الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 163 |  |  |
| | | from | 163 | | |
Abstract
We used the Cephalomedullary nail in the treatment of 20 reversed oblique intertrochanteric fractures in 20 patients, including 13 males and 7 females, whose age ranged from 37 to 70 years with a mean of 55 years. The most frequent modes of trauma were fall from height and a fall at home. These fractures were in the right side in 11 cases and in the left side in 9 cases. Follow up ranged from 3-24 months with an average of 12 months. The average time to surgical interference was 5 days. All pateints were clinically assessed according to the Merle d’Aubigné hip scoring system. Our final results were excellent in 25%, good in 40%, fair in 20% and poor in 15%. Poor results occurred in three cases. Radiologic assessment include union, malunion, failure of fixation and implant failure. There was only one case of delayed union and two non-united cases, with a union ate of 85% at final follow up. Shortening and varus deformity occurred in two cases but had no effect o the clinical and functional outcome. Failure of fixation occurred in only one case but there were no implant failures. Also there were no intraoperative or postoperative shaft fractures. from the above results, it can be seen that this implant may be used to treat reversed oblique intertrochanteric fractures of the trochanteric region. It can be considered a treatment alternative when the fracture pattern is complex and the bone is osteoporotic. The presence of the long cephalomedullary nail adds to the versatility of this implant, allowing its use even when there -is long subtrochanteric extension or shaft involvment. Performing the procedure slowly and carefully, attending to every detail, and being warned of the possible complications are enough to allow the surgeon to fix the fracture and reach a satisfactory result. The following are important considerations, which must always be put in mind: ● Pre-operative planning and measurement of the medullary canal, neck-shaft angle and a lateral view of the femur to detect abnormal curvature of femoral shaft. ● Proper and accurate choice of the entry point at the tip of the greater trochanter. ● Avoiding over-reaming. ● Manual insertion of the nail, without force, hammering or rotation. ● Correction of rotational mal-alignment by partial withdrawal of the nail, then re-introduction. ● A careful selection of the postion of the lag screw guide wire on both AP and LAT views so as to place the lag screw in an acceptable position. The main advantage of the chephalomedullary nail is the superior strength of the device and its excellent purchase, even in osteoporotic bones. The ability to lock the lag screw proximally and to lock the nail distally using 1 or 2 locking screws affords a stable fixation, which provides the patients with a sense of security and stability around the fracture and allows them to get out of bed early - When this device was first used, many technical problems were reported. This is common at the start of a learning curve. Later, complications were related to the design of the implant. Many modifications in nail design, especially after anthropometric studies, have tried to reduce preoperative fractures. Now, the nail has become shorter, narrower and with less valgus bend compared to its predecessors. This has made it possible to insert and remove the nail without producing an iatrogenic fracture. A sliding hip screw is not indicated for stabilization of reverse obliquity fracture patterns. The problem with use of the sliding hip screw is that the large-diameter lag screw does not cross the primary fracture line. A less than perfect reduction or a gap from fracture line resorption is not compensated for by telescoping of hip screw. In fact, telescoping of the implant can promote fracture separation rather than impaction. This leads to an unacceptably high failure rate when a conventional sliding hip screw is used to treat this fracture pattern. Reverse obliquity intertrochanteric fractures are best stabilized with a cephalomedullary nail. The intramedullary location provides a buttress against lateral displacement and it decreases bending strain on the implant. However, the nail should not be used for small patients, as these usually have a narrow medullary canal, nor in patients with excess antecurvature of the femur. Although initially, the procedure is technically demanding, similar to many other new implants, there is learning curve. With repetition, and a surgeon experienced in interlocking nailing, the procedure become easy to perform and complications can be avoided