The Holland nailW: a universal implant for fracturesof the proximal femur and the femoral shaft

P. Krastman, W.N. Welvaart, S.J.M. Breugem, A.B. van Vugt*

Department of Traumatology, Erasmus Medical Centre, P.O. Box 2040, 3000 CA Rotterdam,The Netherlands

Accepted 10 April 2003

Introduction

In 1940, Kuntscher introduced the intramedullaryoperative treatment of femoral fractures. Nowa-days, nailing is a well-known and widely usedmethod of treatment for proximal femoral fracturesas well as femoral-shaft fractures.1,11,14 The advan-tages of intramedullary nailing are a minimallyinvasive technique with the possibility of early full

weight-bearing. Only a powerful implant that isfirmly anchored upwards and downwards will permitfull weight-bearing without impairing the healing ofa femoral fracture.12

In 1998, the Holland nail� was introduced byBiomet for clinical use. It is a titanium device thatcan be inserted as an unreamed nail. A short (24 cm)and a long (35—52 cm) version are available. Theupper anchorage of both devices must be in thefemoral head for fractures of the neck, trochantericregion and proximal shaft, and is provided by can-nulated hip screws. The long nails can also be usedwith proximal transverse interlocking screws for alltypes of shaft fractures. The lower anchorage pro-

Injury, Int. J. Care Injured (2004) 35, 170—178

KEYWORDS

Femoral shaft fracture;

Hip fracture;

Pathological fracture;

Osteosynthesis;

Intramedullary nail;

Holland nail�

Summary Objective: To study the possibilities and outcomes for hip and femoralfractures treated with the universal Holland nail�. Design: Retrospective study fromNovember 1998 to December 2001. Setting: Department of Traumatology, ErasmusMedical Centre, Rotterdam. Subjects: 112 patients with 115 fractures of the proximalfemur and/or the femoral shaft, due to traumatic causes or to metastatic disease. Mainoutcome measures: Implant possibilities of the Holland nail� and observed complica-tions.Results: 110patients presented forprimary fracture treatment.Two patientsweretreated secondarily. In three patients, both femora were fractured. Nineteen patientssuffered a pathological (impending) fracture. During operation we dealt with 27 minordifficulties. Postoperatively, in 80% of the cases full weight-bearing was allowed. Threepatients developed wound infection. In follow-up, 14 patients were lost and two died.The remaining 77 patients (80 fractures) were available for follow-up with regard tofracture healing. Overall consolidation was achieved in 89% of the patients within 12months. Two patients developed perforation of the femoral head, necessitating removalof the hip screws, and in two patients failure of the nail was seen. Overall, 19 patientsneeded a non-planned secondary intervention, of which 12 were deemed a minorprocedure (e.g. ‘dynamisation by distal screw removal’). Conclusion: The Holland nail�

is technically easy to use for any type of hip and femoral-shaft fracture.� 2003 Elsevier Ltd. All rights reserved.

*Corresponding author. Present address: 410 Surgery, UMC St.Radboud, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.Tel.: þ31-24-361-5339.

E-mail address: A.vanVugt@chir.umcn.nl (A.B. van Vugt).

0020–1383/$ — see front matter � 2003 Elsevier Ltd. All rights reserved.doi:10.1016/S0020-1383(03)00165-7

vides the possibility of both static and dynamicinterlocking (Fig. 1). There are several indicationsfor using the Holland nail� (Fig. 2).

The operative technique is by closed reductionusing a fracture table and fluoroscopic control.Because of the design of the nail (88 lateral bend-ing), the entry point is exactly on the tip of themajor trochanter, at which site a guide wire isinserted, using a working sleeve (Fig. 3). All screwsare inserted percutaneously, using working sleeves.Distal interlocking of the long nail is achieved by afree-hand technique and fluoroscopic control. Theimplant allows immediate full weight-bearing evenin unstable fracture types.

