 |
 |
 |
|
| home | CME | help | feedback | subscriptions | archive |
|
© 1999 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: We read with much interest the article "Use of an Intramedullary Hip-Screw Compared with a Compression Hip-Screw with a Plate for Intertrochanteric Femoral Fractures. A Prospective, Randomized Study of One Hundred Patients" (80-A: 618–630, May 1998), by Hardy et al. We compliment the authors on an excellent study, but we do not agree with some of the techniques that were used or with the conclusion that was reached. The technique that was used to insert the intramedullary nail is somewhat questionable. The proximal end of the femoral canal is opened, but the canal in the region of the isthmus is not reamed unless the nail jams. This technique could cause a femoral fracture, which would explain the pain in the mid-portion of the thigh that some patients have. It could also explain the cortical hypertrophy at the tip of the nail. To minimize these complications, it is better to ream the femoral canal two millimeters wider than the diameter of the nail. The remark made by Hardy et al. regarding the relationship between the larger diameter of the nail and the presence of a stress-riser seems logical, but the larger diameter could also cause pain in the mid-portion of the thigh. Our conclusion would be to overream the canal and to use a nail with a small diameter. The relationship between pain in the mid-portion of the thigh and the use of two screws was not proved in their study. Most likely because of their relative inexperience with an intramedullary hip-screw, greater experience with a compression hip-screw, and interpretation of the meta-analysis performed by Parker and Pryor1, the authors concluded that routine use of intramedullary hip-screws cannot be recommended. This conclusion was neither supported nor proved by their study. What is evident is that every device has its learning curve and that complications occur as a result of inexperience. The previously mentioned complications are well known to those who used the Gamma nail during the early years after its introduction. On the basis of this experience, techniques have evolved that greatly ameliorate complications such as fractures of the femoral shaft and pain in the mid-portion of the thigh, which seldom occur now.
V. A. de Ridder, M.D., Ph.D.; S. de Lange, M.D.: Department of Traumatology, Medical Center Haaglanden, Westeinde Ziekenhuis, P.O. Box 432, 2512VA Den Haag, The Netherlands
Dr. Hardy, Dr. Descamps, Dr. Krallis, Dr. Fabeck, Dr. Smets, Ms. Bertens, and Dr. Delince reply: We appreciate the interest and comments of Dr. de Ridder and Dr. de Lange regarding our manuscript. They point out that overreaming of the femoral cavity and use of a nail with a smaller diameter is likely to minimize the prevalence of cortical hypertrophy at the tip of the nail. In order to address their interesting suggestions, we identified twenty-seven patients from our study who were managed with insertion of an intramedullary hip-screw after overreaming of the femur. Nineteen of these patients were still alive at one year. With the numbers available, no association could be found between reaming and cortical hypertrophy (p = 0.901, Yates's corrected chi-square = 0.05) (Table I). Of course, these numbers are small. Our prospective study has been expanded since its publication, and it now includes 160 patients (eighty who have a compression hip-screw and a plate and eighty who have an intramedullary hip-screw). We performed the same evaluation again, but we did not find any significant association between reaming and cortical hypertrophy (p = 0.595, Yates's corrected chi-square = 0.07) (Table II).
It would be useful for Dr. de Ridder and Dr. de Lange to provide the readers of The Journal with controlled data regarding their hypothesis before they publish it as a conclusion. From a morphological standpoint, cortical thickening is always located around the heads and tips of the screws (Fig. 5 of our manuscript and the current Fig. 1-A) and is never visible on the lateral radiographs (Fig. 1-B). If cortical thickening was due to impingement on the cortex by the nail itself, it would be localized at the very tip of the nail and would affect the anterior portion of the cortex, against which the tip of the nail impinges in most patients. These morphological data as well as the significant association that was found between cortical hypertrophy and the use of two screws (p = 0.02) are inconsistent with the suggestions of Dr. de Ridder and Dr. de Lange.
Finally, we have included in our study the learning curve for the patients who were managed with an intramedullary hip-screw (Tables I and II) in order to give the reader a realistic view of what one might expect to observe if one begins using this implant. The technique that we used was strictly consistent with that recommended by the designers of this implant. Since then, we have considerably modified the technique (to a strictly percutaneous one) and the implants (use of one locking screw in a slot, to allow the nail to subside when loaded). A dramatic decrease in the prevalence of cortical thickening has resulted along with a total absence of pain in the mid-portion of the thigh.
Dominique C. R. Hardy, M.D.; Pierre-Yves Descamps, M.D.; Laurent Fabeck, M.D.; Catherine L. Bertens; Phillippe E. Delince, M.D.: Department of Orthopaedic Surgery, University Hospital Saint-Pierre, 290, Rue Haute, B-1000 Brussels, Belgium Panagiotis Krallis, M.D.: Kosti Palama, 14123 Lykovrissi, Athens, Greece Paul Smets, M.D.: Pacheco Institute of Rehabilitation, 7, Rue de Grand Hospice, B-1000 Brussels, Belgium
References
  CiteULike  Connotea  Del.icio.us  Facebook  Technorati  Twitter What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| home | CME | help | feedback | subscriptions | archive | site index |
|
Stanford University Libraries' HighWire Press (TM) assists in the publication of JBJS Online. |