Interlocking Nail

By

dr. Husna Dharma Putera, M.Si, SpOT(K)

AO / OTA

31
Factors Influencing Construct Strength:

Uncontrolled factors
Bone Quality
Fracture Geometry
Controlled factors
Quality of Reduction
Implant Placement
Implant Selection

Kaufer, CORR 1980

This lecture will examine each factor

Uncontrolled factor: Fracture geometry

“STABILITY”

The ability of the reduced fracture to

support physiologic loading

Fracture Stability relates not only to the # of

fragments but the fracture plane as well
Uncontrolled factor: Fracture geometry

Stable Unstable
Uncontrolled factor: Fracture geometry

AO/OTA31A3:
Uncontrolled factor: Bone quality

A 33 year old pt with intertrochanteric fracture following a fall from height-

Note the dense, cancellous bone throughout the proximal femur;
Not at all like a geriatric fracture
Surgeon controlled factor: Implant selection

What’s the big deal?

IM vs Plate
Fixation
 GAMMA
The First to Reach the
Market
Gamma Clinical Results
Advantages : ±
Complications : +++

Bridle JBJS(B) '91 Williams Injury '92

Boriani Orthopaedics '91 Leung JBJS(B) '92
Lindsey Trauma '91 Aune ActOrthopScan '94
Halder JBJS(B) '92
Surgeon controlled factor: Implant selection

Gamma Nail vs. CHS

1996 Meta-analysis of ten randomized trials

• Shaft fractures: Gamma 3 x CHS (p < 0.001)

• Required Re-ops: Gamma 2 x CHS (p < 0.01)

• IM fixation may be superior for inter/subtroch

extension & reverse obliquity fractures

• “ CHS is a forgiving implant when used by

inexperienced surgeons, the Gamma nail is not”

MJParker,
Parker, International Orthopaedics '96
Surgeon controlled factor: Implant selection

IM Fixation: Clinical Results

RCT, IMHS vs CHS, N = 135
• No difference for stable fxs

• Faster & less bloody for unstable fxs

• Fewer IM complications than Gamma

• Weaknesses:
No stratification of unstable fractures
Learning curve issues
No anatomic outcomes, wide functional outcomes

Baumgaertner, Curtin, Lindskog, CORR ‘98

Surgeon controlled factor: Implant selection

IM Fixation: Clinical Results

Well analyzed RCT, IMHS vs CHS, N = 100
• Longer surgery, less blood loss
• Improved post-op mobility
@ 1 & 3 months *
• Improved community ambulation
@ 6 & 12 months *
• 45% less sliding, LLD*

(* p < 0.05)
Hardy, et. al JBJS(A) ‘98
Surgeon controlled factor: Implant selection
IM
IMFixation:
Fixation:Mechanical
MechanicalAdvantages
Advantages

? !
The nail substitutes for the incompetent posteromedial cortex
31.A33 2 weeks 7 months

The nail substitutes for the incompetent lateral cortex

 CHS: Unique risk of failure
Palm, et al JBJS(A) ‘07

Iatrogenic, intraoperative lateral wall

fracture

31% risk in A2.2&3 fxs 22%

failure rate
(vs. 3% overall)

A2 to A3 fx!
Surgeon controlled factor: Implant selection
CHS Improvements: 1975-2010
Trochanteric Stabilizing Plate (TSP)
plate adjunct to limit shaft medialization

major (≥20mm screw

slide) collapse

op time, blood loss

? complications,
length of rehab
Madsen, JOT '98

Su, Trauma ‘03

Bong, Trauma ‘04
Surgeon controlled factor: Implant selection

IM Fixation: Best Indications

Reverse Oblique
Fractures

Intertroch +
subtrochanteric
fractures
Surgeon controlled factor: Implant selection

Reverse Oblique Fractures

Retrospective review of 49 consecutive R/ob. fractures
@ Mayo: overall 30% failure rate
• Poor Implant Position: 80% failure
• Implant Type:
Compression Hip Screw: 56% failure (9/16)
95° blade / DCS: 20% failure
(5/25)
IMHipScrew: 0% failure (0/3)

Haidukewych, JBJS(A) 2001

Recovery room control X-ray shows loss of medial
support, but nail prevents excessive collapse
Reduction Aids
CHS

31
AO / OTA
Surgeon controlled factor: Implant selection

IM Fixation vs. CHS

Randomized/prospective trial of 210 pts.
Utrilla, et al. JOT 4/05
Results
• Skin to skin time unchanged
• Fewer blood transfusions needed with IM
• Better walking ability in Unstable fractures with IM
• No shaft fxs
• Fewer re-ops needed in IM group (1 vs 4)
Conclusion
• IM fixation or CHS for stable fxs
• Unlocked IM for most Unstable fxs
Surgeon controlled factor: Implant selection

IM Hip Screw: Contraindications

• young patients (excess bone removal)

• basal neck fxs (iatrogenic displacement)
• stable fractures requiring open reduction
(inefficient)
• stable fractures with very narrow canals
(inefficient)
Technical
Tips
 Patient Set-up
Position for nailing:
Hip Adducted
●

●Unobstructed AP &

lateral imaging
●Fracture Reduced(?)

Strong traction (without well leg countertraction) abducts fractured hip

and prevents gaining proper entrance site
Strong traction (without well leg countertraction) abducts fractured hip
and prevents gaining proper entrance site
The solution is the “Scissors position”
for the extremities
•Both feet in txn
•Fx: flexed & add
•Well leg extended &
abducted
• Lateral Xray: a little
different, but adequate
Guide Pin Insertion
 Guide Pin Insertion (Usually by hand…)

Ostrum, JOT 05: The entrance is at the

trochanteric tip or slightly MEDIAL
 Ream a channel for implant!

(don’t just displace the fracture as you pass

reamer through it)

Medial directed force prevents fracture gapping during

entrance reaming
Achieve a Neck-Shaft Axis > 130°

Use at least a 130° nail

Varus Corrections
Advance nail
✓

✓Increase traction

✓ABDUCT extremity!! (adduction

only necessary at time

of nail insertion)
Which nail design is best ??

Proximal diameter?
Nail Length?
Distal interlocking?

Proximal screw ?
Sleeve or no sleeve?
Loch & Kyle, JBJS(A)‘98

One or two needed ?

Nobody knows!
Small Screws protect
lateral wall
Gotfried, CORR ‘04
Im, JOT ‘05
Only relevant for plate fixation?
 Small Screws protect
lateral wall from fx
Gotfried, CORR ‘04
Im, JOT ‘05

Only relevant for plate fixation?

But… the “Z effect”

• 7/70, 10% Werner-Tutschku, Unfall ’02
• 5/45 11% Tyllianakis Acta Orthop Belgica ‘04
Long vs.short nails?
Thigh pain from short, loc
nails?
Periprosthetic fracture: S
issue?
Anterior cortex perforation w
long nails?
6% impinge/ 2% fx Robinson,
JBJS(A) 05
Cost/ benefit?

-Nobody knows-
 Conclusions:
Remember Kaufer’s Variables

Uncontrolled factors
Fracture Geometry
Bone Quality
Surgeon controlled factors
Quality of Reduction
Implant Placement
Implant Selection
Conclusions:

Implants have different

traits-choose wisely

Position screw
centrally and
very deep
(TAD≤20mm)
Thank You