The aim of this study is to present treatmentresults for the Holland nail� in different types offemoral fracture to the best of our belief for thefirst time.

Materials and methods

From November 1998 to December 2001, wereviewed all femoral fractures treated at theDepartment of Traumatology, Erasmus Medical Cen-tre, with the Holland nail�, in a retrospective study.

Epidemiological factors, type of injury, and per-operative as well as postoperative variables were

Figure 1 Holland nail� implants. Above: standard 9 mm short nail (24 cm) with two 7.0 mm hip screws proximally andtwo 4.0 mm transverse interlocking bolts distally (static and dynamic). Below: long 9 mm nail (35—52 cm) with 4.0 mmtransverse interlocking bolt proximally and dynamic 4.0 mm interlocking distally.

Figure 2 Indications for the Holland nail� implant.

The Holland nail 171

Figure 3 Peroperative fluoroscopic views showing the entry point and a 3 mm guide wire inserted in the correctdirection towards the femoral shaft in a patient with an intracapsular hip fracture after closed reduction according toLeadbetter’s technique: (a) AP view; (b) axial view.

172 P. Krastman et al.

registered. All fractures were classified accordingto AO principles, except intracapsular hip fractures,which were categorised in accordance with thewell-known Garden and Pauwels classification.Compound fractures were described according toGustilo. In pathological fractures, the site of themetastasis was described as inter-, subtrochantericor shaft region.

Peroperative factors concerning technical diffi-culties, early postoperative complications, and gen-eral aspects of local fracture-related variables wereregistered in a standardised way.

Fracture healing was monitored: a fracture wasconsidered to be healed when the patient couldmobilise full weight-bearing without pain and/orradiological consolidation of the fracture was visi-ble. If there was no complete radiological consoli-dation of the fracture by 26 weeks, it was classifiedas a delayed union. When consolidation exceeded 1year, the fracture was classified as a non-union.Pathological fractures were excluded from follow-up in relation to fracture healing.

Results

Epidemiology

We included 112 consecutive patients with 115fractures during the study period. There were 58men and 54 women (10:9), with an average age of 51years (range: 12—99 years).

Causes of trauma are summarised in Table 1. Thegreatest percentage arose from traffic accidents,with a considerable number of high-energy injuries(n ¼ 47). The mean hospital length of stay was 20days, with a minimum and maximum stay of 3 and120 days, respectively (median: 7 days).

One hundred and ten patients had presented forprimary fracture treatment. One patient was trea-ted secondarily, 4 weeks after insufficient stabilisa-tion of a combined fracture of the proximal femurand the femoral shaft. In another case, we used theHolland nail� secondarily after initial treatment ofa shaft fracture by external fixation in the acute

phase. In three patients, we used the implant forboth legs, because of bilateral fractures. In total,we used 115 implants for 112 patients.

Of the 112 patients, 103 (92%) were operated onthe day of admission or within 24 h. Nine patientswere operated with a delay of 24 h because of theirpoor general condition (elderly patients) or transferfrom another hospital. One patient suffered athrombocytoleucopenia with an impending patho-logical fracture, which resulted in a delay of 48 h.

Indications

The indications for the use of the Holland nail� areshown in Table 2. The fractures are subdivided intotraumatic and pathological causes. Nine fractureswere situated in the neck of the femur: with aPauwels type III steep fracture line a simple percu-taneous screw fixation is not suitable. The remain-ing traumatic fractures were localised in theproximal part and in the shaft in 42 and 40 cases,respectively, based on the AO classification. Fivefractures could not be classified accurately. Onecase showed a fracture reaching from the femoralneck up to the shaft. Another patient suffered acomplex combined per- and subtrochanteric frac-ture with shaft extension. In the remaining threecases, combined fractures of the proximal femurand the shaft were seen: a neck fracture (n ¼ 1), apertrochanteric fracture (n ¼ 1) (Fig. 4) and a sub-trochanteric fracture (n ¼ 1). There were two gradeI open fractures and one grade III open fracturebased on the classification of Gustilo. In 19 cases,pathological (impending) fractures were seen, as aresult of metastatic disease. Causes were breastcancer (n ¼ 11), multiple myeloma (n ¼ 4), lung

