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ABSTRACT: Background: Reviewing patients operatively stabilized following proximal femoral fractures we found several factors that lead to significant
complications. We conducted this survey of proximal femoral fractures stabilized with the implants which were used most frequently.
Purpose was to work out causes and indications to remove implants which were solely employed to stabilize proximal femoral
fractures.
Methods: The indication for using a Dynamic Hip Screw® (DHS) were fractures AO-Class. 31-B or 31-Al. A Gamma Locking Nail® (GN) was
applied in unstable or comminuted trochanteric fractures. We retrospectively analysed 2553 patients who received either a
DHS or a GN within seven years.
Results: Removal of the implants was indicated in 3.2 % mostly due to complications. Most frequent “modes of complication” that lead
to the removal of one of the implants were avascular necrosis (AVN) of the femoral head (24 %), patients request (20 %) and
ipsilateral shaft fractures (17 %).
Conclusions: Referring to the results absolute indications to remove an implant are AVN, deep chronic infections, shaft fractures and
when “cutting out” appears.
Grundlagen: Aufgrund der steigenden Inzidenz proximaler Femurfrakturen gewinnen auch die spezifischen Komplikationen dieser meist operativ
stabilisierten Verletzungen an Bedeutung. Daher haben wir die Ergebnisse der am häufigsten angewandten Implantate retrospektiv
analysiert. Ziel der Studie war es, Ursachen und Indikationen für die operative Entfernung des Osteosynthesematerials zu evaluieren.
Methodik: Indikationen waren proximale Femurfrakturen entsprechend der AO-Klassifikation 31-B oder 31-Al. Die dynamische Hüftschraube
(Dynamic Hip Screw®) wurde bei stabilen, der Gammanagel (Gamma Locking Nail®) bei instabilen Frakturen angewandt. Wir analysierten
die Ergebnisse von 2553 Patienten aus einem Zeitraum von 7 Jahren.
Ergebnisse: Die komplikationsbedingte Materialentfernung war in 3,2 % der Fälle indiziert. Die häufigsten Ursachen waren die avaskuläre
Femurkopfnekrose (24 %), der Patientenwunsch aufgrund subjektiver Beschwerden (20 %) und die ipsilaterale Schaftfraktur (17
%).
Schlußfolgerungen: Bezogen auf die Resultate sehen wir die Operationsindikation zur Implantatentfernung bei avaskulärer Nekrose, tiefer Infektion,
Femurschaftfrakturen und beim sogenannten kranialen Durchschneiden der Hüftschraube.
European Surgery 04/2012; 32(4):196-198. · 0.28 Impact Factor
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ABSTRACT: Isolated meniscus tears with consecutive complete luxation of the meniscus are an exceptional injury especially in children. We report a case of an 11-year-old girl with a complete luxation of the lateral meniscus, injured by a jump from low height. Following clinical examination and magnetic resonance imaging, a surgical refixation of the entire lateral meniscus was performed. Short-time clinical and radiological follow-up was conducted.
Knee Surgery Sports Traumatology Arthroscopy 07/2011; 20(2):304-7. · 2.21 Impact Factor
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ABSTRACT: Recent studies indicate alterations of local and systemic growth factor level during fracture healing. As a result, osteogenic and angiogenic growth factors allow us to monitor fracture healing on a molecular level. We hypothesised that closed intramedullary (IM) reaming and nail fixation, in contrast to open reduction and internal plate fixation (ORIF), could exert an effect on the cellular elements present in the intramedullary canal, leading to increased release of mediators. The purpose of the study was to investigate whether different osteosynthesis techniques influence the released quantity of cytokines.
A total of 34 patients with tibia fractures treated with IM fixation and 19 patients treated with ORIF were included in the study. In addition to clinical and radiological examination, serum concentrations of transforming growth factor beta 1(TGF-β1), macrophage-colony stimulating factor (M-CSF) and vascular endothelial growth factor (VEGF), were analysed at 1, 2, 4, 6, 8, 12, and 24 weeks after surgery.
