الفهرس 
Classifications and Determining StabilityOnly 14 pages are availabe for public view
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Abstract
This work was to evaluate the results of management of twenty
patients with unstable trochanteric femoral fractures at Menoufia
university hospital with expert femoral nail. Patients age range from
24-80 years. BMI range from 24-36. Ten of patients have chronic
medical disorders. 12 patients are A2 and the other 8 are A3
trochanteric fractures.
Prophylactic antibiotic was given to all patients 30 minutes
before surgery. All patients were operated on supine position on a
radiolucent traction operating table using the C-arm. Closed reduction
was done in all cases except 4 cases in which open reduction was
done,
In trochanteric fracture, the resulting muscle forces lead to a
typical displacement pattern. The gluteal muscles abduct the proximal
fragment. The iliopsoas flexes and externally rotates the proximal
fragment. The adductors and hamstrings cause shortening and
adduction of the distal fragment, thereby resulting in relative varus of
the hip. All three forces must be neutralized for successful
immobilization and reduction of the fracture
Trochanteric entry was used in all cases probably may not to
damage the hip abductors, Cerclage was needed only in 4 cases. The
lower lag screw pins was inserted 5mm away from the subchondral
bone in the lower half in the AP view and center on the neck in the
lateral view. The superior lag screw pin was placed parallel to the
lower pin in AP view and overlapping it in the lateral view. It should
be 5mm shorter than the lower pin from the subchondral bone. Failure
to do this leads to the ―Z- effect‖ in which the inferior lag screw backs
Summary
120
out and the superior lag screw pierces the joint or the vice-versa.
Operation time range from 50-100 mins.
Patients were encouraged to sit in the bed and start ROM and
static exercise in the first day after surgery. Patients were taught
quadriceps setting exercises and knee mobilization from the first day.
After two weeks patients were encouraged to touch weight bearing
with axillary crutches or walker depending on the pain tolerability of
individual patient. Full weight bearing was allowed after full union of
the fracture. All patients were followed up at two weeks for removal
of sutures then at an interval of 6 weeks till the fracture union is noted
and then after once in 3 months till 1year. At every visit patient was
assessed clinically regarding to Merle d’Aubigné scoring system and
hip and knee function, walking ability, fracture union, deformity and
shortening. X-ray of the involved hip with femur was done to assess
fracture union.
Complete union had occurred in 17 patients (85%) and their
functional results revealed that they returned to their preinjury activity
level 1 year postoperative. No union in three patients (15%) who had
to use walking aids with functional impairments in hip function and
postoperative pain. Seven patients (35%) complained of occasional
pain during long distance walking, but were generally satisfied with
their treatment.
5 patients (25% of the sample) have thigh pain. All of them
have displaced and non-united lesser trochanter.
The incidence of infection was 5% (only one case was infected)
and there was no significant association between infection and
operation time or open reduction or DM.
Summary
121
Backing out of screws occurred in 4 cases, one of them was Zeffect
and another was reversed Z-effect and in two cases both screws
were backed out.
Backing out of screws occurred in 4 cases but two of them have
united, there is no significant relationship between the backing out of
screws and the union.
Only one patient has +ve trendlenberg test (abductor
insufficiency) comprising 5% of the sample, this patient had open
reduction but generally in this thesis there was no significant
association between open reduction and abductor insufficiency.
6 patients with reversed obliquity trochanteric fractures were
treated by expert femoral nail. The fractures healed in 5 patients and
one patient failed union and had poor results. There was no significant
differences in clinical outcome between reversed obliguity
trochanteric fracture and other types.
There was one case with basicervical trochanteric fracture and
associated with fixation failure. This case was revised by total hip
arthroplasty. Basicervical type of fractures are highly associated with
fixation failure so fracture classification assisted by 3D-CT can be
more beneficial when IM nailing is performed in trochanteric hip
fractures.
The success of expert nail depended on good surgical technique,
proper instrumentation and good C- arm visualization. We found the
following advantages, Reduction with traction is easier, Less
assistance is required, Manipulation of the patient is reduced to
minimum, Better use of C- arm with better visibility. Placement of the
patient on the fracture table is important for better access to the greater
trochanter. The anatomical reduction and secure fixation of the patient
on the operating table are absolutely vital for easy handling and good
surgical result.