Table 1 Fracture causes in 112 consecutive patients

Causes of injury Number %

Traffic accident 46 41Fall 44 39Gunshot 1 1Secondary treatment 2 2Metastatic disease 19 17

Total 112 100

Table 2 Classification of 115 fractures, subdividedinto traumatic and pathological, treated with theHolland nail�

Fracture type Traumatic (n) Pathological (n)

Intracapsular 9Undisplaced 1Displaced 8

Trochanteric 42 15Stable 17 1Unstable 25 14

Diaphysis (AO 32) 40 4A 30 4B 9C 1

No classification 5

Total 96 19

The Holland nail 173

cancer (n ¼ 2), prostate cancer (n ¼ 1) and anunknown primary malignancy (n ¼ 1). The subtro-chanteric region was the most frequent site ofmetastatic disease (n ¼ 10/19, 53%).

Operative procedure

In 97% of the cases (n ¼ 109/112), a closed proce-dure was possible; only three patients underwent anopen reduction, as a result of lack of control of adislocation of the proximal part (flexion, abduction,exorotation). All the neck fractures and 89% of the

stable trochanteric fractures were treated with theshort nail. In the remaining 75 fractures, the longtype of nail was inserted.

During the operation 27 difficulties were docu-mented, none of which interfered with the pero-perative or postoperative course. In four cases, anadditional fracture/fissure was registered, notinterfering with peroperative planning. Other pro-blems we came across were: suboptimal positioningof the implant, distal positioning of the nail (n ¼ 2);the depth and axial position (AP) of the proximalscrew (n ¼ 11); or malpositioning of the distal

Figure 4 Patient with combined fracture of the proximal femur and the shaft. Successful treatment by closedreduction and a statically interlocked, long Holland nail�.

174 P. Krastman et al.

screws due to failed interlocking (n ¼ 10). Malposi-tioning of the distal screw was mainly seen duringinterlocking the short implant with the guidingdevice (n ¼ 7/33, 21%). Although, there is a ‘learn-ing curve’ in such procedures in general, even withminor adjustments of the instruments and the tech-nique, only slightly better results were seen than inthe first series: 2/8 (25%) versus 5/25 (20%) in thefollowing cases. On careful evaluation, even in thesecond series not every surgeon used the adjust-ments of the instruments optimally, so further stu-dies are needed on this important subject.

None of the above-mentioned complicationscaused serious problems during the operation orat follow-up. An important observation in this con-text was the absence of the most feared complica-tion, an additional femoral-shaft fracture due to thenailing, necessitating a change-over to anotherimplant.

Early morbidity

Ninety-five patients remained free of any generalmorbidity. Nine patients developed pneumonia,two a pulmonary embolism and one a deep venousthrombosis, despite adequate prophylaxis.

Early operation-related morbidity was seen infour patients. Infection was seen in 2.6% (n ¼ 3)of the cases, in two patients fortunately only super-ficially. In one case, a deep infection occurred incontinuity with the distal locking screw. Antibioticsand removal of the screw controlled the infectionsuccessfully. After 7 weeks, one patient developeda false aneurysm of the superficial femoral artery,treated by endovascular methods.

The surgeons decided on full weight-bearing in80% of the cases (n ¼ 90). In 25 cases, weight-bearing was to be delayed for a minimum of 3—6weeks. This decision was mostly related to co-mor-bidity (polytrauma, other fractures of the extremityin 12 cases) but also due to a rather conservativeattitude in the surgeon responsible.

