Medial migration of the intramedullary Gamma 3 nail - a case report^☆

ABSTRACT

Intertrochanteric femur fractures are very common in patients over 65 years old, and are often associated with osteoporosis. Proximal femoral nails are preferred because of their biomechanical advantages in the treatment of these fractures, especially if the fracture is unstable. However, many complications associated with intramedullary fracture fixation have been described. The medial migration of the intramedullary gamma nail is a rare complication. The authors report an uncommon but potentially fatal complication, medial and intrapelvic migration of the intramedullary Gamma 3 nails, recorded after one month of osteosynthesis. This article aims to alert the orthopedic community to this rare complication, which may present a high risk of morbidity and mortality.

Keywords:
Hip fractures; Bone nails; Bone screws

RESUMO

As fraturas intertrocantéricas do fêmur proximal são muito comuns em pacientes acima de 65 anos, por estarem muitas vezes associadas à osteoporose. A fixação do fêmur proximal com dispositivos cefalomedulares, pelas suas vantagens biomecânicas, constitui o tratamento preferencial, especialmente no tratamento das fraturas instáveis. Várias complicações associadas com a fixação cefalomedular tipo Gamma desse tipo de fraturas foram descritas na literatura, a migração medial do cravo cefálico é uma complicação excecionalmente singular. Os autores relatam uma complicação incomum mas potencialmente fatal, a migração medial intrapélvica do cravo cefálico do dispositivo intramedular Gamma 3, verificada após um mês da osteossíntese. Este trabalho aspira a despertar a comunidade ortopédica para essa rara complicação, a qual pode apresentar alto risco de morbilidade e mortalidade.

Palavras-chave:
Fraturas do quadril; Pinos ortopédicos; Parafusos ósseos

Introduction

Intertrochanteric fractures of the proximal femur are very common in patients over 65 years, and are often associated with osteoporosis.^1,2and3

These are extracapsular fractures, whose treatment generally consists of osteosynthesis with intramedullary (cephalomedullary nail with more evident indication in unstable fractures, but also indicated in stable fractures) or extramedullary implant (plate and sliding screw, in stable fractures).^4and5

Cephalomedullary nailing of the proximal femur is the preferred treatment especially for unstable fractures nailing of the proximal femur, due to its biomechanical advantages.^6,7,8and9

However, various complications associated with intramedullary fixation of this type of fracture have been described; cut-out of the cephalic screw is one of the most frequent complications (incidence ranging from 3% to 10%). In turn, medial migration of the cephalic screw in Gamma nails is an exceptionally unique complication.^{10,11,12,13and14}

The authors report a very rare complication, medial migration of the cephalic screw of the Gamma3 intramedullary nail, recorded one month after osteosynthesis.

This study aimed to alert the orthopedic community to this rare complication of osteosynthesis, which may present a high risk of morbidity and mortality.

Case report

A female patient, aged 92 years, partially dependent for activities of daily living, previously walking with crutches, was taken to the Emergency Department (ED) after a fall from own height with left hip injury. The medical history and physical examination indicated intense hip pain and functional disability. The patient had no apparent neurovascular injuries in the affected limb. Radiographs showed an AO 31-A2.2 intertrochanteric fracture (Fig. 1). Seven days after the initial trauma, under antiplatelet therapy, the patient underwent closed reduction on the traction table and internal fixation with the Gamma3 Stryker 130° cephalomedullary nail, with fluoroscopy control of the fracture reduction and proper positioning of the implant according to the surgical technique and placement of the locking screw without apparent intraoperative complications (Fig. 2). The patient was discharged from the hospital on the fourth postoperative day, with partial weight bearing on the affected limb. At the 36th postoperative day, she was taken to a primary healthcare center due to incapacitating pain and functional disability of the operated lower limb; the symptoms worsened gradually, without apparent traumatic events when the patient already beared full weight on the operated limb. She was once again referred to the ED; a hip radiograph demonstrated intrapelvic medial migration of the cephalic screw and loss of the fracture reduction (Fig. 3). The presence of internal organ injury was not observed through imaging using pelvic CT scan nor clinically. The patient underwent the extraction of the Gamma3 nail and second osteosynthesis with plate and sliding screw (Fig. 4), without intra- or postoperative complications. During the outpatient follow-up, cut-out of the cephalic screw was observed at six months postoperatively (Fig. 5). A new surgery was proposed, but was refused by the patient and her relatives; the patient was kept in outpatient monitoring. Eighteen months after the initial trauma, the patient had general condition worsening with limited mobility, moving in a wheelchair and without significant pain complaints. She still refused to undergo a new surgery.

Fig. 1
Radiograph disclosing an intertrochanteric fracture.

Fig. 2
The patient underwent closed reduction and osteosynthesis with cephallomedulary screw and nail Gamma3 Stryker 130°; intraoperative radiography of the hip, anteroposterior and lateral views.

Fig. 3
Hip radiograph showing intrapelvic medial migration of the cephalic screw and loss of fracture reduction.

Fig. 4
The patient underwent extraction of the Gamma3 nail and revision osteosynthesis with plate and sliding screw.

Fig. 5
During the outpatient follow-up, cut-out of the head screw was observed.

Discussion

Cephalomedullary nailing is widely used in the fixation of proximal femur fractures presenting numerous benefits, namely high mechanical stability with shorter operative time, smaller incision, early weight bearing, and good clinical and radiological results. However, several complications have been associated with this procedure; varus reduction loss and cut-out are the most common. Conversely, medial migration of the cephalic screws in Gamma nails is an exceptionally unusual complication, as there have been only nine cases reported in the literature.^{6,7,8,9,10,11,12,13,14,15,16,17and18} The exact etiology of this condition remains unknown due to its uniqueness.

