Fatigue failure of the cephalomedullary nail: revision options, outcomes and review of the literature

  • Adam Tucker
  • Michael Warnock
  • Sinead McDonald
  • Laurence Cusick
  • Andrew P. Foster
Up-to date Review and Case Report • HIP - FRACTURES
  • 278 Downloads

Abstract

Cephalomedullary nail (CMN) failure is a rare entity following hip fracture treatment. However, it poses significant challenges for revision surgery, both mechanically and biologically. Nail failure rates have been reported at < 2%; however, no published studies have reported revision surgery procedures and their respective outcomes. We present a regional experience, with outcomes, of the revision options. We identified 20 fatigued CMNs that underwent four different revision procedures. Mean age was 73 ± 15.24 years, with a 3:1 female preponderance, and a median ASA grade of 3. Post-operative CMN radiographs demonstrated a significant number of fractures were fixed in varus, with reductions in neck-shaft angles post-operatively. A “poor” quality of reduction resulted in significantly earlier nail failure, compared to “adequate” and “good” (p = 0.027). Tip-Apex Distance (TAD) mean was 23.2 ± 8.3 mm, and an adequate TAD with three-point fixation was seen in only 35% of cases. Mean time to failure was 401.0 ± 237.2 days, with mean age at failure of 74.0 ± 14.8 years. Options after failure included revision CMN nail, proximal femoral locking plate (PFLP), long-stem or restoration arthroplasty, or femoral endoprosthesis. Barthel Functional Index scores showed no significant difference at 3 and 12 months post-operatively, nor any difference between treatment groups. Mean 12-month mortality was 30%, akin to a primary hip fracture mortality risk according to NICE guidelines. Mortality rates were lowest in revision nails. Subsequent revision rates were higher in the PFLP group. There is no reported evidence on the best surgical technique for managing the failed CMN, with no clear functional benefit in the options above. Good surgical technique at the time of primary CMN surgery is critical in minimising fatigue failure. After revision, overall mortality rates were equivalent to reported primary hip fracture mortality rates. Further multicentre evaluations are required to assess which technique convey the best functional outcomes without compromising 12-month mortality rates.

Keywords

Hip Fracture Cephalomedullary nail Fatigue failure Revision 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