Fracture healing

From the group of traumatic fractures (n ¼ 96), 14patients were lost to follow-up and two died (poly-trauma). Thus, 77 patients sustaining 80 fractureswere available for long-term follow-up. The medianfollow-up time was 11 months (range: 1—24months), in which failure and re-operation was seenas a primary endpoint. In 56 of the 80 fractures(70%), bone healing was reached within 6 months.Fifteen fractures (19%) took longer to consolidate,but healing was achieved within 1 year (delayedunion). In the remaining nine cases (11%), the result

was classified as a non-union, but in three of thesebony healing was eventually seen at 18 monthswithout intervention. Of the femoral-shaft frac-tures, 95% healed within 12 months.

Four of the implanted nails were dynamised, tooptimise consolidation, by removing the staticanchored screw as a planned minor procedure. Asa routine, in nine younger patients the nail wasremoved after bony healing, without any complaintsrelated to the implant.

Non-planned secondary interventions

Failure of fracture fixation (4—6 weeks) occurred intwo patients with a femoral-neck fracture (Table 3).Re-intervention was required by means of endopros-thetic replacement of the hip. In four cases, a non-union necessitated re-surgery, all by nail exchangeand in three cases with additional autologous bonegrafting. All of these cases healed eventually.

In five patients, malunion occurred. In two cases,a slight varus position of the proximal part resultedin healing without complaints. In two other cases, arotational deformity was observed, with re-inter-vention at short term by derotation and distal inter-locking as a minor procedure. The last case was apolytraumatised patient with an intracapsular hipfracture, which healed in a disabling endorotationdeformity. A subtrochanteric osteotomy withangled-blade plate osteosynthesis had to be carriedout at 2-year follow-up.

Two patients developed perforation of thefemoral head and three hip screws had slid laterally,causing symptoms of a trochanteric bursa. Removalor exchange of the hip screws was carried out as aminor procedure in these cases. In three patients,pain was noticed at the level of the knee, probablyrelated to the distal screws. Selective removal ofthe implant was done in these cases.

Material defects were registered six times. Onehip and three transverse interlocking screwssnapped, without complaints or clinical conse-quences. In two patients, the nail implant failed,both at the site of the distal hip screw. The first casewas a male patient with an impending pathologicalfracture. A long nail with two hip screws proximallyand static interlocking was used. Local radiotherapywas administered, but the metastatic diseaseshowed progression and led to a defect of at least3 cm in the proximal femoral shaft. With fullweight-bearing the nail broke at 7 months follow-up and a re-operation was carried out (Fig. 5). Witha lateral open approach the nail could be removedwithout difficulties. Autologous bone grafting at themedial site, shortening and stabilisation with adynamic locked 11 mm Holland nail� resulted in

The Holland nail 175

good palliation up to 22 months. The nail brokeagain and eventually a total hip prosthesis wasimplanted as the final solution. The second casewas a young man with multiple injuries, suffering asubtrochanteric fracture. A long nail with staticinterlocking was used. In this case, a delayed unionoccurred, with fracture distraction of 3 mm. Thepatient eventually showed up at 18 months post-trauma with pain due to a non-union (one of theseven mentioned above) and a broken nail. Dyna-mically interlocked re-intervention with an 11 mmlong Holland nail� and an autologous bone graft ledto a good end-result. In this case, early dynamisa-tion or at least an earlier intervention at 6—12months might have prevented this failure of thenail.

Nineteen patients suffering from pathologicalfractures were excluded from the follow-up evalua-tion on fracture healing. Nevertheless, we treatedthe pathological fractures with very good palliativeresults, although in one case mentioned above amajor secondary intervention was required twice.

Overall, 19 patients needed an unplanned sec-ondary procedure, with good end-results. In 12 ofthese, only a minor procedure was needed. In sevencases (6%), a major procedure was necessary (in onepatient twice), leading to a good result.

Discussion

During the operation a considerable number of minordifficulties occurred. Malpositioning of thedistal boltby an error (deviation) in the guiding device for theshort nail still remains the largest problem. In con-trast to experience with the first generation of hipnails, we did not observe any serious additionalmorbidity such as fracture of the femoral shaft.

