No displacement was measured at stabile and type 31A2 fracture models. In addition, higher levels of stress were measured at the body of the nail (up to 133 MPa), proximal screws (up to 133 MPa) and at the bone distal to the nail (up to 84.3 MPa), but all values were under the limit of the yield stress of the bone and the titanium.ConclusionFull weightbearing after intramedullary fixation of trochanteric femur fractures may be allowed except in obese patients and patients with 31A3 type fractures according to the AO/OTA classification. The use of support is recommended in order to prevent complications. Implant removal can be discussed with patients after fracture union in order to prevent possible periprosthetic fractures.     

Management of subtrochanteric femoral fractures and metastases using long proximal femoral nail

We report our initial experience with a new reconstruction nail, the long proximal femoral nail (L.PFN), in the treatment of subtrochanteric femoral fractures and metastases. We performed 52 L.PFN in 49 patients over a period of 18 months with an average follow-up period of 47.7 weeks. Group I consisted of 24 patients, who had L.PFN for traumatic subtrochanteric femoral fractures. Group II consisted of 25 patients, who had L.PFN for femoral metastases and pathological fractures. (Three bilateral.) In nine patients in group I, the fracture was extending to the intertrochnateric region with involvement of the piriformis fossa. Eight patients in group I had open reduction and cerclage cabling of the fracture prior to L.PFN. All the traumatic fractures in group I had united with an average time to union of 19.4 weeks. In eight operations there were technical difficulties with the insertion of proximal locking screws. Five patients in our series had complications but we had no mechanical failures of the implant. L.PFN is a reliable implant for subtrochanteric femoral fractures and metastases. We also showed that open reduction and cerclage cabling of unstable subtrochanteric fractures prior to nailing was not detrimental to fracture healing in our series.     

The treatment of difficult proximal femoral fractures with the Russell-Taylor reconstruction nail

The outcome of 30 proximal femoral fractures and pathological lesions in 29 patients treated with the Russell-Taylor reconstruction nail are reported. Four patients had fractures involving both the femoral neck and shaft (segmental). Fifteen patients had extensive comminuted fractures of the proximal femur and ten patients underwent nailing because of pathological fractures (one bilateral). In nineteen operations there were technical difficulties, nail insertion and proximal interlocking being the commonest. In the elderly there was a high post-operative complication rate. Three nails needed to be revised for failure of fixation. On review, all patients under sixty years of age regained full mobility and returned to their pre-fracture level of activities. Patients with per-trochanteric fractures over the age of sixty had less favourable results. No cancer patient returned to their prefracture mobility level. The Russell-Taylor reconstruction nail proved to be useful in the treatment of segmented and, in a lesser degree, pathological fractures. However, the surgical technique is demanding and there is a high incidence of post-operative complications in the patients over the age of sixty.     

Russell-Taylor重建钉内固定治疗股骨干多节段骨折并同侧股骨颈骨折

目的 探讨使用Russell-Taylor股骨重建钉内固定治疗股骨干多节段骨折并同侧股骨颈骨折的临床疗效、手术要点和围手术期注意事项。方法 对1998年6月～2002年10月使用股骨重建钉静力固定治疗7例的疗效进行回顾性分析。手术采用闭合穿钉、小切口切开复位。结果 平均股骨颈骨折临床愈合时间5.2个月、股骨干骨折7.3个月,一期骨折愈合率达到71.4％(5/7),其中2例术后12、15个月远端骨折段骨延迟愈合改为动力固定,4～6个月后骨折愈合。无股骨头坏死征象。1例浅表感染。结论 股骨颈骨折强调不切开复位,并争取解剖复位;股骨干骨折则常规闭合穿钉、小切口复位、有限扩髓、静力固定。认为股骨重建钉是目前治疗股骨干多节段骨折并同侧股骨颈骨折的最佳方法。     

Biomechanical evaluation of internal fixation for the treatment of comminuted subtrochanteric femur fractures

BackgroundSeveral biomechanical studies on subtrochanteric femur fractures have reported that use of an intramedullary nail is superior to extramedullary implant. However, the optimal choice of intramedullary nail for the treatment of comminuted subtrochanteric femur fracture remains unclear. Here, we evaluated the biomechanical properties of comminuted subtrochanteric femur fracture treated with four different internal fixations.MethodsA comminuted subtrochanteric femur fracture model was created with a 2-cm gap below the lessor trochanter in 20 synthetic femurs. The fractures were fixed with one of four implants - Antegrade Femoral Nail (AFN), Trochanteric Fixation Nail Advanced with a femoral neck blade (TFNA blade), TFNA with a femoral neck screw (TFNA screw), and the reversed distal femoral locking compression plate (DF-LCP) - all manufactured by DePuy Synthes. Axial compression tests and torsion tests were performed and the stiffness of each implant was compared.ResultsFor compression, the TFNA blade, TFNA screw, and AFN provided significantly higher stiffness than DF-LCP (p < 0.001, p < 0.001, p = 0.001, respectively), and the TFNA blade provided significantly higher stiffness than AFN (p = 0.049). For torsion, there were no significant differences among the groups in internal rotation, while the TFNA screw had significantly lower torsional stiffness than the AFN, TFNA blade and DF-LCP in external rotation (p = 0.036, p = 0.034, p = 0.037, respectively).ConclusionsThese findings could help to provide biomechanical evidence regarding choice of implant for the treatment of comminuted subtrochanteric femur fracture. The TFNA blade may be more suitable for the treatment of comminuted subtrochanteric femur fracture.