Expression of TGF-β1 and M-CSF was increased during the first 2 weeks of fracture healing in patients treated with the IM fixation technique compared with those treated by ORIF. After 24 weeks, M-CSF levels in patients with IM fixation were clearly higher. Conversely, VEGF levels were higher during the first 2 weeks of fracture healing in patients treated by ORIF compared with IM fixation. However, these results were not significant.
Our results show that 1 week after surgery neither reamed IM fixation nor ORIF of the tibia could increase the expression of VEGF, M-CSF and TGF-β1 in its favour.
Injury 12/2010; 42(8):772-7. · 1.98 Impact Factor
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ABSTRACT: An experimental study was performed on 20 cadaveric human proximal femurs to investigate both the reproducibility of their mechanical behavior under uniaxial compression and the correlation of mechanical properties with geometric dimensions and bone density. These variables were assessed by radiography, physical measurement, and dual-energy X-ray absorptiometry (DEXA). The specimens were immobilized, loaded to the point of fracture, and analyzed with the help of a materials testing machine. The fractures invariably showed a similar pattern both in location (i.e. at the femoral neck) and in nature (i.e. "axial-shear" type according to the AO classification system). The mechanical properties of the tested proximal femurs correlated negatively with age (r = -0.39) and positively with sex (male femurs were stronger and correlated more closely than female femurs, P = 0.005). They showed a strong positive correlation with head diameter (r = 0.713, P = 0.0004), a moderate positive correlation with both neck axis length (r = 0.63) and neck diameter (r = 0.502), and a slight positive correlation with femoral neck-shaft angle (r = 0.326). All DEXA-based densitometry measures turned out to be powerful predictors of fracture force. The establishment of this solidly reproducible fracture model based on standardized loading conditions should have implications for future research on osteopenia/osteoporosis and preventive stabilization techniques.
Injury 07/2002; 33(5):427-33. · 1.98 Impact Factor
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ABSTRACT: We retrospectively analyzed 1334 patients who were implanted standard gamma interlocking nails (SGN) to stabilize trochanteric femoral fractures over the years 1992-1998. Reoperation to remove the nails was performed in 37 patients, in 9 of them purely because of pain. Three out of these 9 patients with removed SGN suffered femoral neck fractures in the early postoperative course after having been mobilized to full weight-bearing capacity. This complication was not observed with other implant systems and, considering the notoriously high complication rate of femoral neck fractures, severely reduces the value of the SGN concept per se. These findings in combination with other known shortcomings of SGNs prompted us to conduct an experimental study on the fracture force of excavated femurs addressing the hypothesis that the specific design of the SGN is responsible for the occurrence of fatigue fractures of the femoral neck. Eighteen matched pairs of fresh human cadaveric proximal femurs, which were treated by insertion and removal of (i) SGNs or (ii) dynamic hip screws (DHS) or (iii) by excavation in the absence of an implant, were subjected to incremental loading cycles and compared to the untreated contralateral femurs. Overall, the fracture force was found to be significantly lower among the treated than among the untreated bones. However, the fracture force required after removal of the DHS system was still significantly higher than for SGN or excavation alone. In this way, our findings demonstrate that removing relatively big implants such as SGN can cause serious complications such as femoral neck fractures. We therefore recommend to leave this type of device in place even after fracture healing except in cases of deep and chronic infection.
Journal of Biomechanics 01/2002; 34(12):1519-26. · 2.43 Impact Factor
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ABSTRACT: The continuous increase in the number of fractures of the proximal femur is directly attributable to the worldwide increase in life expectancy. The standard version of the Gamma Interlocking-Nail (standard Gamma nail [SGN], 200-mm length, 10-degree valgus curvature, two distal locking bolts) was designed because of the demands in orthopedic hip surgery to develop an implant stable enough to mobilize old patients as soon as possible to avoid further morbidity and mortality.
