Resumo

RAPOSO, João; REBELO, António; SOARES, Renato  e  TAVARES, Luís. Migração medial do parafuso cefálico de cavilha cefalo-medular Gamma3: Uma complicação rara e potencialmente fatal. Rev. Port. Ortop. Traum. [online]. 2015, vol.23, n.2, pp.185-194. ISSN 1646-2122.

Introduction: proximal femoral fractures are a common cause of morbidity and mortality in the elderly. They usually require surgical treatment, with indication for a PFN or Gamma-like nail in the unstable fractures. One of the most common complications after this procedure is a superior cut-out of the cephalic screw. A medial migration of the referred screw is an exceptionally rare complication (only 8 cases described in the literature) and it can occur with pelvic penetration, with potential organ lesion and death. We will describe one case in this paper. Material and methodos: clinical case and literature revision. Clinical case: we describe a case of a 77-year old female, who suffered a left hip trauma, with an intertrochanteric AO 31-A2.2 fracture. We did a closed reduction in traction table and a fixation with a 130º Gamma3 nail. One month after the surgery, we observed a medial migration of the cephalic screw, with acetabular penetration and loss of reduction. She underwent a second procedure, with extraction of the nail, reduction and fixation with a plate-and-screw implant (DHS) and a trochanteric plate. After 6 months, she had a cut-out of the neck screw. We did a third procedure - extraction of the osteosynthesis material and a cemented total hip arthroplasty. The patient is currently with a good function of the operated hip, without pain. Discussion: the medial migration of the cephalic screw must be clearly distinguished from the cut-out (antero-superior), usually a consequence of an inadequate fracture reduction (in varus) of inadequate positioning of the cephalic screw. A precise fracture reduction is extremely important in an unstable intertrochanteric fracture, especially because poor bone quality interferes negatively in the surgical stabilization. The clinical case reported in this paper is a very rare complication, with an unknown etiology. In this case, all the surgical steps were done correctly, the post-op and follow-up were done without any major incident, both the fracture reduction and fixation were done adequately, so we dont know why the medial migration happened. Conclusion: cephalomedullary nail fixation is a valid and common option in the treatment of intertochanteric fractures in the elderly population. The varus loss of reduction and cephalic screw cut-out are among the most common complications, and the surgeon must think about them when reducing the fracture and placing the femoral head screw, aiming for a biomechanically favorable location on the femoral neck. Despite very rare, the screw cut through is also described in the Gamma-like nails, and the surgeon must always have it in mind, because of its potencial fatality outcome.

Palavras-chave : Osteoporosis; interthrocanteric fracture; medial migration cephalic screw; cephalomedullary nail.

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