References

  1. 1.
    Anglen JO, Weinstein JN (2008) Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice: a review of the American Board of orthopaedic surgery database. JBJA(Am) 90:700–707Google Scholar
  2. 2.
    Giannoudis PV, Ahmad MA, Mineo GV, Tosounidis TI, Calori GM, Kanakaris NK (2013) Subtrochanteric fracture non-unions with implant failure manaed with the “Diamond” concept. Injury 44(S1):S76–S81CrossRefPubMedGoogle Scholar
  3. 3.
    Baumgartner MR, Curtin SL, Lindskog DM, Keggi JM (1995) The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. JBJS(Am) 77:1058–1064CrossRefGoogle Scholar
  4. 4.
    Abram SG, Pollard TC, Andrade AJ (2013) Inadequate ‘three-point’ proximal fixation predicts failure of the gamma nail. BJJ 95-B(6):625–630Google Scholar
  5. 5.
    Koval KJ, Aharonoff GB, Rokito AS, Lyon T, Zuckerman JD (1996) Patients with femoral neck and intertrochanteric fractures; are they the same? Clin Orthop 330:166–172CrossRefGoogle Scholar
  6. 6.
    Yli-Kyyny TT, Sund P, Juntunen M, Salo JJ, Kroger HP (2012) Extra- and intra-medullary imaplnts for the treatment of pertrochanteric fractures- results from a Finnish National Database Study of 14,915 patients. Injury 43:2156–2160CrossRefPubMedGoogle Scholar
  7. 7.
    Nikolaou VS, Papathanasopoulos A, Giannoudis PV (2008) Whats new in the management of proximal femoral fractures. Injury 39(12):1309–1318CrossRefPubMedGoogle Scholar
  8. 8.
    Calebi L, Can M, Muralti HH, Yagmurlu MF, Yuksei HY, Bicimoglu A (2006) Indirect reduction and biological internal fixation of comminuted subtrochanteric fractures of the femur. Injury 37:740–750CrossRefGoogle Scholar
  9. 9.
    Lindskog DM, Baumgaetner MR (2004) Unstable interochanteric hip fractures in the elderly. J Am Acad Ortho Surg 12(3):179–190CrossRefGoogle Scholar
  10. 10.
    Zain Elabdien BS, Olerud S, Karlstorm G (1984) The influence of age on the morphology of trochanteric fracture. Arch Orthop Trauma Surg 103:156–161CrossRefPubMedGoogle Scholar
  11. 11.
    Pervez H, Parker MJ (2001) Results of the long gamma nail for complex proximal femoral fractures. Injury 32:704–707CrossRefPubMedGoogle Scholar
  12. 12.
    Valverde JA, Alonso MG, Porro JG et al (1998) Use of the gamma nail in the treatment of fractures of the proximal femur. Clin Orthop Relat Res 350:56–61CrossRefGoogle Scholar
  13. 13.
    Leung KS, So WS, Shen WY, Hui PW (1992) Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br 74:345–351CrossRefPubMedGoogle Scholar
  14. 14.
    Radford PJ, Needoff M, Webb JK (1993) A prospective randomized comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br 75:789–793CrossRefPubMedGoogle Scholar
  15. 15.
    De Vries JS, Kloen P, Borens O, Marti RK, Helfet DL (2006) Treatment of subtrochanteric nonunions. Injury 37:203–211. doi: 10.1016/j.injury.2005.09.017 CrossRefPubMedGoogle Scholar
  16. 16.
    Reindl R, Harvey EJ, Berry GK, Rahme E (2015) Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures; a prospective randomized control trial. JBJS(Am) 97:1905–1912CrossRefGoogle Scholar
  17. 17.
    Maes M, Deboer Y, Brabants K (2012) Failure of the titanium trochanteric gamma nail in united femoral fractures. Acta Orthop Belg 78:552–557PubMedGoogle Scholar
  18. 18.
    Bojan AJ, Beimel C, Speitling A, Taglang G, Ekholm C, Jonsson A (2010) 3066 consecutive gamma nails: 12 years experience at a single centre. BMC Musculoskelet Disord 11:133CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Rybicki EF, Simonen FA, Weiss EK Jr (1972) On the mathematical analysis of stress in the human femur. J Biomech 5:203–215CrossRefPubMedGoogle Scholar
  20. 20.
    Fielding JW, Cochran GV, Zickel RE (1974) Biomechanical characteristics and surgical management of subtrochanteric fractures. Clin Orthop North Am 5:629–650Google Scholar
  21. 21.
    Gaebler C, Stanzl-Tschegg S, Tschegg EK, Kula C, Menth-Chiari WA, Wozasek GE et al (1999) Implant failure of the gamma nail. Injury 30(2):91–99CrossRefPubMedGoogle Scholar
