Aust. N . Z . J . Surg. 1992,62,382-384

THE ZICKEL NAIL IN THE TREATMENT OF METASTATIC BONE DISEASE IN THE UPPER END OF THE FEMUR

ALISON TAYLOR AND JONATHAN RUSH Department of Orthopaedics. St Vincent’s Hospital, Melbourne, Victoria, Australia

During a period of 5 years, 39 cases (37 patients) with metastatic bone disease in the proximal femur were treated by the insertion of a Zickel intramedullary nail using a ‘closed’ operative technique. The use of methyl methacrylate as an adjunct to fixation was not considered necessary. The results were satisfactory in terms of achieving stabilization of the fracture if present, relief of pain and the ability to commence early ambulation.

Key words: femur, Zickel intramedullary nail.

Introduction

The management of metastatic bone disease involv- ing the proximal end of the femur is a common problem. From a biomechanical viewpoint, intra- medullary fixation has been demonstrated to be more satisfactory than fixation with extramedullary (nail and plate) devices. ’

The ‘Zickel’ nail was devised by Robert E. Zickel of St Luke’s Hospital, New York for the treatment of subtrochanteric fractures of the femur.’ This in- tramedullary rod can achieve excellent stability and impaction at the fracture site. This is not possible with nail/plate fixation. Firm anchorage of the Zickel device in the femoral head and neck fixes the proximal fragment in a way that cannot be achieved by intramedullary nails. Other features of the device which add to the stability are the fact that it is a solid nail unlike most other intramedullary nails and that it has an anatomical anterior curve.

Recent reports have advocated the use of methyl methacrylate in the surgery of metastatic bone dis- ease.3 This is often not necessary and tends to in- crease the difficulty of the procedure as well as the extent of exposure and time of operation.

At St Vincent’s Public Hospital in Melbourne the Zickel nail has been used for over 10 years. This report is a review of 5 years experience (1985-89) with the use of the Zickel nail in the treatment of metastatic lesions of the femur. None of the pro- cedures included the use of cement. The closed technique was used in all cases.

In this series an effort was made to treat those

Correspondence: Mr Jonathan Rush, Medical Centre. Level 6. 55 Victoria Parade, Fitzroy, Vic 3065, Australia.

Accepted for publication 18 September 1991

patients presenting with ‘mechanical’ pain in the bone due to a metastatic lesion with prophylactic nailing rather than to treat the inevitable fracture through the lesion. There are a group of patients who present with significant metastatic deposits which are evident radiologically and on bone scan. There is no evidence of a fracture but the patient has ‘mechanical’ pain, that is, pain with movement and pain on weight-bearing but little if any pain at rest. In most cases such metastases are quite large and involve a significant amount of the cortical bone (often greater than 30%). One can predict that these lesions will almost certainly fracture if left untreated.

Methods

Thirty-seven patients were treated with 39 Zickel nails (two were bilateral) for metastatic fractures or impending fracture during 1985-89. Their ages ranged from 34 to 84 years with a mean of 60.5 years. Fourteen of the patients were male and 23 female. All patients had obvious metastatic lesions in the proximal femur. The primary tumour was carcinoma of the breast in 13, carcinoma of the lung in six, carcinoma of the prostate in five, multi- ple myeloma in four, lymphoma in two, sarcoma in two, supraglottic carcinoma in one and carcinoma of the bladder in one.

The indication for operation was either a patho- logical fracture (14 patients), or ‘mechanical’ pain indicating impending fracture (21 patients). Of the remaining four patients, three were found to have large lesions (involving greater than 50% of the cortex) during routine investigation and were con- sidered to be in danger of imminent fracture. One patient had a Zickel nail inserted after failure of

THE ZICKEL NAIL 383

a nail and plate device for a pathological fracture 1 year previously.

About 50% of the patients were referred to the St Vincent’s Hospital Orthopaedic Department from the Peter MacCallum Clinic. The remainder were referrals from the community, from the Oncology Department of St Vincent’s Hospital or directly through the Accident and Emergency Department of St Vincent’s Hospital.

In 25 of the 39 cases the site of the metastatic lesion was subtrochanteric, the remainder involving the upper end of the femoral shaft (six), the intertro- chanteric region (four), the lesser trochanter (three), and the femoral neck (one). Fifteen cases had further metastatic disease in the femur at the time of opera- tion in addition to the lesion for which they were having the surgery. Twenty-eight of the 37 patients had widespread bony metastases. And 24 had associ- ated soft tissue metastases. Fourteen patients had had radiotherapy (DXRT) pre-operatively before referral.

OPERATIVE TECHNIQUE

Thirty-five of 39 procedures were performed by the ‘closed’ technique. This technique, previously de- scribed by Sangeorzan et al . , has been shown to give very satisfactory results. A standard orthopaedid fracture operating table was used with C-arm fluoro- scopic imaging. Twenty-two of the 39 operations were performed under spinal anaesthesia and four under epidural anaesthesia. The patient was placed in the supine position with both legs strapped into the traction attachment.

