MANAGEMENT OF FEMORAL FRACTURES IN PAGET’S DISEASE

Abstract

Twenty five femoral fractures in 23 patients with Paget’s disease had been treated since 1974 with a locking titanium Huckstep nail designed by the author in 1967 and used in the first seven patients in 1971. Paget’s disease is frequently complicated by delayed or non-union; Dove in 1980 (J. Bone Joint Surg (Br)1980;62:12–17), in an analysis of the literature, found an incidence of between 32%–35% reported non-unions after treatment in 182 femoral fractures in Paget’s disease.

Twenty-one femoral fractures in 19 patients in this series had been followed up since April 1974. Fifteen fractures had been united for over six months and eight for more than a year. Radiological union occurred in 12 fractures within six months and in a further five fractures within 12 months of operation. Three fractures took longer than 12 months to unite and one fracture remained ununited, an overall union rate of over 95%. Only three nails required removal after union, as stress shielding was not observed. This was presumably due to the low modulus of elasticity of the 12. 5 mm square section titanium alloy nail with multiple screw holes for the 4. 5 mm fine threaded titanium locking screws. Drilling for these multiple titanium screws used an accurate jig system which obviated the necessity for image intensifier control in most cases. Bowing due to Paget’s disease was improved apparently by the internal splinting effect of the nail. Difficulties of operation included increased vascularity and sclerosis of the Paget bone and associated hypercalcaemia. Bowing sometimes required a shorter nail inserted retrogradely at the fracture site. Advantages of the nail included a strength greater than the average femoral shaft which allowed for early postoperative weight-bearing in most cases. The operative and post-operative complication rate were relatively low.