“Reverse miss-a-nail technique” of reconstruction nailing for successful fixation of the ipsilateral femoral neck and shaft fracture

Abstract

Although reconstruction nails have an advantage of single-construct fixation in ipsilateral femoral neck and shaft fractures, they have not been used widely due to the technical challenges associated with their placement. Reduction is particularly demanding in patients with displaced neck fractures after nailing of the shaft fracture, and can be resulted in nonunion, malunion, and osteonecrosis. We report a new technique of reconstruction nailing after the provisional reduction and fixation of a neck fracture to achieve successful healing of this injury. Osteosynthesis using a reconstruction nail was performed in ten consecutive patients with displaced femoral neck and shaft fracture. After closed reduction of the displaced neck fracture, the femoral neck was provisionally fixed with pins in an anterolateral-to-medial direction. While maintaining reduction of the neck fracture, a nail was inserted and passed into the medullary canal posterior to the provisionally fixed pins with indirect reduction of the shaft fracture. After two reconstruction locking screws were fixed for proximal interlocking, the provisional pins were removed once distal interlocking was achieved. The radiologic outcomes included quality of reduction, healing rate, and time to the union were appraised, and the functional outcomes were assessed with Friedman and Wyman's criteria. This novel technique provided satisfactory reduction of both the femoral neck and shaft fractures with no malunion. All fractures achieved primary union, except for one case of nonunion of femoral shaft. Eight of ten patients experienced good results in functional outcome, whereas the remaining two patients reported moderate limitations in activities of daily living. At the latest follow-up, all patients had excellent range of motion in hip and knee joints. Provisional fixation after reduction of a femoral neck fracture may facilitate successful reconstruction nailing in the ipsilateral fractures of the femoral neck and shaft. This "Reverse Miss-a-Nail Technique" may minimize complications and maximize the radiologic and functional outcomes of patients who experience this injury.