Treatment of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

TENG Lin ¹ , XIAO Yongchuan ¹ ,  ZHONG Gang ²

1. Department of Orthopedics, the First People’s Hospital in Shuangliu District/West China Airport Hospital, Sichuan University, Chengdu Sichuan, 610200, P.R.China;
2. Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

ZHONG Gang, Email: zg730927@163.com

Keywords：

Intertrochanteric fracture; intramedullary nail; refracture; stress concentration

DOI：

10.7507/1002-1892.202010011

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Objective To investigate the occurrence, treatment, and effectiveness of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures.Methods The clinical data of 16 patients with peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures who met the inclusion criteria between April 2014 and November 2019 were retrospectively analyzed. There were 7 males and 9 females with an average age of 78.4 years (range, 65-93 years). The 14 cases of initial intertrochanteric fractures were classified according to the classification of AO/Orthopaedic Trauma Association (AO/OTA): 5 cases of type A1, 7 cases of type A2, and 2 cases of type A3; the other 2 cases were intertrochanteric combined with subtrochanteric fractures (Seinsheimer type Ⅴ). According to the classification of peri-implant refracture which was proposed by Chan et al., there were 10 cases of type 1 (6 cases of type 1A, 3 cases of type 1B, 1 case of type 1C) and 6 cases of type 2 (4 cases of type 2A and 2 cases of type 2B). The average interval between refracture and initial surgery was 14.6 months (range, 1-52 months). The incidence of peri-implant refracture in short nail group (the length of intramedullary nail used in initial surgery≤240 mm) was 1.92% (11/573), while the incidence of long nail group (the length of intramedullary nail used in initial surgery≥340 mm) was 1.66% (5/301), showing no significant difference between the two groups (χ²=0.073, P=0.786). The peri-implant refractures were revised with extended intramedullary nail (5 cases) or fixed with additional limited invasive stabilization system (11 cases).Results The average operation time was 115.8 minutes (range, 78-168 minutes) and the average intraoperative blood loss was 283.1 mL (range, 120-500 mL). One patient died of myocardial infarction at 3 months after operation, and the other 15 patients were followed up 9-46 months (mean, 16.8 months). The peri-implant refractures healed at 14-20 weeks (mean, 16.4 weeks) after operation. There was no complications such as incision infection, nonunion, internal fixator loosening and rupture, screw cutting-out, and the second refracture during the follow-up. At last follow-up, all injured limbs regained walking function, and the Hospital for Special Surgery (HSS) score was 56-92 (mean, 80.2). The results were classified as excellent in 2 cases, good in 10, fair in 2, and poor in 1, with the excellent and good rate of 80%.Conclusion Stress concentration at the tip of initial intramedullary nail and distal interlocking screw aera is the main cause of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures. Revision with extended intramedullary nail or fixation with limited invasive stabilization system according to the length of initial intramedullary nail and the type of refracture can get satisfactory effectiveness.

Citation： TENG Lin, XIAO Yongchuan, ZHONG Gang. Treatment of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(3): 312-317. doi: 10.7507/1002-1892.202010011 Copy