  22. 22.
    Sitthiseripratip K, Van Oosterwyck H, Vander Stolen J, Mahaisavariya B, Bohez ELJ, Suwanprateeb J, Van Audekercke R, Oris P (2003) Finite element study of trochanteric gamma nail for trochanteric fracture. Med Eng Phys 25(2):99–106CrossRefPubMedGoogle Scholar
  23. 23.
    Seral B, Garcia JM, Cegonino J, Doblare M, Seral F (2004) Finite element study of intramedullary osteosynthesis in the treatment of trochanteric fractures of the hip: gamma and PFN. Injury 35(2):130–135CrossRefPubMedGoogle Scholar
  24. 24.
    Kasimatis GB, Lambiris E, Tyllianakis M, Giannikas D (2007) Gamma nail breakage: a report of four cases. J Ortho Surg 15(3):368–372CrossRefGoogle Scholar
  25. 25.
    Georgiannos D, Lampridis V, Bisbinas I (2014) Complications following treatment of trochanteric fractures with the Gamma3 nail: is the latest version of gamma nail superior to its predecessor? Surg Res Pract. doi: 10.1155/2014/143598 PubMedPubMedCentralGoogle Scholar
  26. 26.
    Alvarez DB, Paz Aparicio J, Lopez-Anglada Fernandez E, Congazlez-Busto Mugica I, Nunez Batalla D, Paz Jimenez J (2004) Implant breakage, a rare complication with the Gamma nail: a review of 843 fractures of the proximal femur treated with a Gamma nail. Acta Orthop Belg 70(5):435–443PubMedGoogle Scholar
  27. 27.
    Zafiropoulos G, Pratt DJ (1994) Fractured gamma nail. Injury 25(5):331–336CrossRefPubMedGoogle Scholar
  28. 28.
    Iwakura T, Niikura T, Lee SY, Sakai Y, Nishida K, Kuroda R, Kurosaka M (2013) Breakage of a third generation gamma nail: a case report and review of the literature. Case Rep Orthop. doi: 10.1155/2013/172352 PubMedPubMedCentralGoogle Scholar
  29. 29.
    Randle JA, Meisami-Fard B, McKee MD (1999) Mechanical failure of a gamma nail in a patient with an impending pathological subtrochanteric fracture. Can J Surg 42(5):384–386PubMedPubMedCentralGoogle Scholar
  30. 30.
    Haidukewych GJ, Berry DJ (2004) Nonunion of fractures of the subtrochanteric region of the femur. CORR 419:185–188CrossRefGoogle Scholar
  31. 31.
    Boriani S, De Iure F, Bettelli G, Specchia L, Bungaro P, Montanari G et al (1994) The result of a multi-center Italian study on the use of the gamma nail for the treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases. Chir Organi Mov 79(2):193–203PubMedGoogle Scholar
  32. 32.
    Van Doorn R, Stapert JWJL (2000) Treatment of impending and actual pathological femoral fractures with the long Gamma nail in the Netherlands. Eur J Surg 166(3):247–254CrossRefPubMedGoogle Scholar
  33. 33.
    Docquier PL, Manche E, Autrique JC, Geulette B (2002) Complications associated with gamma nailing: a review of 439 cases. Acta Orthop Belg 68(3):251–257PubMedGoogle Scholar
  34. 34.
    Sehat K, Baker RP, Pattison G, Price R, Harries WJ, Chesser TJS (2005) The use of the long gamma nail in proximal femoral fractures. Injury 36(11):1350–1354CrossRefPubMedGoogle Scholar
  35. 35.
    Tzioupis C, Panteliadis P, Gamie Z, Tsiridis E (2011) Revision of a nonunited subtrochanteric femoral fracture around a failed intramedullary nail with the use of RIA products, BMP-7 and hydroxyapatite: a case report. J Med Case Rep 5:87CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Wee JLH, Sathappan SS, Yeo MSW, Low YP (2009) Management of gamma nail breakage with a bipolar hemi-arthroplasty. Singapore Med J 50(1):e44PubMedGoogle Scholar
  37. 37.
    Chen T, Li K, Wang X, Lan H, Zhang J (2010) Revsion cause and effect of gamma nail fixation (Abstract only-Original article in Chinese). Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 24(1):78–81PubMedGoogle Scholar
  38. 38.
    Hernigou P, Poignard A, Mathieu G, Cohen G, Manicom O, Filippini P (2006) Total hip arthroplasty after failure of per- and subtrochanteric fracture fixation in elderly subjects (Abstract only). Rev Chir Orthop Reparatrice Appar Mot 92(4):310–315CrossRefPubMedGoogle Scholar
