CASE REPORT Forward Progression of the Helical Blade Into the Pelvis After Repair With the Trochanter Fixation Nail (TFN) Matthew A. Frank, MD, Richard S. Yoon, BS, Praveen Yalamanchili, MD, Edward W. Choung, DO, and Frank A. Liporace, MD Summary: Unstable intertrochanteric and subtrochanteric fractures historically have been prone to inferior displacement of the femoral head as well as varus collapse. Efforts to mitigate these untoward outcomes have led to the evolution of the Trochanteric Fixation Nail (TFN) with its helical spiral blade. The TFN has many proposed advantages such as simpliﬁed insertion, less hardware, and improved resistance to ‘‘cutout’’ of cephallomedullary ﬁxation. Previous case reports have shown spiral blade perforation through the femoral head and, in some cases, into the hip. However, to our knowledge, there have not been any reports describing the advancement of the helical spiral blade into the pelvic cavity. We present a case of forward advancement of the helical spiral blade through the femoral head and acetabulum into the pelvic cavity. Key Words: intertrochanteric hip fracture, intramedullary femoral nail, forward progression, helical blade, trochanter ﬁxation nail (TFN) (J Orthop Trauma 2011;25:e100–e103) INTRODUCTION As the US population ages, orthopaedic surgeons will be faced with increasing incidence of fractures about the hip. In regard to unstable fractures (AO types A2/A3), improved techniques and recent studies have elucidated the mechanical advantage of intramedullary (IM) ﬁxation devices 1–4 ; whether repair is performed using either an IM nail with a lag screw or a helical blade, ideal results have not yet been realized with complication rates ranging to upwards of 18%. 5 Commonly reported complications of the gamma nail include: hip screw cutout, femoral stress fractures, varus deformity, femoral collapse, and peri-implant fracture. 6–9 These failures have led to the development of the Trochanter Fixation Nail (TFN) (Synthes, Inc, West Chester, PA), substituting a helical blade design for the lag screw design. Initial analyses have been promising. Biomechanically, the blade achieves its ﬁxation by compacting cancellous bone, allowing for a single construct with superior angular stability against varus collapse and antirotation. 3,10–12 Like any device, the TFN is not without its complica- tions. Recent reports of forward progression of the blade with perforation into, but not through, the hip have been reported despite achievement of ideal fracture reduction and hardware placement. 13,14 Although a few of the cases have been associated with a fall onto the affected side, 14 the majority have been without associated trauma. Hypothetically, the sharp end of the helical blade may provide less resistance to osteoporotic bone than the force required for controlled sliding of the device during fracture impaction. CASE REPORT An 87-year-old woman with long-standing insulin-dependent diabetes and hypertension sustained a fall from standing height onto her right hip and presented to the emergency department of an outside institution. Initial radiographs revealed an unstable intertrochanteric fracture (AO A3) of her right hip (Fig 1), prompting immediate closed reduction and ﬁxation with a long TFN (Synthes, Inc) using a helical spiral blade. Albeit slightly posterior, blade positioning appeared adequate with a completely engaged set screw (Fig 2A–C). The patient tolerated the procedure well and had an uneventful hospital course. Subsequently, she was discharged to a subacute rehabilitation facility on the third postoperative day with full weightbearing mobilization. Of note, without appropriate anteroposterior or lateral views of the hip, we were unable to determine the postoperative Garden-Alignment angle, the tip–apex distance, or the Cleveland index. 3,15,16 The operative report, however, did indicate conﬁrmed insertion of the set bolt within the nail with adequate reduction after the IM ﬁxation. During her third week at the rehabilitation facility, the patient reported acute onset of right hip pain. She denied any falls or trauma to the affected side. Repeat radiographs were obtained, although sliding compression of the fracture occurred and medial migration of the helical blade through the femoral head and acetabulum into the pelvic cavity was present. With these ﬁndings, the patient was transferred to our facility for deﬁnitive management. On arrival, repeat radiographs conﬁrmed the intrapelvic location of the helical blade (Fig 3) and computed tomography indicated the tip of the helical blade approximately 2.1 cm medial to the quadrilateral plate in close proximity to the right iliac arteries, which were noted to have a pseudoaneurysm on the radiology report (Fig 4A–D). Doppler ultrasonography as well as computed tomog- raphy ruled out perforation of any vessels and no evidence of free ﬂuid or active hemorrhage. Operative treatment began with removal of the TFN com- ponent hardware through an extended posterolateral approach. Removal of the proximal femur with the femoral head revealed Accepted for publication November 15, 2010. From the Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Medicine and Dentistry of New Jersey (UMDNJ)– New Jersey Medical School, Newark, NJ. No funds were received in support of this work. The authors declare no conﬂicts of interest. Reprints: Frank A. Liporace, MD, Associate Professor of Orthopaedic Surgery, Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, UMDNJ–New Jersey Medical School, 90 Bergen Street, Newark, NJ 07103 (e-mail: liporace33@gmail.com). Copyright Ó 2011 by Lippincott Williams & Wilkins e100 | www.jorthotrauma.com J Orthop Trauma  Volume 25, Number 10, October 2011