Intrapelvic Migration of the Cephalic Screw of a Proximal Femoral Long Intramedullary Nail: Case Report*

Abstract

The use of cephalomedullary devices has gained popularity in the treatment of proximal femoral fractures. Despite their biomechanical advantages, several complications are well described in the literature. One of these complications, which is rarely reported, is the medial migration of the cephalic screw. The authors present this unusual complication in a case of a long-nail implant, which was treated with removal of the implants as a first step, and posterior osteosynthesis with a locked proximal femur plate as a second step, as well the outcome until fracture consolidation and resolution of the case.

Keywords

femoral fractures - fracture fixation - internal - prostheses and implants

Introduction

Intertrochanteric fracture of the proximal femur is one of the most common fractures in patients over 65 years old, and it is often associated with osteoporosis.[1]

Cephalomedullary osteosynthesis is the preferred treatment for unstable fractures due to its biomechanical advantages. However, several complications are described, and the lateral and superior loosening of the femoral head screw is one of the most frequent problems, occurring in 3% to 10% of the cases.[1]

In turn, medial cephalic screw migration is an uncommon complication, with few cases described in the orthopedic literature, despite the high potential for morbidity and mortality.[2]

We describe a rare complication, the medial migration of the cephalic screw of an intramedullary Gamma 3 (Stryker, Kalamazoo, MI, US) nail, observed three months after osteosynthesis, as well as the conduction of the case until its consolidation.

Case Report

A 70-year-old female patient, with hypothyroidism and osteopenia, was admitted with a history of falls from her own height. She presented pain, shortening and external rotation deformity of the right lower limb associated with inability to ambulate. Radiographs of the pelvis and right hip showed an intertrochanteric fracture (AO 31-A3) of the proximal end of the right femur ([Fig. 1]).

Fig. 1 Right hip anteroposterior (AP) radiograph (preoperative).

She underwent an uneventful surgical treatment, following the principle of relative stability, with indirect reduction in the skeletal traction table, and cephalomedullary osteosynthesis using a long Gamma3 130° nail, with the help of intraoperative fluoroscopy.

In the postoperative radiographic evaluation, a 26.5-mm tip-to-apex distance (TAD) was observed ([Fig. 2]). The patient presented favorable clinical conditions for hospital discharge on the fourth day, with prescription for home rehabilitation and partial and progressive weight bearing unloading in the right lower limb, according to tolerance. Due to the good clinical evolution, she abandoned the help of the four-support walker around the sixth week, but after three months of surgery, a sudden right hip pain started, without new trauma or fall, progressively worsening and progressing towards coxofemoral joint block after two days.

Fig. 2 Right femur AP radiographs  + AP and right hip profile showing TAD calculation.

In the reassessment, we observed delayed fracture healing associated with medial migration of the cephalic screw of the nail to the pelvic region ([Fig. 3]), without signs of peritoneal irritation upon physical examination.

Fig. 3 Right hip AP radiograph showing the medial migration of the cephalic screw.

The patient was readmitted and, after five days, she underwent exploratory laparoscopy with identification of the screw in the retroperitoneal region, close to the internal iliac vessels, without evidence of damage to organs or intra-abdominal or pelvic structures ([Fig. 4]), which enabled the removal of the metallic implants by lateral access.

Fig. 4 Laparoscopic image showing the cephalic screw near the internal iliac vessels.

After one week, she underwent a new osteosynthesis with direct fracture reduction and fixation with principle of relative stability, with a plate locked to the proximal femur (DePuy Synthes, Raynham, MA, US) associated with cancellous bone graft from the iliac bone ([Fig. 5]). The patient presented a satisfactory postoperative evolution, and was discharged after four days, in good condition to restart the rehabilitation process with partial load (15% of body weight). After eight weeks, fracture healing was evidenced, which enabled movement with full load.

Fig. 5 Right hip AP and profile radiographs after definitive treatment.

Discussion

In the literature review, we did not identify the complication of medial migration of the cephalic screw in long-stem implants, as all reports found were associated with short femoral nails. Nor was the treatment of this complication found in association with proximal femur locked plaque.

Tauber and Resch[3] reported a case of intrapelvic migration of the cephalic screw with perforation of the sigmoid portion of the intestine in a patient who subsequently underwent total hip arthroplasty (THA) cemented with a long revision femoral stem. Flint et al[4] reported a case of intrapelvic migration in an 82-year-old female patient, 7 months after the fixation of an unstable pertrochanteric fracture, and a cementless THA was performed.

Heineman et al[5] described the case of an 83-year-old woman who, after three weeks of fixation, presented pin migration to the pelvic region, and was submitted to a two-stage treatment: initially, removal of the implants, and later, cementless THA. Takasago et al[6] presented a case of a 63-year-old woman with medial migration, 6 weeks after surgery. They also performed the review in two stages, with implant removal and subsequent THA.

Another migration report was made by Thein et al[7] in a patient with five weeks of osteosynthesis, in whom the internal iliac artery was embolized by the contact evidenced on computed tomography (CT), and, afterwards, THA was performed. Li et al[2] described a case of a 77-year-old woman who had a short cephalomedullary implant that was medially displaced in the 10th postoperative week. The patient underwent osteosynthesis review with placement of a shorter cephalic pin associated with a cannulated screw for anterior cancellous bone. Lucke et al[8] also described two cases of medial migration treated with partial arthroplasty of the bipolar hip.

Most recently, Pinheiro et al[9] described the same complication in a 92-year-old woman after 5 weeks of osteosynthesis with a short cephalomedullary nail. The patient underwent plate and sliding screw revision, evolving with a cut-out observed six months postoperatively, which was not reopened due to refusal of the patient and her relatives.

Several causes have been postulated to justify this potentially serious complication. Weil et al[10] tested five cephalomedullary implants and created a biomechanical simulation model. They identified that certain conditions would need to be present to achieve medial migration, such as lateral support deficiency and unstable medial cortex, constant friction within the femoral head, and varus axial load. They also suggest that the phenomenon seems to present a higher risk of occurring in unstable fractures. Other possible causes also reported in the literature are cephalic screw misplacement, improper insertion of the anti-rotation locking device, increased TAD, femoral head damage by repetitive milling, and avascular necrosis of the femoral head.[6]

Medial migration of the cephalic screw is an uncommon complication in the orthopedic literature, without description of reported cases associating it with the long cephalomedullary nail or with the treatment with proximal femur locking plate.

Conflito de Interesses

Os autores declaram não haver conflito de interesses.

^* Study conducted at the Orthopedics and Traumatology Service, Centro Médico Hospitalar Vila Velha (CMHVV), Vila Velha, ES, Brazil. Originally Published by Elsevier Editora Ltda.

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