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Advances in Orthopedics
Volume 2015, Article ID 834582, 5 pages
http://dx.doi.org/10.1155/2015/834582
Research Article

Perceptions and Realities for Distal Freehand Interlocking of Intramedullary Nails

Department of Orthopaedic Surgery, University of North Carolina, 3160 Bioinformatics Building, CB 7055, Chapel Hill, NC 27599, USA

Received 18 October 2014; Accepted 25 February 2015

Academic Editor: Panagiotis Korovessis

Copyright © 2015 Robert F. Ostrum. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

There is a perception that distal freehand interlocking (DFHI) of intramedullary nails can be difficult and time consuming. This study consists of a survey of surgeons’ practices for DFHI screws and their reasons for not using this technique. A survey was sent to 1400 orthopaedic surgeons who were asked to agree or disagree with statements regarding the difficulty and indications for the usage of distal freehand interlocking screws. The results were analyzed by practice demographics, resident availability, and completion of an orthopaedic trauma fellowship. Overall, 316 surgeons (22.6%) responded to the survey. Fellowship trained surgeons were 60% less likely to find DFHI difficult when compared to nonfellowship surgeons and surgeons with residents were 76% less likely to perceive DFHI as difficult than surgeons without residents. In all groups, 40–43% of surgeons used distal interlocking based on their comfort with the technique and not the fracture pattern. Distal freehand interlocking is perceived as difficult by community orthopaedic surgeons without residents and surgeons who have not done an orthopaedic trauma fellowship. Forty percent of surgeons based their usage of DFHI screws on their comfort with the technique and not the fracture pattern.

1. Introduction

Proximal femur fractures are a common injury treated by orthopaedic surgeons. Currently, a large number are surgically treated with an intramedullary nail (IMN). Which type of IMN is employed appears to be based on surgeon preference and other associated variables. Starr et al. compared piriformis entry IMNs to trochanteric IMNs in the treatment of proximal femur fractures. The authors found no differences in any of the surgical parameters that they looked at nor did they find that either nail was preferable for functional outcome [1]. Other authors have looked at the use of trochanteric entry, cephalomedullary devices such as the Gamma nail (Stryker, Mahwah, New Jersey) in the treatment of subtrochanteric fractures [214]. In two reviews of the Cochrane Database of Systematic Reviews, Parker and Handoll found that when comparing a short IMN to a sliding hip screw (SHS) in the treatment of extracapsular femur fractures the short IMNs had a higher complication rate [2, 3]. Hesse and Gächter demonstrated a 16% general complication rate and an 8% implant related complication rate when they studied the use of a short Gamma nail for trochanteric fractures [4, 5]. Thigh pain and refracture at the tip of the short IMN have been the most common complications seen with use of a short intramedullary implant [214]. Some orthopaedic surgeons have progressed to using a long intramedullary device to treat proximal femur fractures to avoid the complications seen with short nails and because they believe that these fractures, often associated with osteoporosis, represent a pathologic fracture [15]. The use of a short IMN allows the surgeon to use an outrigger device attached to the insertion handle to insert the interlocking screws in the distal end of the IMN. However, the use of a long intramedullary nail requires the surgeon to employ the technique of distal freehand interlocking screw placement. This cannot be done with the assistance of a jig and requires some level of surgical expertise and additional operating room and fluoroscopic time.

The purpose of this study was to look at the practice patterns and preferences of orthopaedic surgeons when treating a proximal femur fracture with an intramedullary nail and to determine whether the use of distal freehand interlocking of a long nail was driven by the fracture pattern or surgeon comfort with the technique.

2. Materials and Methods

An anonymous, voluntary survey was sent out to 1400 orthopaedic surgeons through an Internet link via SurveyMonkey (https://www.surveymonkey.com/) to the Pennsylvania Orthopaedic Society, New Jersey Orthopaedic Society, and the Orthopaedic Trauma Association. There were a total of 316 (22.6%) responses received out of the approximately 1400 surveys that were sent. The survey included the following: (1) the utilization of distal, freehand interlocking screws can be difficult and is often time consuming; (2) the use of distal, freehand interlocking screws is an easy, learnable technique; (3) my choice to use distal, freehand interlocking screws is based on my comfort with the technique and not the fracture pattern. Demographic data was collected on the respondents that included their extent of orthopaedic training, that is, those who had done an orthopaedic trauma fellowship (WF) and those who did not have a fellowship (NF) (Figure 1). Further, the type of practice was recorded and categorized into the following: those surgeons practicing in the community with residents (CWR), those community surgeons without residents (CNR), and those in academic practice with residents (AWR) (Figures 2 and 3). Responses were analyzed by Pearson or Fisher exact test in accordance with distributional assumptions and filtered by the type of practice and presence or absence of trauma fellowship. Separate multiple logistic regression models were fit to utilization of distal freehand interlocking screws, ease of the DFHI technique, and choice to use distal freehand interlocking screws.
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