Risk Factors for Avascular Necrosis and Nonunion after Multiple Pinning for an Intracapsular Femoral Neck Fracture

PURPOSE: We wanted to analyze the influences of risk factors on avascular necrosis and nonunion after multiple pinning for a femoral neck fracture. MATERIALS AND METHODS: Among the cases of multiple pinning for a femoral neck fracture that were seen at our department from June 1995 to May 2006, we analyze 102 cases that had more than 2 years of follow-up. We evaluated the influence of such factors as the age, gender, injury on the right- or left-side, the degree of displacement, the time to operation, the angle of fracture, the accuracy of reduction and posterior cortex comminution on avascular necrosis and nonunion after multiple pinning for a femoral neck fracture. RESULTS: The incidences of AVN and nonunion were 13.7% (14/102) and 10.7% (11/102), respectively. The degree of displacement was a significant factor that influenced the development of nonunion (p<0.05). The time to operation and the angle of fracture were significant factors that influenced nonunion (p<0.05 & p<0.05) and avascular necrosis (p<0.05 & p<0.05). The posterior cortex comminution was a significant factor that influenced nonunion (p<0.05) and avascular necrosis (p<0.05). CONCLUSION: The important risk factor for avascular necrosis was the angle of fracture over 60 degrees. The important risk factors for nonunion were the time to operation (over 24 hours), posterior cortex comminution and an angle of fracture over 60 degrees.

Multiple Pinning in Base Fracture of Distal Phalanx

PURPOSE: The purpose of this study was to evaluate the use of multiple pinning in base fracture of distal phalanx. MATERIALS AND METHODS: We reviewed the results of 8 patients treated with a multiple pinning in fracture of distal phalanx base. There were 7 men and 1 woman, and the mean age was 52.6 years(45~66 years). The type of injury was a crushing injury in 6 patients and, in direct trauma in 2. The injured finger was thumb in 4 patients, index finger in 1, long finger in 1, and ring finger in 2. We used three K-wires for fixative devices in all fractured phalanx. The average removal period of K-wire was 6.5 weeks(5~8 weeks). RESULTS: Postoperatively, immobilization was applied for 6.5 weeks (5~8 weeks). The mean fragment size was 33.8%(10~50%) of long axis of distal phalanx. The range of motion was 1.3degrees (0~5degrees ) in extension lag and 88.1degrees (85~90degrees ) of flexion of the distal interphalangeal joint. CONCLUSION: The multiple pinning of base fracture of distal phalanx was one of the useful method to stabilizing of distal phalanx fracture.

Factors Predicting Complications After Multiple Pinning of Femoral Neck Fractures / 대한정형외과학회잡지

PURPOSE: To report upon factors predicting complication after multiple pinning of femoral neck fractures, the authors performed a comparative study upon a success group and a failure group and reviewed the literature. MATERIALS AND METHODS: Among cases of multiple pinning from July 1990 to June 1998, we defined 63 cases as successful that had more than 2 years follow-up and had no complications, and 18 cases as unsuccessful that had complications like avascular necrosis, nonunion and required a secondary operation. We analyzed the two groups from the viewpoints of age, cause of injury, classification of fracture, degree of displacement, degree of osteoporosis, time interval to operation and accuracy of reduction. RESULTS: Statistically significant factors were the degree of displacement by Garden classification (p=0.007), the degree of displacement and anatomical position by AO classification (p=0.005), the time interval to operation after 7 days (p=0.012) and the postoperative accuracy of reduction (p=0.010). However, age, Singh index and the type of internal fixation device did not show statistical significance. CONCLUSION: Displaced subcapital fracture, time interval to operation after 7 days and reduction accuracy may be prediction of complications.

Femoral Neck Fracture in Young Adult: 25 Cases Treated with Multiple Pinning / 대한정형외과학회잡지

In general. femoral neck fracture in young adult presents poor prognosis due to the high velocity injury, high angle shear fracture, and poor candidate for arthroplasty. In addition to the relative rarity of the injury, the high incidence of aseptic necrosis and nonunion have been reported in the management of these fractures. 25 cases of femoral neck fracture in young adult were treated with multiple pinning and analyzed at Sung-Ae general hospital from 1987 to 1994 after 28 months follow up in average with review of charts, X-ray and clinical result. There were 18 male and 7 female, 5 cases of them had significant polytrauma to other organs or skeletal system, authors tried to treat them as soon as possible to decrease the interval time between fracture and fixation (the average time was 39.7 hours.) Union occurred in all of Garden stage I (4 cases) and II (4 cases), but in Garden stage III (7 among 8 cases) and IV (7 among 9 cases) the union rate was lower. Average union time was 16.5 weeks. The incidence of complications (12%, 3 among 25 cases) was higher in displaced fractures group (Garden stage III, IV) and also in poorly reduced group of Garden’s alignment index. In conclusion, the prognosis of femoral neck fractures in young adult was related with mainly initial reduction and rigid fixation than the initial injury.