Between the years 1992 and 1998, 1,000 consecutive patients with peritrochanteric fractures were stabilized by using the SGN and included in this study. Special emphasis was given to the evaluation of the learning curve of the department of traumatology (not of single surgeons) and the influence of prognostic factors on the outcome of such operations.
The results of this study show that increasing "department experience" resulted in a reduction of the intraoperative complication rate by a factor of 0.5 (p = 0.0001) per year. This means that even an inhomogeneous mass of 78 surgeons can lower the rate of intraoperative complications by 50% per year because of increased experience. The number of early postoperative complications annually decreased by a factor of 0.8 (p = 0.0042).
Late postoperative complications correlate negatively with the patient's age (odds ratio, 0.9; p = 0.0001).
The Journal of trauma 08/2001; 51(1):77-83. · 2.48 Impact Factor
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ABSTRACT: The gamma nail is a temporary implant characterised by a limited life expectancy under continuous dynamic stress. We reviewed a series of 839 patients with gamma nail stabilisation and found two fatigue fractures (0.2%) at the aperture of the distal locking holes. This complication has not been described in the literature. Metallurgic and scanning electron microscopic examinations proved that the fatigue zones occurred at the clover-leaf grooves, which is where the diameter of the gamma nail is reduced. The clover-leaf diameter is of no biomechanical use in gamma nail stabilisation. We suggested product modification of the gamma nail to produce implants with a round diameter instead of a clover-leaf shape. A modified implant is already in use at our institution.
Injury 04/1999; 30(2):91-9. · 1.98 Impact Factor
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ABSTRACT: In 1993 a solid 7.5-mm tibial nail was developed and is composed of a wrought stainless steel alloy. In a preclinical testing series its static and dynamic mechanical properties proved to be superior to other small diameter nails. The clinical application of the Solid Tibial Nail in 70 cases of acute tibial diaphyseal fractures showed promising results. Neither severe intraoperative complications nor infections were observed. The entire series, including seven Grade I, eight Grade II, four Grade IIIA, and nine Grade IIIB open fractures, revealed a union rate of 95% at 6 months postoperative. After dynamization in one case and reaming and renailing in three cases, the fractures with delayed healing progressed to union within the following 3 months. There was no need for bone grafting in any of the cases. Locking screw breakage was observed in 10 (14%) cases 8 to 24 weeks postoperatively. This did not lead to any additional complications. No nail failures were observed. The excellent results of unreamed nailing with the Solid Tibial Nail consequently led to its use as the primary method of treatment for tibial fractures associated with soft tissue injury at the authors' institution.
Clinical Orthopaedics and Related Research 06/1998; · 2.53 Impact Factor
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ABSTRACT: Background: Previous studies comparing the management of proximal femoral fractures by Gamma nail (GN) and Dynamic Hip Screw (DHS) with
the purpose to evaluate and correlate the results of the 2 implants yielded conflicting results.
Methods: We prospectively studied 120 patients with special regard to differences within the first 6 months after pertrochanteric
femoral fractures according to the AO/ASIF Classification 31-A.1-A.3, and randomly allocated them to either GN or DHS. Intra-
and postoperative blood loss, operating time, mobility at 6 months (as a general indicator of postoperative complications),
and limb length discrepancy were statistically analyzed.
Results: None of the studied issues showed significant inter group differences. The follow-up percentage was 97%.
Conclusions: The results lend support to the empirical practice of using the DHS as a sound, lower-cost option for stable, proximal femoral
fractures, while for unstable fractures, the superior biomechanics of the GN are relied upon.
Grundlagen: Frühere Vergleichsstudien über die Versorgung proximaler Femurfrakturen mittels Gamma-Nagel (GN) oder Dynamischer Hüftsschraube
(DHS) haben insgesamt widersprüchliche Ergebnisse gezeigt.
Methodik: In einer prospektiv randomisierten Studie untersuchten wir 120 Patienten mit pertrochanteren Femurfrakturen der Klassifikation
AO 31-A.1-A.3. Spezielles Augenmerk wurde auf die Ergebnisse innerhalb der ersten 6 postoperativen Monate gerichtet. Die statistische
Analyse betraf folgende Kriterien: intra-und postoperativer Blutverlust; Operationsdauer; Mobilität nach 6 Monaten (als genereller
Indikator für postoperative Komplikationen); Beinlängendifferenz.
