Rev. bras. ortop. vol.51 número6

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Medial

migration

of

the

intramedullary

Gamma

3 nail

–

a

case

report

夽

Ana

Costa

Pinheiro

∗

_,

_Bruno

_Alpoim,

_António

_Félix,

_Carlos

_Alves,

_Cristina

_Sousa,

António

Rodrigues

UnidadeLocaldeSaúdedoAltoMinho,VianadoCastelo,Portugal

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Articlehistory:

Received5November2015

Accepted1December2015

Availableonline17October2016

Keywords:

Hipfractures

Bonenails

Bonescrews

a

b

s

t

r

a

c

t

Intertrochantericfemurfracturesareverycommoninpatientsover65yearsold,andare

oftenassociatedwithosteoporosis.Proximalfemoralnailsarepreferredbecauseoftheir

biomechanicaladvantagesinthetreatmentofthesefractures,especiallyifthefracture

isunstable.However,many complicationsassociatedwithintramedullaryfracture

fixa-tionhavebeendescribed.Themedialmigrationoftheintramedullarygammanailisa

rarecomplication.Theauthorsreportanuncommonbutpotentiallyfatalcomplication,

medialandintrapelvicmigrationoftheintramedullaryGamma3nails,recordedafterone

monthofosteosynthesis.Thisarticleaimstoalerttheorthopediccommunitytothisrare

complication,whichmaypresentahighriskofmorbidityandmortality.

eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Migrac¸ão

medial

do

cravo

cefálico

de

dispositivo

cefalomedular

Gamma

3 –

Relato

de

caso

Palavras-chave:

Fraturasdoquadril

Pinosortopédicos

Parafusosósseos

r

e

s

u

m

o

Asfraturasintertrocantéricasdofêmurproximalsãomuitocomunsempacientesacima

de 65 anos, por estarem muitas vezes associadas à osteoporose. A fixac¸ão do fêmur

proximalcomdispositivoscefalomedulares,pelassuasvantagensbiomecânicas,

consti-tuiotratamentopreferencial,especialmentenotratamentodasfraturasinstáveis.Várias

complicac¸õesassociadascomafixac¸ãocefalomedulartipoGammadessetipodefraturas

foramdescritasnaliteratura,amigrac¸ãomedialdocravocefálicoéumacomplicac¸ão

exce-cionalmentesingular.Osautoresrelatamumacomplicac¸ãoincomummaspotencialmente

夽

StudyconductedattheLocalHeathUnitofAltoMinho,VianadoCastelo,Portugal;andatthePlasticSurgeryService,HospitaldeGaia,

Porto,Portugal.

∗ _{Corresponding}_author_.

E-mail:[email protected](A.C.Pinheiro).

http://dx.doi.org/10.1016/j.rboe.2016.10.004

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fatal,amigrac¸ãomedialintrapélvicadocravocefálicododispositivointramedularGamma

3,verificadaapósummêsdaosteossíntese.Estetrabalhoaspiraadespertaracomunidade

ortopédicaparaessararacomplicac¸ão,aqualpodeapresentaraltoriscodemorbilidadee

mortalidade.

OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Intertrochanteric fractures ofthe proximal femur are very

commoninpatientsover65years,andareoftenassociated

withosteoporosis.1–3

These are extracapsular fractures, whose treatment

generally consists of osteosynthesis with intramedullary

(cephalomedullary nail with more evident indication in

Fig.1–Radiographdisclosinganintertrochantericfracture.

Fig.2–ThepatientunderwentclosedreductionandosteosynthesiswithcephallomedularyscrewandnailGamma3

Stryker130◦_;_{intraoperative}_radiography_of_the_hip,_{anteroposterior}_and_lateral_views.

unstable fractures,but alsoindicatedinstablefractures)or

extramedullary implant (plate and sliding screw, in stable

fractures).4,5

Cephalomedullarynailingoftheproximalfemuristhe

pre-ferred treatmentespeciallyforunstablefractures nailingof

theproximalfemur,duetoitsbiomechanicaladvantages.6–9

However, various complications associated with

intramedullary fixation of this type of fracture have been

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frequentcomplications(incidencerangingfrom3%to10%).

Inturn,medialmigrationofthe cephalicscrewinGamma

nailsisanexceptionallyuniquecomplication.10–14

Theauthorsreportaveryrarecomplication,medial

migra-tionofthecephalicscrewoftheGamma3intramedullarynail,

recordedonemonthafterosteosynthesis.

Thisstudyaimedtoalerttheorthopediccommunitytothis

rarecomplicationofosteosynthesis,whichmaypresentahigh

riskofmorbidityandmortality.

