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Complications of Femoral IM Nailing


- See: Comminuted Femoral Shaft Fractures

- Complications:
    - compartment syndrome of thigh
    - femoral IM nail infection 
    - avascular necrosis from IM nailing 
    - femoral non union

- Implant failures:
    - associated w/ either the insertion of a small diameter nail or use of an interlocking nail for a very prox. or distal shaft frx;
    - plastic deformation (bending) of the IM rod mainly occurs w/ nails that are less than 10 mm in diameter;
          - minimal nail diamters range 12-14 mm for women & 13-15 mm for men;
    - failures w/ interlocking nails: tendency to use smaller diamter nails (nail may fail at hole site);
    - weak part of the nail is proximal of the 2 distal holes;
          - frx located w/ in 5 cm of this hole will be stressed above endurance limit w/ ambulation;
          - these frx must have delayed wt bearing until callus is present;
    - early dynamization, esp of subisthmal fractures, is associatted w/ increased risk of developing a valgus deformity at the fx site;
    - bending of the nail at the fracture site usually occurs as an early complication caused by premature wt bearing, lack of adequate support, or deficient material (nail) strength;
    - bent distal screws may result from early wt bearing if the screws are too close to the fracture site;
    - nail removal:
          - if inner diameter of nail is threaded, use a cone shaped universal extractor in order to lock on to the nail, allowing its removal;
          - or use a metal cutting carbide tip to create a hole in the nail, which then allows an extracting device to be inserted;
    - reference: Broken intramedullary nails.
 
- Shortening:
    - often due to dyanamic interlocking w/ excessive post op wt bearing;
    - management of limb length inequality:
         - descrepancy < 1.2 cm: does not require intervention except for contra-lateral show lift;
         - descrepancy between 1.2 - 2.5 cm;
                - this is the grey zone, and treatment is controversial;
                - patients will often compensate for the leg length inequality thru increased flexion and circumduction of the long extremity and through toe walking of the short limb;

          - descrepancy > 2.5 cm;
                - most agree that all discrepancies projected to be > 2.5 need treatment;
                - limb lengthening:
                       - only indicated for severe deformities in relatively short adults;
                - limb shortening:
                       - closed femoral shortening is often the treatment of choice;
                       - references:
                             - Closed shortening of the femur
                             - Closed intramedullary osteotomies of the femur.

- Malunion:
    - malrotation of more than 10 deg
    - varus or valgus angulation more than 7 deg
    - AP angulation more than 10 deg
    - leg shortening of more than 1.5 cm;
    - high rate (11%) of valgus deformity produces w/ lateral position;
    - when a nail is loose, the solution is less definite;
    - references:
         - The Clamshell Osteotomy: a New Technique to Correct Complex Diaphyseal Malunions 
         - Osteotomy planning using the anatomic method: a simple method for lower extremity deformity analysis.

- Hetertopic Ossification:
    - may be more common w/ head injury
    - references:
          - Heterotopic ossification about the hip after intramedullary nailing for fractures of the femur.
          - Heterotopic ossification around the hip with intramedullary nailing of the femur.

- Misc Complications:
    - irritation of soft tissues over the heads of the proximal transfixing screws has occurred in 7% of cases;
          - this may lead to the formation of an adventitious bursa over the screw heads or snapping of the iliotibial band;
          - removal of the proximal screws usually alleviates the problem



Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review.

Pitfalls, errors, and complications in the use of locking Küntscher nails.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, September 13, 2012 2:55 pm