Ergebnisse: Bezüglich der untersuchten Kriterien ergaben sich keinerlei statistisch signifikante Unterschiede. 97% der Patienten konnten
nachuntersucht werden.
Schlußfolgerungen: Die DHS wird, vor allem aus Kostengründen, für die Versorgung stabiler proximaler Femurfrakturen empfohlen. Bei den instabilen
Frakturen verwenden wir jedoch, aufgrund seiner in biomechanischen Studien nachgewiesenen Vorteile weiterhin den Gamma-Nagel.
European Surgery 04/1997; 29(5):290-293. · 0.28 Impact Factor
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ABSTRACT: The borderline indications of locked intramedullary nailing of the femur and the tibia, based on Küntscher nailing, are defined by the location of the fracture, the associated soft tissue injury, the appearance of infection and the patient's pulmonary status. From 1975 to 1995 at the Department of Traumatology, Vienna University School of Medicine, 551 patients with 559 femoral fractures and 536 patients with 548 tibial fractures were stabilized using locked intramedullary nailing. A total of 135 (24%) proximal femoral fractures were stabilized using intramedullary locking nails in 54 cases, and using long gamma nails in 81 cases. Ninety-one distal femoral fractures (16%) were stabilized in 82 cases with intramedullary locking nails and in 9 cases using retrograde nailing. In open fractures predominantly a reamed technique was used. Fifty-two of these fractures were femoral fractures and 101 were tibial fractures. Seventy-two femoral fractures (13%) were associated with compromised pulmonary function and polytrauma. Procedural changes from external fixation to the intramedullary locking nail technique were performed in 21 cases of femoral fractures and in 21 cases of tibial fractures. Six tibial fractures diagnosed as having compartment syndrome were treated using unreamed nailing and fasciotomy. The overall infection rate of femoral fractures was 1.7% and 1.9% for all tibial fractures; the nonunion rate of both femoral and tibial fractures was 0.5%. Because of the success rate observed in the treatment of borderline indications for locked intramedullary nailing of femoral and tibial fractures and the improvement in equipment, training and techniques, we have expanded the indications for treatment of these fractures by intramedullary nailing.
Der Orthopäde 07/1996; 25(3):234-46. · 0.51 Impact Factor
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ABSTRACT: Results of the treatment of 60 intraarticular distal fractures of the femur (AO classification: 33-B and 33-C fractures) are summarized. Frequencies of the different types of fractures were B1, 7; B2, 10; B3, 4; C1, 10; C2, 1; C3, 8. In 36 patients an isolated fracture, was present, in 9 patients, one additional injury, and in 16 patients there was more than one fracture or multiple trauma. We found 16.7% open fractures. Operation was possible within 24 h in 16 patients, in 21 patients between the 2nd and the 5th days, and in the rest after the 5th day. Check-ups took place an average of 46.4 months after the accident. The average age of the patients was 64.1 years (16-93). We encountered 3 cases of infection; we were able to treat 2 of these successfully, while 1 led to chronic osteomyelitis. Further complications were: loosening of implants (6 cases), non-union (1) fractures of plates (2), haematoma requiring operative treatment (1) refracture (1). All fractures resulted in osseous consolidation. Mobilization of patients was achieved an average of 12 days after operation. We evaluated the cases according to the Neer score. In 32 cases the result was excellent, in 18, average and in 4, unsatisfactory. Failure had to be recorded in 1 case. The combination of locking nails and lagscrews is an alternative method of osteosynthesis for distal femural fractures with an intra-articular component, provided strict selection criteria are applied.