1.	Lee SH, Chen IJ, Li YH, et al. Incidence of second hip fractures and associated mortality in Taiwan: A nationwide population-based study of 95, 484 patients during 2006-2010. Acta Orthop Traumatol Turc, 2016, 50(4): 437-442.
2.	杨明辉, 朱仕文, 李庭, 等. 老年股骨转子间骨折诊疗指南. 中华创伤骨科杂志, 2020, 22(2): 93-99.
3.	Arslan A, Utkan A, Koca TT. Results of a compression pin alongwith trochanteric external fixation in management of high risk elderly intertrochanteric fractures. Indian J Orthop, 2016, 50(6): 636-640.
4.	Anglen JO, Weinstein JN. American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg (Am), 2008, 90(4): 700-707.
5.	张雨, 杨旭辉, 曾秋铭. 长型和短型髓内钉用于不稳定转子间骨折疗效比较的 meta 分析. 重庆医学, 2020, 49(14): 2390-2395, 2403.
6.	Roberts KC, Brox WT, Jevsevar DS, et al. Management of hip fractures in the elderly. J Am Acad Orthop Surg, 2015, 23(2): 131-137.
7.	Matre K, Havelin LI, Gjertsen JE, et al. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury, 2013, 44(6): 735-742.
8.	Yu X, Wang H, Duan X, et al. Intramedullary versus extramedullary internal fixation for unstable intertrochanteric fracture, a meta-analysis. Acta Orthop Traumatol Turc, 2018, 52(4): 299-307.
9.	Müller F, Galler M, Zellner M, et al. Peri-implant femoral fractures: The risk is more than three times higher within PFN compared with DHS. Injury, 2016, 47(10): 2189-2194.
10.	Daner WE, Owen JR, Wayne JS, et al. Biomechanical evaluation of the risk of secondary fracture around short versus long cephalomedullary nails. Eur J Orthop Surg Traumatol, 2017, 27(8): 1103-1108.
11.	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(6): 706-711.
12.	Boone C, Carlberg KN, Koueiter DM, et al. Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2). J Orthop Trauma, 2014, 28(5): e96-e100.96-100.
13.	Kleweno C, Morgan J, Redshaw J, et al. Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years. J Orthop Trauma, 2014, 28(7): 391-397.
14.	Lindvall E, Ghaffar S, Martirosian A, et al. Short versus long intramedullary nails in the treatment of pertrochanteric hip fractures: Incidence of ipsilateral fractures and costs associated with each implant. J Orthop Trauma, 2016, 30(3): 119-124.
15.	Dunn J, Kusnezov N, Bader J, et al. Long versus short cephalomedullary nail for trochanteric femur fractures (OTA 31-A1, A2 and A3): a systematic review. J Orthop Traumatol, 2016, 17(4): 361-367.
16.	Chan LWM, Gardner AW, Wong MK, et al. Non-prosthetic peri-implant fractures: classification, management and outcomes. Arch Orthop Trauma Surg, 2018, 138(6): 791-802.
17.	Insall JN, Ranawat CS, Aglietti P, et al. A comparison of four models of total knee-replacement prostheses. J Bone Joint Surg (Am), 1976, 58(6): 754-765.
18.	Pagnani MJ, Lyden JP. Postoperative femoral fracture after intramedullary fixation with a Gamma nail: case report and review of the literature. J Trauma, 1994, 37(1): 133-137.
19.	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(2): 330-334.
20.	Socci AR, Casemyr NE, Leslie MP, et al. Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations. Bone Joint J, 2017, 99-B(1): 128-133.
21.	Osnes EK, Lofthus CM, Falch JA, et al. More postoperative femoral fractures with the Gamma nail than the sliding screw plate in the treatment of trochanteric fractures. Acta Orthop Scand, 2001, 72(3): 252-256.
22.	Wang CJ, Brown CJ, Yettram AL, et al. Intramedullary nails: some design features of the distal end. Med Eng Phys, 2003, 25(9): 789-794.
23.	Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect, 1995, 44: 293-304.
24.	Dhar SA, Halwai MA, Wani MI, et al. Operative management of a subtrochanteric fracture in severe osteoporosis. A case report. Cases J, 2008, 1(1): 193.
25.	Ruchholtz S, El-Zayat B, Kreslo D, et al. Less invasive polyaxial locking plate fixation in periprosthetic and peri-implant fractures of the femur—a prospective study of 41 patients. Injury, 2013, 44(2): 239-248.
26.	陈挺, 田立杰, 汤欣. LISS 治疗股骨近端骨折术后髓内钉远端再骨折. 实用骨科杂志, 2017, 23(8): 736-738.
27.	Kim HK, Noh KC, Chung KJ, et al. Use of Huckstep nail in the periimplant femoral shaft fracture. Indian J Orthop, 2012, 46(6): 718-720.
28.	Perren SM, Fernandez Dell’Oca A, Lenz M, et al. Cerclage, evolution and potential of a Cinderella technology. An overview with reference to periprosthetic fractures. Acta Chir Orthop Traumatol Cech, 2011, 78(3): 190-199.
29.	Apivatthakakul T, Phornphutkul C, Bunmaprasert T, et al. Percutaneous cerclage wiring and minimally invasive plate osteosynthesis (MIPO): a percutaneous reduction technique in the treatment of Vancouver type B1 periprosthetic femoral shaft fractures. Arch Orthop Trauma Surg, 2012, 132(6): 813-822.