Case

report

Afemalepatient,aged92years,partiallydependentfor

activ-ities ofdailyliving, previously walking with crutches,was

takentotheEmergencyDepartment(ED)afterafallfromown

heightwithlefthipinjury.Themedicalhistoryandphysical

examinationindicatedintensehippainand functional

dis-ability.Thepatienthad noapparentneurovascular injuries

in the affected limb. Radiographs showed an AO 31-A2.2

intertrochantericfracture (Fig. 1). Sevendays afterthe

ini-tialtrauma,underantiplatelettherapy,thepatientunderwent

closedreductiononthe tractiontableand internalfixation

withtheGamma3Stryker130◦ _{cephalomedullary}_nail,_with

fluoroscopycontrolofthefracturereductionandproper

posi-tioningof the implant according to the surgical technique

andplacementofthelockingscrewwithoutapparent

intra-operativecomplications(Fig.2).Thepatientwasdischarged

fromthehospitalonthefourthpostoperativeday,withpartial

weightbearingontheaffectedlimb.Atthe36th

postopera-tiveday,shewastakentoaprimaryhealthcarecenter due

toincapacitatingpainandfunctional disabilityofthe

oper-atedlowerlimb;thesymptomsworsenedgradually,without

apparenttraumaticeventswhenthepatientalreadybeared

fullweightontheoperatedlimb.Shewasonceagainreferred

totheED;ahipradiographdemonstratedintrapelvicmedial

migrationofthecephalicscrewandlossofthefracture

reduc-tion (Fig. 3). Thepresenceofinternalorgan injurywas not

observed through imaging using pelvic CT scan nor

clini-cally.ThepatientunderwenttheextractionoftheGamma3

nailandsecondosteosynthesiswithplateandslidingscrew

(Fig.4),withoutintra-orpostoperativecomplications.During

theoutpatientfollow-up, cut-outofthecephalicscrewwas

observedatsixmonthspostoperatively(Fig.5).Anewsurgery

wasproposed,butwasrefusedbythepatientandher

rela-tives;thepatientwaskeptinoutpatientmonitoring.Eighteen

monthsaftertheinitialtrauma,thepatienthadgeneral

condi-tionworseningwithlimitedmobility,movinginawheelchair

andwithoutsignificantpaincomplaints.Shestillrefusedto

undergoanewsurgery.

Discussion

Cephalomedullary nailing is widely used in the fixation

ofproximalfemur fractures presentingnumerous benefits,

namelyhighmechanicalstabilitywithshorteroperativetime,

smallerincision,earlyweightbearing,andgoodclinicaland

radiologicalresults.However,severalcomplicationshavebeen

associated with this procedure; varus reduction loss and

Fig.3–Hipradiographshowingintrapelvicmedial

migrationofthecephalicscrewandlossoffracture

reduction.

cut-outarethemostcommon.Conversely,medialmigration

ofthe cephalic screwsinGamma nails isan exceptionally

unusual complication, as there havebeen onlynine cases

reportedintheliterature.6–18 _The_exact_etiology_of_this

con-ditionremainsunknownduetoitsuniqueness.

Iatrogenic damageofthe femoralhead duringreaming,

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Fig.4–ThepatientunderwentextractionoftheGamma3nailandrevisionosteosynthesiswithplateandslidingscrew.

Fig.5–Duringtheoutpatientfollow-up,cut-outoftheheadscrewwasobserved.

earlyloading,subjecting the implanttoexcessive torsional

forces,direct trauma that producesa defect in the

screw-nailslotinterface,themisplacementofthesetscrewinthe

proximalnailextremity,andthechoiceofatooshortortoo

longcephalicscrewhavebeenassociatedwiththisunusual

complication.15–18

Inthepresentcase,allthestepsofthesurgicaltechnique

wereproperlyexecuted,andthereductionandosteosynthesis

wereappropriate;therefore,thecause(s)ofthemedial

migra-tionofthescrewis(are)unknown.Earlyloading,subjectingthe

implanttoexcessivetorsionalforces,ordirecttraumanot

dis-closedbythepatientmayhavecontributedtoosteosynthesis

failure.

Inthiscase,asecondfixationdevicewithscrewinafemoral

headandneckalreadyweakenedbyosteoporosisina

92-year-oldpatientandbypriorsurgeryrequiringlocalapproachfor

theextractionoftheproximalscrewwasshowntonothave

beenagoodoption.Atthetime,theauthorscouldhave

cho-sentoperformfixationwithmethylmethacrylatecement,to

increasethemechanicalstrengthofthecephalicfixation,such

astheproximalfemoralantirotationnail.19,20

Theorthopedicsurgeonmustbeawareoftheoccurrenceof

thiscomplicationanditsassociatedrisks,notablyintrapelvic

penetrationandassociatedvisceralinjury.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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