Der Unfallchirurg 08/1995; 98(7):392-7. · 0.61 Impact Factor
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ABSTRACT: Coxal femoral fractures in the elderly present a growing problem due to the increasing life expectancy of the population. The most rapid intervention possible with an implant best tailored to the individual's needs and general medical condition, followed by early mobilisation and individual physiotherapeutic management are the basic prerequisites in the attempt to achieve a decrease in the post-operative complication rate, the mortality rate and spiraling costs. Preoperative management, the choice of surgical procedure according to strict indication criteria and post-operative measures are discussed on the basis of an analysis of 719 patients admitted to our department between August 1992 and December 1993. The mean age of the patients was 79.9 years and the ratio of women to men was 4:1. Operation took place on average 14.2 hours after admission and the patients were discharged on average 15.6 days after hospitalisation. 37 of 620 (5.9%) patients operated on during the first 24 hours (group 1) and 9 of the 99 (9.1%) delayed operation patients (> 24 h = group 2) died in hospital. The findings are discussed in the light of the shortage of hospital beds, an aging population and rising hospital costs.
Wiener klinische Wochenschrift 01/1995; 107(5):169-74. · 0.81 Impact Factor
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ABSTRACT: The analysis of 310 cases of fractures of the femur, treated with a Gamma-nail osteosynthesis, done in two clinics for trauma surgery in Vienna, revealed to a high number of complications. For this reason we decided to start an evaluation aming at complications in connection to this type of treatment, with 440 patients treated over a five year period. We observed 148 complications, which will be described. The intraoperative failures were as follows: False drilling during the interlocking procedure 64, wrong length of lag screw 13, breakage of the drill bit during interlocking procedure 7, additional shattering of shaft 5, external malrotation of diaphysis (> or = 20 degrees) 6, internal malrotation of the diaphysis (> or = 20 degrees) 1, elongation of diaphysis (2 cm) 1, mistakes in using the proximal nail-plaque 4, breakage of bone elevator, used for reduction procedure 1 and 1 failure at the target-device during nailing. The complications during the postoperative treatment were: Infection 11, perforation of lag screw towards cranial 10, towards central 2, migration of the lack screw within the femoral head 7, diaphysial fracture at the distal end of nail 6, movement of interlocking bolts 4, osteolytic process at fracture site 2 and 3 haematomas, needing a revision. Most of these reported complications were due to technical failures, lack of experience or inadequate treatment modality. The specifications and descriptions should give information about the reasons of these complications, but it is the purpose of this publication too, to figure out the technical errors which were responsible for most of the complications described.
Der Chirurg 12/1994; 65(11):943-52. · 0.70 Impact Factor
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ABSTRACT: Treatment of fractures of the coxal femur has become routine at the Clinic for Trauma Surgery at the University of Vienna. This paper reports on the follow up on 310 patients treated with the gamma nailing (average follow up: 21.4 months). In all, 240 women and 70 men were operated on between 1987 and 1992. Most of the fractures wer unstable and many were located in the subtrochanteric region (38.3% A3). It was possible to operate on 45.8% of these patients during the first 2 days. The modalities of treatment and mobilization are described, and the clinical and radiological results are presented. Mobilization was possible after an average of 10.2 days in 81.6% of these cases. Complications we had to face and ways they might be prevented in future are discussed.
Der Unfallchirurg 04/1994; 97(3):132-8. · 0.61 Impact Factor
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ABSTRACT: The results of treatment of 35 intraarticular distal fractures of the femur are presented. Treatment was performed in 8 cases with a condylar plate, in 8 cases with dynamic compression screw (DCS), in 2 cases with two plates, in 9 cases with screws only, and eight times the fracture was treated with a combination of lag screws and locking nail. Examination took place at an average of 45.5 months after the accident. 19 patients had an isolated fracture, 8 patients one accidental injury and 8 patients had more than one fracture or were polytraumatised. In 75% of the patients treatment lasted for between day 1 and 5. We found 17.1% open fractures and had to face infections in 5.7% (two cases). Bone healing occurred in all fractures, the reported infections could be overcome by early revision and the use of gentamycin-PMMA beds. It is remarkable that locking nails were successfully used in 8 cases of fractures with intraarticular component of the distal femur.