1. Lee SH, Chen IJ, Li YH, et al. Incidence of second hip fractures and associated mortality in Taiwan: A nationwide population-based study of 95, 484 patients during 2006-2010. Acta Orthop Traumatol Turc, 2016, 50(4): 437-442.
2. 杨明辉, 朱仕文, 李庭, 等. 老年股骨转子间骨折诊疗指南. 中华创伤骨科杂志, 2020, 22(2): 93-99.
3. Arslan A, Utkan A, Koca TT. Results of a compression pin alongwith trochanteric external fixation in management of high risk elderly intertrochanteric fractures. Indian J Orthop, 2016, 50(6): 636-640.
4. Anglen JO, Weinstein JN. American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg (Am), 2008, 90(4): 700-707.
5. 张雨, 杨旭辉, 曾秋铭. 长型和短型髓内钉用于不稳定转子间骨折疗效比较的 meta 分析. 重庆医学, 2020, 49(14): 2390-2395, 2403.
6. Roberts KC, Brox WT, Jevsevar DS, et al. Management of hip fractures in the elderly. J Am Acad Orthop Surg, 2015, 23(2): 131-137.
7. Matre K, Havelin LI, Gjertsen JE, et al. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury, 2013, 44(6): 735-742.
8. Yu X, Wang H, Duan X, et al. Intramedullary versus extramedullary internal fixation for unstable intertrochanteric fracture, a meta-analysis. Acta Orthop Traumatol Turc, 2018, 52(4): 299-307.
9. Müller F, Galler M, Zellner M, et al. Peri-implant femoral fractures: The risk is more than three times higher within PFN compared with DHS. Injury, 2016, 47(10): 2189-2194.
10. Daner WE, Owen JR, Wayne JS, et al. Biomechanical evaluation of the risk of secondary fracture around short versus long cephalomedullary nails. Eur J Orthop Surg Traumatol, 2017, 27(8): 1103-1108.
11. 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(6): 706-711.
12. Boone C, Carlberg KN, Koueiter DM, et al. Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2). J Orthop Trauma, 2014, 28(5): e96-e100.96-100.
13. Kleweno C, Morgan J, Redshaw J, et al. Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years. J Orthop Trauma, 2014, 28(7): 391-397.
14. Lindvall E, Ghaffar S, Martirosian A, et al. Short versus long intramedullary nails in the treatment of pertrochanteric hip fractures: Incidence of ipsilateral fractures and costs associated with each implant. J Orthop Trauma, 2016, 30(3): 119-124.
15. Dunn J, Kusnezov N, Bader J, et al. Long versus short cephalomedullary nail for trochanteric femur fractures (OTA 31-A1, A2 and A3): a systematic review. J Orthop Traumatol, 2016, 17(4): 361-367.
16. Chan LWM, Gardner AW, Wong MK, et al. Non-prosthetic peri-implant fractures: classification, management and outcomes. Arch Orthop Trauma Surg, 2018, 138(6): 791-802.
17. Insall JN, Ranawat CS, Aglietti P, et al. A comparison of four models of total knee-replacement prostheses. J Bone Joint Surg (Am), 1976, 58(6): 754-765.
18. Pagnani MJ, Lyden JP. Postoperative femoral fracture after intramedullary fixation with a Gamma nail: case report and review of the literature. J Trauma, 1994, 37(1): 133-137.
19. 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(2): 330-334.
20. Socci AR, Casemyr NE, Leslie MP, et al. Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations. Bone Joint J, 2017, 99-B(1): 128-133.
21. Osnes EK, Lofthus CM, Falch JA, et al. More postoperative femoral fractures with the Gamma nail than the sliding screw plate in the treatment of trochanteric fractures. Acta Orthop Scand, 2001, 72(3): 252-256.
22. Wang CJ, Brown CJ, Yettram AL, et al. Intramedullary nails: some design features of the distal end. Med Eng Phys, 2003, 25(9): 789-794.
23. Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect, 1995, 44: 293-304.
24. Dhar SA, Halwai MA, Wani MI, et al. Operative management of a subtrochanteric fracture in severe osteoporosis. A case report. Cases J, 2008, 1(1): 193.
25. Ruchholtz S, El-Zayat B, Kreslo D, et al. Less invasive polyaxial locking plate fixation in periprosthetic and peri-implant fractures of the femur—a prospective study of 41 patients. Injury, 2013, 44(2): 239-248.
26. 陈挺, 田立杰, 汤欣. LISS 治疗股骨近端骨折术后髓内钉远端再骨折. 实用骨科杂志, 2017, 23(8): 736-738.
27. Kim HK, Noh KC, Chung KJ, et al. Use of Huckstep nail in the periimplant femoral shaft fracture. Indian J Orthop, 2012, 46(6): 718-720.
28. Perren SM, Fernandez Dell’Oca A, Lenz M, et al. Cerclage, evolution and potential of a Cinderella technology. An overview with reference to periprosthetic fractures. Acta Chir Orthop Traumatol Cech, 2011, 78(3): 190-199.
29. Apivatthakakul T, Phornphutkul C, Bunmaprasert T, et al. Percutaneous cerclage wiring and minimally invasive plate osteosynthesis (MIPO): a percutaneous reduction technique in the treatment of Vancouver type B1 periprosthetic femoral shaft fractures. Arch Orthop Trauma Surg, 2012, 132(6): 813-822.

Chinese Journal of Reparative and Reconstructive Surgery

Treatment of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures

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