Rev. bras. ortop. vol.51 número4

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r e v b r a s o r t o p . 2016;51(4):482–485

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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

Case

Report

Pelvic

migration

of

the

helical

blade

after

treatment

of

transtrochanteric

fracture

using

a

proximal

femoral

nail

夽

Pedro

Luciano

Teixeira

Gomes

∗

_,

_Luís

_Sá

_Castelo,

_António

_Lemos

_Lopes,

_Marta

_Maio,

Adélia

Miranda,

António

Marques

Dias

CentroHospitalardeTrás-os-MonteseAlto-Douro,DepartamentodeOrtopediaeTraumatologia,VilaReal,Portugal

a

r

t

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c

l

e

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n

f

o

Articlehistory:

Received1July2015

Accepted25July2015

Availableonline4July2016

Keywords:

Femoralfractures

Prosthesesandimplants

Orthopedicpins

Elderly

a

b

s

t

r

a

c

t

Proximalfemoralnailswithahelicalbladeareanewgenerationofimplantsusedfor

treat-ingtranstrochantericfractures.Thebladedesignprovidesrotationalandangularstability

forthefracture.Despitegreaterbiomechanicalresistance,theysometimespresent

com-plications.Intheliterature,therearesomereportsofcasesofperforationofthefemoral

headcausedbyhelicalblades.Here,aclinicalcaseofmedialmigrationofthehelicalblade

throughthefemoralheadandacetabulumintothepelviccavityispresented.

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

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

Migrac¸ão

pélvica

de

lâmina

helicoidal

após

tratamento

de

fratura

transtrocantérica

com

cavilha

proximal

do

fêmur

Palavras-chave:

Fraturasdofêmur

Próteseseimplantes

Pinosortopédicos

Idoso

r

e

s

u

m

o

Ascavilhasproximaisdofêmurcomlâminahelicoidalrepresentamumanovagerac¸ão

deimplantesusadosnotratamentodefraturastranstrocantéricas.Odesenhodalâmina

forneceestabilidaderotacionaleangularàfratura.Apesardamaiorresistênciabiomecânica,

porvezesapresentamcomplicac¸ões.Naliteraturaencontram-sedescritosalgunscasosde

perfurac¸ãodacabec¸afemoralporlâminashelicoidais.Apresenta-seumcasoclíniconoqual

ocorreumigrac¸ãomedialdalâminahelicoidalatravésdacabec¸afemoraledoacetábulopara

acavidadepélvica.

Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

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

夽

StudyconductedattheCentroHospitalardeTrás-os-MonteseAlto-Douro,DepartamentodeOrtopediaeTraumatologia,VilaReal,

Portugal.

∗ _{Corresponding}_author_.

E-mail:pedrotxgomes@gmail.com(P.L.Gomes).

http://dx.doi.org/10.1016/j.rboe.2015.07.013

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rev bras ortop.2 0 1 6;51(4):482–485

483 Introduction

Transtrochantericfracturesare aprevalent conditioninthe

elderly. The incidence of this disease has increased

con-siderablyin recent years,as a resultof populationaging.1

Improving the treatment ofthesefractures is essential for

patientquality oflife, reducing the lengthofhospitalstay

andpromotingaquickrecoverytopre-fracturefunctional

sta-tus.Therearemanyimplantsavailableforthetreatmentof

suchfractures.InstableAO31-A1transtrochantericfractures,

extramedullary devices(plates) can beapplied, with

favor-able results.2 _However, _in _unstable _AO _31-A2/A3 _fractures,

intramedullaryimplantshaveabiomechanicaladvantage,2,3

withbettertransmissionoftheaxialload.Morerecently,anew

generationofproximalfemoralnailswithhelicalbladeshas

beendeveloped,featuringalargercontactareaand

compres-sionbetweenthebladeandthecancellousbone,promoting

betterstabilityagainstvaruscollapse,especiallyinpatients

with osteoporoticbones.4,5 _Nonetheless, _{complications} _are

sometimesobserved,especiallythose relatedtofixation.6–8

Thisstudypresentsacaseofperforationofthefemoralhead

andthebottomoftheacetabulumwithpelvicmigrationofthe

helicalblade.

Case

report

An88-year-old female, with ahistory ofhypertension and

heart failure,had a fallfrom herown heightin2014 with

traumaintheleft hip.Aradiographic studyrevealed aleft

AO 31-A1 trochanteric fracture (Fig. 1). She was urgently

treatedwith proximal femoralnail (10mm×170mm, 130◦)

and antirotation blade (100mm). Surgical procedure was

uneventful.Ahelicalbladewasplacedinthecenter-bottom

position in the anteroposterior incidence (Fig. 2A) with a

Parker’sratio (anteroposterior)9 _of₃₈ _and _slightly_posterior

in the lateral incidence (Fig. 2B) with a Parker’s ratio

(lat-eral)of36.Thecalculated“tip-apex”distance10_was₂₄_mm,

andthecervicodiaphysealanglewas136◦_._{Postoperatively,}_the

fracture wassignificantly reduced (Fig. 3).The patientwas

dischargedtoarehabilitationinstitution,withtheindication

Fig.1–TransthrocanthericAO31-A1fractureontheleft.

ofambulation withawalker andpartialload. Shewas

re-evaluedatanoutpatientconsultationonthesecondmonth

postoperative,complainingofpaininthelefthipanddifficulty

inmobilization;thepatientdeniednewtraumaticepisodes.

Radiographically,aperforationofthefemoralheadand the

bottomoftheacetabulumbythehelicalbladewasobserved,

withintrapelvicmigrationFigs. 4and5).Thematerialwas

extractedusingthepreviousapproach,uneventfully.The

frac-tureevolvedtovarusmalunionandallowedambulationofthe

patient.

