Research Article: Perceptions and Realities for Distal Freehand Interlocking of Intramedullary Nails

Date Published: April 5, 2015

Publisher: Hindawi Publishing Corporation

Author(s): Robert F. Ostrum.


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.

Partial Text

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 [2–14]. 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 [2–14]. 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.

An anonymous, voluntary survey was sent out to 1400 orthopaedic surgeons through an Internet link via SurveyMonkey ( 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 X2 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.

Of the 316 respondents, the practice groups included 125 surgeons who were community surgeons without residents (CNR), 33 were community surgeons with residents (CWR), 150 were in academic practice with residents (AWR), and 8 surgeons listed their practice as other and were not included in the analysis. When analyzing the sample by fellowship training there were 183 surgeons who had finished an orthopaedic trauma fellowship (WF) and 130 who had not done a fellowship (NF); 3 did not answer and were not included in the analysis. The analyses were done comparing the CWR, the CNR, and the AWR groups to each other and then the results for the WF and NF groups were compared. With Bonferroni correction to P < 0.003, the CWR and AWR groups had no significant differences on any of the variables considered, nor did the CWR and CNR physicians. When analyzing whether distal freehand interlocking was a difficult and time consuming procedure, there were no differences when comparing the AWR and the CWR groups. However, the CNR group was significantly more likely than the AWR group (P = 0.001) to perceive distal interlocking as difficult and not easily learned as was the NF group compared to the WF group (P = 0.001). The greatest disparity was seen when comparing the AWR group to the CNR group and the NF group to the WF group who were dissimilar in their perceptions of the difficulty of distal interlocking and whether this was an easily learned technique (P = 0.002). Multiple logistic regression results show fellowship trained surgeons to be 60% (95% CI, 18–81%) less likely (P = 0.01) to find DFHI difficult after adjusting for community versus academic practice and whether or not residents were present. Multiple logistic regression results further showed that surgeons with residents were 76% (95% CI = 0.05–1.09) less likely (P = 0.07) to perceive DFHI as difficult when compared to surgeons without residents. When questioned about whether “DFHI is an easy, learnable technique,” the WF surgeons were 6.8 times more likely (95% CI = 1.47–31.17) to agree that DFHI is easily learned than the NF surgeons. As for “my choice to use DFHI screws is based on my comfort with the technique and not the fracture pattern,” 41% of all surgeons used distal freehand interlocking based on their comfort with the technique and not the fracture pattern. This study demonstrated that surgeons who work with residents and those that had done an orthopaedic trauma fellowship found distal freehand interlocking an easily learned technique and that it was employed by them more often than those surgeons without residents or fellowship training. The pendulum seems to have swung in the intramedullary nailing direction for the treatment of pertrochanteric fractures. Anglen and Weinstein showed that, among those orthopaedists taking Part II of the American Board of Orthopaedic Surgery certification examination in 2006, 67% preferred an intramedullary nail over a sliding hip screw for fixation of a trochanteric fracture versus only 3% intramedullary fixation in 1999 [16]. The reasons for this paradigm shift are unclear as the literature supports no clear advantage to the short IM nail over a SHS and to the contrary short intramedullary nailing has a higher complication rate than plate fixation [2–14]. Mortality and functional outcome were the same independent of the implant utilized [2]. Hesse and Gächter reported an 8% of implant related complications when treating proximal femur fractures with a short Gamma nail [4, 5], while Madsen et al. reported a reoperation rate of 8% and a 4% implant related fractured femur rate was reported with the use of short Gamma nail in the treatment of unstable pertrochanteric fractures [6]. All of these studies as well as other comparative studies demonstrated little benefit to the short IM nail versus the SHS, but all showed a higher complication rate with the short intramedullary nail [2–14]. Although there are many papers that examine the differences between a short IMHS and a SHS, there are none comparing a long intramedullary nail to a short intramedullary nail in the treatment of proximal femur fractures.   Source: