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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.