Iatrogenic damage of the femoral head during reaming, screw placement in improper position on the femoral head, early loading, subjecting the implant to excessive torsional forces, direct trauma that produces a defect in the screw-nail slot interface, the misplacement of the set screw in the proximal nail extremity, and the choice of a too short or too long cephalic screw have been associated with this unusual complication.^{15,16,17and18}

In the present case, all the steps of the surgical technique were properly executed, and the reduction and osteosynthesis were appropriate; therefore, the cause(s) of the medial migration of the screw is(are) unknown. Early loading, subjecting the implant to excessive torsional forces, or direct trauma not disclosed by the patient may have contributed to osteosynthesis failure.

In this case, a second fixation device with screw in a femoral head and neck already weakened by osteoporosis in a 92-year-old patient and by prior surgery requiring local approach for the extraction of the proximal screw was shown to not have been a good option. At the time, the authors could have chosen to perform fixation with methylmethacrylate cement, to increase the mechanical strength of the cephalic fixation, such as the proximal femoral antirotation nail.^19and20

The orthopedic surgeon must be aware of the occurrence of this complication and its associated risks, notably intrapelvic penetration and associated visceral injury.

References

• ¹
  Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res. 1984;(186):45-56.
• ²
  Haynes RC, Pöll RG, Miles AW, Weston RB. Failure of femoral head fixation: a cadaveric analysis of lag screw cut-out with the gamma locking nail and AO dynamic hip screw. Injury. 1997;28(5-6):337-41.
• ³
  Lorich DG, Geller DS, Nielson JH. Osteoporotic pertrochanteric hip fractures: management and current controversies. Instr Course Lect. 2004;53:441-54.
• ⁴
  Rockwood C, Green D, Bucholz R. Fractures in adults. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1991.
• ⁵
  Campbell WC, Canale ST, Beaty JH. Campbell's operative orthopaedics. 11th ed. Philadelphia: Mosby/Elsevier; 2008.
• ⁶
  Sehat K, Baker RP, Pattison G, Price R, Harries WJ, Chesser TJ. The use of the long gamma nail in proximal femoral fractures. Injury. 2005;36(11):1350-4.
• ⁷
  Valente M, Crucil M, Alecci V. Treatment of lateral femoral neck fractures with the Proximal Femoral Nail Antirotation (PFNA). GIOT. 2009;35:79-83.
• ⁸
  Chen Q, Zhou Z, Guan L. Comparison of effects between two operating methods of treating intertrochanteric hip fracture with Gamma nail fixation. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2007;21(10):1027-30.
• ⁹
  Pelet S, Arlettaz Y, Chevalley F. Osteosynthesis of per- and subtrochanteric fractures by blade plate versus gamma nail. A randomized prospective study. Swiss Surg. 2001;7(3):126-33.
• ¹⁰
  Hesse B, Gächter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg. 2004;124(10):692-8.
• ¹¹
  Kukla C, Heinz T, Gaebler C, Heinze G, Vécsei V. The standard Gamma nail: a critical analysis of 1,000 cases. J Trauma. 2001;51(1):77-83.
• ¹²
  Weil YA, Gardner MJ, Mikhail G, Pierson G, Helfet DL, Lorich DG. Medial migration of intramedullary hip fixation devices: a biomechanical analysis. Arch Orthop Trauma Surg. 2008;128(2):227-34.
• ¹³
  Tauber M, Resch H. Sigmoid perforation after medial migration of lag screw in gamma nailing. Arch Orthop Trauma Surg. 2006;126(2):118-22.
• ¹⁴
  Lasanianos N, Mouzopoulos G, Georgilas I. Hip screw lateral migration with no cut-out or non-union implication: a case report. Cases J. 2009;2:6419.
• ¹⁵
  Flint JH, Sanchez- Navarro CF, Buckwalter JA, Marsh JL. Intrapelvic migration of a gamma nail lag screw: review of the possible mechanisms. Orthopedics. 2010;33(4).
• ¹⁶
  Lucke M, Burghardt RD, Siebenlist S, Ganslmeier A, Stöckle U. Medial migration of lag screw with intrapelvic dislocation in gamma nailing - a unique problem? A report of 2 cases. J Orthop Trauma. 2010;24(2):e6-11.
• ¹⁷
  Li X, Heffernan MJ, Kane C, Leclair W. Medial pelvic migration of the lag screw in a short gamma nail after hip fracture fixation: a case report and review of the literature. J Orthop Surg Res. 2010;5:62.
• ¹⁸
  Lozano- Alvarez C, Alier A, Pelfort X, Martínez-Díaz S, Puig L. Cervicocephalic medial screw migration after intertrochanteric fracture fixation, OTA/AO 31-A2, using intramedullary nail Gamma3: report of 2 cases and literature review. J Orthop Trauma. 2013;27(11):e264-7.
• ¹⁹
  Wähnert D, Hofmann-Fliri L, Richards RG, Gueorguiev B, Raschke MJ, Windolf M. Implant augmentation: adding bone cement to improve the treatment of osteoporotic distal femur fractures: a biomechanical study using human cadaver bones. Medicine (Baltimore). 2014;93(23):e166.
• ²⁰
  Fensky F, Nüchtern JV, Kolb JP, Huber S, Rupprecht M, Jauch SY, et al. Cement augmentation of the proximal femoral nail antirotation for the treatment of osteoporotic pertrochanteric fractures - a biomechanical cadaver study. Injury. 2013;44(6):802-7.

• ☆
  Study conducted at the Local Heath Unit of Alto Minho, Viana do Castelo, Portugal; and at the Plastic Surgery Service, Hospital de Gaia, Porto, Portugal.

Publication Dates

• Publication in this collection
  Nov-Dec 2016

History

• Received
  05 Nov 2015
• Accepted
  01 Dec 2015