Aktuelle Traumatologie 06/1993; 23(3):111-5.
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ABSTRACT: An alternative treatment of fractures of the coxal femur side is a new implant called "GAMMA-NAIL". The article describes the new implant and the operative technique. Furthermore, we present the results of a first series of 58 patients, mainly women (w:m = 8:1) with an average on age of 78.09 years. Although these patients were characterised by a number of complicating factors, it was possible to mobilise 86.2% at an average of 9.4 days after surgery with full load. We present a report on the quality of walking, a pain report, data on the mobility of joints and the x-ray findings. The 5.1% of infections and 8.6% of operative and postoperative complications we have to face, are described in detail.
Aktuelle Traumatologie 09/1992; 22(4):163-9.
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ABSTRACT: A patient presented with neck impalement after a traffic accident. Respiratory arrest demanded immediate tracheal intubation, which was impossible as a wooden splinter had partially obstructed the pharynx and prevented laryngoscopy. An oesophageal tracheal Combitube airway was inserted successfully and the patient's lungs were ventilated adequately until tracheotomy was performed.
BJA British Journal of Anaesthesia 06/1992; 68(5):534-5. · 4.24 Impact Factor
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ABSTRACT: Interlocking nailing is presented as an optimal method for the treatment of fractures of femur and tibia, which are complicated because of the length of these bones. Cases from the literature and cases treated by the authors gave a total of 208 fractures of the femur and 158 fractures of the tibia (comminuted fractures and fractures "à deux étages"). There is a low complication rate as a closed procedure was applied whenever possible. In the femur the nail fractured in eight cases (3.9%), while in seven cases infection was observed (3.5%) and in three cases pseudarthrosis. Following interlocking nailing of the tibia we found deviation of the axis by greater than 5 degrees in eight cases (5%) of 158, including 44 open fractures. Fracture of the nail occurred in one case (0.6%), and we observed six cases of infection (3.8%) and one of pseudarthrosis (0.6%).
Der Unfallchirurg 12/1990; 93(11):512-8. · 0.61 Impact Factor
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ABSTRACT: Treatment with interlocking nails is sufficient for fractures at the distal diaphysis and the distal methaphyseal region of the femur. Fractures associated with intracondylar fissures can be treated with an interlocking nail only in isolated cases. This paper gives a report on 47 cases and compares two series. The complications observed were: infection (4.25%); fracture of nail (4.25%); and deviation of axis (12.08%). We didn't observe pseudarthrosis in any of these patients. Bone healing occurred in all cases.
Der Unfallchirurg 12/1990; 93(11):523-7. · 0.61 Impact Factor
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ABSTRACT: The authors report on a series of open fractures (Type I and Type II) on the lower extremities of 91 patients, treated at the I. University Clinic of Traumatology, Vienna and at the Traumatologic Department of Wilhelminenspital, Vienna from 1975-1987. There were 25 open femoral- and 66 open tibial fractures. We have seen 60% Type I and 40% Type II fractures on the femur as well as on the tibia. 74% of the patients were male. The patients' ages ranged from 15 to 92 years with a median of 32 years. The main fracture type was the comminuted fracture with over 50%. In contrast to the references in the literature (9, 11, 21) we noticed an infection rate of only 1.2%. 96% of the operated and checked up patients received bone union with the interlocking nail. We cannot in any way attribute these results solely to the used implant. Conscientious indication in the application of the interlocking nail, an exact preoperative management with prophylactic antibiotic as well as an excellent operative technique are also taken into consideration. The choice of the static interlocking nail (73%) after the closed reduction (80%) of these open fractures is supposed to be a measure against infection. Due to these results we are of the opinion that the interlocking nail when selectively used in the hands of an expert can be recommended not only in closed fractures but also in Type I and II open fractures of the femur and the tibia as long as the special principles of treatment are not neglected.
Aktuelle Traumatologie 05/1990; 20(2):67-73.
