Remote nailing of intertrochanteric and subtrochanteric fractures of the femur.

Remote nailing of intertrochanteric and subtrochanteric fractures of the femur is a definite addition to the armamentarium in the management of these injuries. The advantages of the technique are too great to ignore. The surgeon should not be misled, however, into thinking that this is an easy operation or that it represents a panacea for difficult fracture situations. Considerable time must be spent learning the operative technique, its pitfalls and complications, and the postoperative management of patients. After the operation we allow our patients early weight bearing in the knee-extended position, this being maintained by the use of a Jones bandage. We believe that the prevention of knee flexion minimizes stresses across the fracture site and prevents the tendency toward external rotation. Early external rotation deformity in the patient lying in bed may cause concern, but this tendency toward external rotation disappears as soon as the patient begins to walk and bear weight. In the patient with the fracture anatomically reduced and fixed a significant external rotation will not be a problem. The use of remote nailing does not eliminate complications in the surgical treatment of intertrochanteric fractures but merely replaces one set of complications for another. It is our belief that the complications arising from remote nailing in intertrochanteric and subtrochanteric fractures are of less severity to the patient and more easily managed by the surgeon than the more traditional complications occurring as a result of direct attack on the fracture site with the implantation of various nail plate devices. Lower blood loss, shorter operating time, decreased incidence of infection, earlier walking, extremely high rate of union, and extremely low rate of implant failure are sufficient returns for occasional shortening and occasional external rotation deformity, the two complications most frequently mentioned in the literature. Excessive deformity, failure of fixation, and pin migration either proximally or distally are attributable to poor technique (with the system) and are not inherent defects of the method itself. As a relatively unbiased observer I find praise and fault with both techniques and am not in a position to recommend one over the other for any given surgeon or any given fracture. The concept advanced by both Ender and Harris, however, is sound and if used correctly can improve the overall care of the unfortunate patient who suffers an intertrochanteric fracture of the femur.