  39. 39.
    Johnson B, Stevenson J, Chamma R, Patel A, Rhee SJ, Level C, Starks I, Roberts PJ (2014) Short-term follow-up of pertrochanteric fractures treated using the proximal femoral locking plate. J Orthop Trauma 28:283–287CrossRefPubMedGoogle Scholar
  40. 40.
    Forward DP, Doro CJ, O’Toole RV, Kim H, Floyd JCP, Sciadini MF, Turen CH, Hsieh AH, Nascone JW (2012) A biomechanical comparison of a locking plate, a nail and a 95 angled blade plate for fixation of subtrochanteric femoral fractures. J Orthop Trauma 26:334–340CrossRefPubMedGoogle Scholar
  41. 41.
    Ozkan K, Turkmen I, Sahin A, Yildiz Y, Erturk S, Soylemez MS (2015) Biomechanical comparison of proximal femoral nails and locking proximal anatomic femoral plates in femoral fracture fixation. Indian J Orthop 49(3):347–351CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA (1996) Complications of iliac crest bone graft harvesting. Clin Orthop Relat Res 329:300–309CrossRefGoogle Scholar
  43. 43.
    Kovar FM, Wozasek GE (2011) Bone graft harvesting using RIA system- A quantative assessment. Central Eur J Med 123:285. doi: 10.1007/s00508-011-1565-8 Google Scholar
  44. 44.
    Friedlaender GE, Perry CR, Cole JD, Cook SD, Cierny G, Muschler GF, Zych GA, Calhoun JH, LaForte AJ, Yin S (2001) Osteogenic protein-1 (bone morphogenic protein-7) in the treatment of tibial nonunions. JBJS 83-A(Supp 1 part II):S151–S158Google Scholar
  45. 45.
    Conway JD, Shabtai L, Bauernschub A, Specht SC (2014) BMP-7 versus BMP-2 for the treatment of long bone nonunion. Orthopaedics 37(12):e1049–e1057CrossRefGoogle Scholar
  46. 46.
    Swanson EA, Garrard EC, Bernstein DT, O’Connor DP, Brinker MR (2015) Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions. J Orthop Trauma 29:21–27CrossRefPubMedGoogle Scholar
  47. 47.
    Brinker MR, O’Connor DP, Monla YT, Earthman TP (2007) Metabolic and endocrine abnormalities in patients with nonunions. J Orthop Trauma 21:557–570CrossRefPubMedGoogle Scholar
  48. 48.
    Haidukewych GJ, Berry DJ (2003) Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. JBJS(Am) 85(5):899–904CrossRefGoogle Scholar
  49. 49.
    Stappaerts KH, Deldycke J, Broos PL, Saes FF, ROmmens PM, Claes P (1995) Treatment of unstable peritrochanteric fractures in elderly patients with a compression hip screw or with the Vandeputte (VDP) endoprosthesis: a prospective randomized study. J Orthop Trauma 9(4):292–297CrossRefPubMedGoogle Scholar
  50. 50.
    Haentjens P, Lamraski G (2005) Endoprosthetic replacement of unstable, comminuted intertrochanteric fractures of the femur in the elderly, osteoprotic patient: a review. Disabil Rehabil 27(18–19):1167–1180CrossRefPubMedGoogle Scholar
  51. 51.
    El-Ghandour SM (2014) Endoprosthetic replacement for failed internally fixed intertrochanteric hip fractures. EJO 49(1):61–68Google Scholar
  52. 52.
    Chandrasekar CR, Grimer RJ, Carter SR, Tillman RM, Abudu AT (2008) Modular endoprosthetic replacement for metastatic tumours of the proximal femur. J Orthop Surg Res 3:50CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Harvey N, Ahlmann ER, Allison DC, Wang L, Menendez LR (2012) Endoprostheses last longer than intramedullary devices in proximal femur metastases. CORR 470(3):684–691CrossRefGoogle Scholar
  54. 54.
    Calabro T, Van Rooyen R, Piraino I et al (2016) Reconstruction of the proximal femur with a modular resection prosthesis. Eur J Orthop Surg Traumatol 26(4):415–421CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France SAS 2017

Authors and Affiliations

  • Adam Tucker
    • 1
  • Michael Warnock
    • 1
  • Sinead McDonald
    • 2
  • Laurence Cusick
    • 3
  • Andrew P. Foster
    • 1
  1. 1.Altnagelvin Area HospitalLondonderryNorthern Ireland, UK
  2. 2.Fracture Outcomes and Research DepartmentRoyal Victoria HospitalBelfastNorthern Ireland, UK
  3. 3.Royal Victoria HospitalBelfastNorthern Ireland, UK

Personalised recommendations