Surgical Treatment of the Trochanteric Fracture of the Femur / 대한정형외과학회잡지

The authors have treated 30 cases of trochanteric fracture of the femur from June 1987, to July 1988 at Dong Suwon General Hospital. The 30 cases included, 8 Condylocephalic Kuentscher nailing, 9 Ender nailing, 7 Multiple pinning, 5 Antegrade Kuentscher nailing and 1 Row plating. 1. The shape of condylocephalic Kuentscher nail should be designed differently, contoured circular arc in anteroposterior and angled in lateral plane. In the anteroposterior plane : The length of the radius of the arc is measured by following way. 1) Design the shape of the nail on the X-ray film of the normal femur which was taken in full internal rotation of the leg. 2) Make three points in the femoral film. One is A, midcentral point of the femoral canal of the isthmus. Point B is center of upper lateral quadrant of the femoral head. Point C is apart from medial cortex 5-7mm at the level of entry portal of the nail. 3) Make point D: Draw the perpendicular lines from the right middle of the AB and AC. These lines meet at the point D. AD is radius of the arc of nail. Draw an arc measuring by the length of AD and mold the nail following the arc. In the lsteral plane ; The nail is bent into three or four segments and the length of the longest segment should not be exceeded the permissible length of straight nail, the latter is distance from entry portal of the nail to anterior cortex of the femur where the tip of the inserted nail is impinged, about 15cm. 2. Two different types of the Ender nailings are used depend on the type of the fracture. In intertrochanteric fracture, the trochanter is remained in the distal fragment and acts as the crane post to fix the proximal fragment(interfragmental compression screw fixation) by horizontal screw inserted through the lateral cortex of the distal fragment into medial cortex of the proximal fragment and fixed with another screw inserted into the distal fragment by tension band wiring. In transtrochanteric frscture, the proximal fragment is fixed by two different kinds of the nails, prior to the nailing medial displacement of the distal fragment is not reduced. The first nail is driven along the medial wall of the medullary canal of the distal fragment, the tip of the nail comes out of the fracture site and impinges to the inferomedeial aspect of the head along the out side of the neck. The nail is inserted into the head after correction of nail direction. The second and third nails are inserted through the medullary canal of the fragments. The proximal fragment is fixed between two nail groups. 3. Antegrade Kuentscher nailing is used for undisplaced trochanteric fracture with segmental fracture or comminuted, segmental subtrochanteric fracture. The open reduction and fixation is preferable in comminuted segmental subtrochanteric fracture for its accurate reduction. The authors msde additional several holes, transverse, sagittal (at the dorsum of the nail) oblique holes around the nail, so the interlocking screw can be easily inserted to the nail when the insertion of the screw through the transverse holes are difficult. 4. It's extremely important to study the fracture carefully when the surgeon plans to use the multiple pinning for trochanteric fracture. The fracture configuration has to be determined in regard to expect stability after local pinning especially in lateral plane. The fracture is fixed by horizontal pin, low angle pin, curved buttress pin(or screw) solidly, not parallel as in neck fracture. The curved buttress rush pin should be inserted as acting as the anteromedial or posteromedial buttress.

Percutaneous Multiple Knowles Pinning in Femur Neck Fractures / 대한정형외과학회잡지

Femoral neck fracture has given marked attention to the orthopaedic surgeon due to complications, such as avascular necrosis of femoral head, non-union and degenerative arthritis, moveover common in older age group since early part of the 20th century. It is one of disabling and unsolved problems, so various techniques and implants were introduced and applied. Percutaneous Knowles pinning is one of simple, safe and reasonably effective method in treating femoral neck fracture, provided it is performed correctly. Nineteen cases of femoral neck fracture treated with precutaneous Knowles pinning at the Department of Orthopaedic Surgery, National Medical Center were analyzed and following result were obtained. l. Among the 19 cases, 13 cases were female and 6 cases were male, and high incidence was noted in older age group. 2. The amout of bleeding during operation was less than 100ml and the operative time was less than one and half hour under the local anesthesia in majority. 3. Good result was obtained in the group of operation less than 3 days after initial injury compared to more than 3 days group. 4. There was high complication rate in poor group than acceptable group according to Garden alignment index and we could predict the end result by aid of alignment index. 5. There was no cast immobilization in case of stable reduction, good fixation and good Rapport. 6. Bony union was established within 4.7 months in non-displaced fracture and 7.3 months in displaced fracture in average. 7. There were 1 case of avascular necrosis. 3 cases of non-union and 2 cases of degenerative osteoarthritis and poor results were correlated with Garden stage.