Closed reduction limits the number of infec-tion.12 The number of successfully closed reduc-tions was high in this series, with an infection rate of2.6%, similar to data in the literature.5,8,9,11,14

The recent literature still lacks consensus onfemoral nailing with or without reaming.3,4,5—7,13

Table 3 Fracture healing and re-operation

Fracture type Number Lost tofollow-upor died

Fracture healing Re-operation Implementation

Union Delayedunion

Non-union

Intracapsular 9Undisplaced 1 1Displaced 8 1 4 3 3 Angled-blade plate

(n ¼ 1)/nail exchange (n ¼ 2)

Trochanteric 42Stable 17 5a 12 2 Removal or exchange hip

screw (n ¼ 2)Unstable 25 5 15 2 3 5 Endoprosthetic replacement

(n ¼ 2)/removal or exchangehip screw (n ¼ 2)/removaldistal screw (n ¼ 1)

Diaphysis (AO 32) 40A 30 3 17 8 2 4 Nail exchange (n ¼ 2)/

derotation (n ¼ 1)/exchangebroken nail (n ¼ 1)

B 9 1a 6 2 3 Removal or exchange hipscrew (n ¼ 1)/removal distalscrew (n ¼ 2)

C 1 1 1 Derotation (n ¼ 1)

No classification 5 1 2 2Subtotal 96 16 56 15 9 18Pathological 19 1 Exchange broken nail, second

THP (n ¼ 1)/good palliation inall cases

Total 115 16 56 15 9 19

THP, total hip prosthesis.a One person died due to polytrauma.

176 P. Krastman et al.

The Holland nail� is a solid interlocking 9 mm tita-nium nail, which was used as a non-reamed device inthis series, with results similar to those for the unionrate of femoral-shaft fractures in the litera-ture.8,9,16 Data from other investigations using atitanium nail for femoral-shaft and/or subtrochan-teric fractures display approximately the sameresults.5,8,9,16 Even combined hip and shaft frac-tures could be stabilised with the universal Hollandnail� implant with satisfactory results.

The rate for major surgery to complete healingwas acceptable. Failure in intracapsular hip frac-tures reached 30% in this small series and cannot berelated accurately to results in the literature. Insubtrochanteric fractures as well as shaft fractures,re-interventions were mainly related to non-union.The rate of implant failure, especially of the nail,was acceptable.

The function of the hip bolts is to prohibit rota-tional instability of the proximal fragment. Theproximal interlocking bolts thread into the femoralhead; the smooth shank of these screws allows forsliding and compression of the proximal femoralfracture and thus prevents penetration of thefemoral head. Nevertheless, we observed twopatients where removal of the hip screws had tobe carried out, because of imminent perforation ofthe femoral head.

Patients with pathological fractures had satisfac-tory functional results, with good quality of remain-

ing life obtained by a minimally invasive procedure,except in one of 19 cases. Like other authors weassume that stabilisation and diminished pain is oneof the important results for patients with a patho-logical (impending) fracture.2,10,15

In summary, the Holland nail� is technically easyto use for any type of hip and femoral-shaft frac-ture. These first surgical and clinical results in ouropinion are sufficient, but require further prospec-tive evaluation.

References

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2. Broos PL, Rommens PM, Vanlangenaker MJ. Pathologicalfractures of the femur: improvement of quality of life aftersurgical treatment. Arch Orthop Trauma Surg 1992;111:73—7.

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Figure 5 Patient with failure after Holland nail� osteosynthesis.

The Holland nail 177

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12. Tencer AF, Johnson KD, Johnston DW, Gill K. A biomecha-nical comparison of various methods of stabilization ofsubtrochanteric fractures of the femur. J Orthop Res 1984;2:297—305.

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178 P. Krastman et al.