If there was a fracture it was reduced on the table with image intensifier control. An incision was made over the greater trochanter and the upper end of the femur. Using an awl, a hole was made in the usual site at the tip of the greater trochanter and a guide wire inserted. Hand reamers were then used to ream the femur across the fracture and into the intramedullary canal. Biopsy specimens were then taken. The Zickel nail was inserted making sure that the nail was externally rotated sufficiently to allow for the anteversion of the femoral neck. This ensures the successful placement of the guide wire and subsequently the small trifin nail through the hole in the upper end of the intramedullary nail and into the neck of femur.

On no occasion was methyl methacrylate used as an adjunct to fixation. Intra-operative fracture through the metastatic deposit occurred in seven of the 39 operations.

Results

Thirty (8 1 O h ) of the patients were ambulant (usual- ly in a walking frame) between the second and seventh postoperative day. Of the remainder, two

were able to walk before the fourteenth day and two were delayed due to other metastases (e.g. spine) but eventually were ambulant. Three patients died before commencing to walk.

Twenty-three of the 37 patients were discharged from the orthopaedic ward within 2 weeks. Thir- teen patients required further treatment at the Peter MacCallum Clinic, eleven were discharged home, seven to convalescent hospitals and three to nursing homes. Seventeen patients had postoperative DXRT after discharge.

Three of the 37 patients died in hospital within 3 weeks of operation. A further three patients died before the first follow-up appointment at 6 weeks. By 3 months a further five patients had died and by 12 months another thirteen. At final follow-up, 13 of the 37 patients were still living. Of the 26 patients who were alive at the 3 month follow- up nine were well, five had pain and four were bedridden.

COMPLICATIONS

There were four postoperative wound infections, one occurred in a limb with marked lymphoedema pre-operatively and there was one case of multi- resistant staphylococcal infection with persistent discharge - this patient died 2 months postoperatively.

There were two implant failures. In one case the nail cut out of the femoral head superiorly at 4 weeks. The nail was removed and revised to a com- pression hip screw and plate. In the second case the patient sustained a displaced subcapital fracture around the nail 10 months after operation. Revision was performed by removal of the Zickel nail and insertion of a long stemmed Moore’s prosthesis

Discussion In the management of metastatic bone lesions in the subtrochanteric region of the femur, internal fixa- tion with a Zickel nail is effective in terms of con- trolling pain and allowing early weight-bearing. One should always attempt to recognize bone lesions early and to intervene surgically before frac- ture has occurred (Fig. I) .

The ‘closed’ technique is preferred as it has been found to minimize operating time and blood loss as well as allowing earlier postoperative m~bilization.~ The disadvantage of the technique is the absence of direct access to the lesion for biopsy and/or curet- tage and insertion of methyl methacrylate. Re- inforcement of the Zickel nail with cement has been advocated to control rotation of the distal femoral shaft, to reinforce fixation of the femoral neck- head fragment and to prevent shortening of the femur

384 TAYLOR AND RUSH

Fig. 1. Metastatic lesion (carcinoma lung) in upper end of femur with avulsed fragment of bone and tumour. Zickel nail in place.

caused by collapse of the weakened bone.3.s.6 None of the 39 nails inserted in this series lost position and all were considered to be stable enough to allow early protected weight-bearing. The introduc- tion of methyl methacrylate in most cases requires the open technique with a resultant increase in morbidity.

The results in this series demonstrate the major

advantage of this technique with rigid intramedul- lary fixation. The technique achieves dramatic relief of pain and allows the patient to recommence walking with the use of less analgesic drugs.

Although the life expectancy of many of these patients is short (six patients died within the first 6 postoperative weeks) this relatively atraumatic technique decreased the seventy of pain and in- creased patient mobility.

From this study it can be concluded that intra- medullary nail fixation using the closed technique is the operation of choice in the management of painful metastatic lesions in the upper end of the femur. Newer devices such as the Richard’s recon- struction nail may have advantages particularly in terms of controlling lesions within the femoral neck and allowing cross-bolting distally to control rota- tion of the distal fragment.

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References FIELDING J . w., CCCHRAN G. v. & ZICKEL R. E. (1 974) Biomechanical characteristics and surgical management of subtrochanteric fractures. Orthop. Clin. North Am. 5 , 629-50. ZICKEL R. E. (1967) A new fixation device for sub- trochanteric fractures of the femur. A preliminary report. Clin. Orthop. Rel. Res.54, 115-23. HARRINGTONK. D., JOHNSON J . O., TURNERR. H. & GREEN D. L. (1972) The use of methylmethacrylate as an adjunct in the internal fixation of malignant neoplastic fractures. J . Bone Joint Surg. 54A, 1665-76.

(1986) Prophylactic femoral stabilization with the Zickel nail by closed technique. J . Bone Joint Surg. 68A, 991-9. MICKELSON M. R. & BONFIGLIO M. (1976) Pathologi- cal fractures in the proximal part in the femur treated by Zickel nail fixation. J . Bone Joint Surg. 58A,

HARRINGTON K . D. (1988) Orthopaedic Management of Metastatic Bone Disease. C. V. Mosley Com- pany, Missouri.

SANGEORZAN B . J., RYAN J. R. & SALClCClOLl G. G.

1067-70.