Discussion

The problem of rotational instability, followed by the

varus collapse of the femoral head and by the cephalic

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484

rev bras ortop.2 0 1 6;51(4):482–485

Fig.3–Hipradiographyintheimmediatepostoperative period.

perforationof the nail tothe hip joint,isa well-described

phenomenon,4 _known _as _cut-out, _and _occurs _with _some

platesandcephalomedullarynailsusedinthetreatmentof

transtrochantericfractures.Proximalfemoralnailswith

heli-calbladesweredevelopedtoaddressthisproblem.Thespiral

bladeisinsertedbyimpactionandpromotesthecompression

ofthecancellous bonearoundthe implant.Several

biome-chanicalstudieshavedemonstratedtheadvantagesofspiral

bladeswhencomparedwithconventionalscrews.4,5_The

sta-bilityobtainedafterfracturefixationisinfluencedbyseveral

factors,suchasthereductionachievedandthepositioningof

thenailinthefemoralhead.Thisinsertionshouldbemade

Fig.4–Pelvicmigrationofthehelicalbladeonthesecond monthpostoperatively.

Fig.5–Amplifiedimages(anteroposteriorandprofile) showingtheperforationofthebottomoftheacetabulumby thehelicalblade.

thecenter-bottompositionintheanteroposteriorandcentral

focus on lateral incidence,thus placingthe implant inthe

areawithhighertrabeculardensity.Baumgaertner10_defined

the variabletip-apexdistanceand concludedthat implants

placedatadistanceofmorethan25mmwereathigherrisk

ofcut-out.However,thecomplicationpresentedinthisreport

isnotaconventionalcaseofcut-out,butanewphenomenon

ofimplantfailuredescribedascut-throughbyFreietal.6_and

previously reported by Simmermacher et al.7 _and _Brunner

etal.8_a_perforation_of_the_femoral_head_by_the_blade_insertion

axis,withoutsignificantlossofreduction.Thecasedescribed,

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rev bras ortop.2 0 1 6;51(4):482–485

485

have presented more serious complications with vascular

injuryand a different outcome.Recently,Nikoloski et al.11

conductedastudytoadapttheconceptoftip-apexdistance

toPFNAimplants;the previous variableshowed abimodal

distributioninthecasesofcut-out,whichwasnotobserved

inprevious implants.This suggests thatthe helical blades

shouldnotbeplacedtooclosetothesubchondralbone.Zhou

andChang12_defined_a_tip-apex_distance_between₂₀_mm_and

25mmforplacementofthehelicalblade.

Osteoporosisinfluencesthecut-outevent.Bonnaireetal.13

haveshownthatbonemineraldensityoflessthan0.6g/cm3

increasestheriskofimplantfailure.Mostauthors6–8_suggest

thatthemaincauseofcentralperforationofthefemoralhead

areduetoafailureofthehelicalbladetoslidesidewaysas

the fracture collapses. This failure toslide may occur due

todefectsoftheblade/nailinterfaceortoimpactionofthe

baseofthebladeagainstthelateral cortex.Furthermore,it

hasbeensuggestedthepresenceoftheZ-effect,which,over

severalloadcyclesduringambulation,wouldpromotemedial

migrationofthehelicalblade.14_The_occurrence_of_a_new

trau-maticepisodecanalsobethesourceoftheproblem.Regarding

thetreatmentofthesecomplications,whichusuallyoccurin

thefirst twomonthsaftersurgery,Brunneret al.,8 _in_their

series ofthree cases, reviewed the fixation with a shorter

helicalblade,maintaining the samenail intwo cases,and

throughcementlesstotalhiparthroplastyinanothercase.In

thepresentcase,theentirematerialwasextracted,sincethe

88-year-oldpatientdidnotpresentanestheticconditionsfor

totalarthroplastyandbecausetheuseofthesameimplant

inanewfixationattemptcouldresultinmigration,requiring

reintervention.Inordertoreducetheincidenceofthis

com-plication,thefractureshouldbeadequatelyreducedandthe

bladeshouldbecorrectlypositionedinthefemoralhead.Prior

drillingoftheentirebladepathisunnecessaryandshould

beavoided,especiallyinthepresenceofosteoporoticbone.6,8

Recently,thepossibilitytoimprovefixationbycementingthe

femoralheadusingaperforatedspiralbladewasdeveloped.

Thecentral perforation ofthe femoralhead bythe helical

bladeisauniquecomplicationinherenttothistypeofimplant.

Morebiomechanicalresearchisneededtoclarifythe

perfora-tionmechanism.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.KumarR,SinghRN,SinghBN.Comparativeprospectivestudy ofproximalfemoralnailanddynamichipscrewinthe treatmentofintertrochantericfracturefemur.JClinOrthop Trauma.2012;3(1):28–36.

3.CurtisMJ,JinnahRH,WilsonV,CunninghamBW.Proximal femoralfractures:abiomechanicalstudytocompare intramedullaryandextramedullaryfixation.Injury. 1994;25(2):99–104.

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7.SimmermacherRK,LjungqvistJ,BailH,HockertzT,Vochteloo AJ,OchsU,etal.Thenewproximalfemoralnailantirotation (PFNA)indailypractice:resultsofamulticentreclinicalstudy. Injury.2008;39(8):932–9.

8.BrunnerA,JöckelJA,BabstR.ThePFNAproximalfemurnail intreatmentofunstableproximalfemurfractures–3casesof postoperativeperforationofthehelicalbladeintothehip joint.JOrthopTrauma.2008;22(10):731–6.

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