Experience with the Zickel device.

SUBTROCHANTERIC fractures of the femur are difficult to treat successfully. Fractures in this region show typical displacement. The strong gluteal muscles abduct the proximal fragment, whereas the adductors inserted below the fracture site adduct the distal fragment-see Figure 1. Biomechanical analysis of stress in the femur shows a high concentration of stress in the subtrochanteric region. Also, these fractures occur in bone that is predominantly cortical. These two factors, i.e. cortical bone and stress, have been suggested as reasons for the high incidence of complications.' The incidence of mechanical complications, i.e. breakage or bending of the fixation devices, has been reported by Seinsheimer I to exceed twenty per cent. Skeletal metastasis in the subtrochanteric region are frequent and pose a problem for fixation. The high stresses plus loss of bone substance make pathological fractures more difficult to stabilise than non-pathological ones. It is generally agreed that the best way to treat subtrochanteric fractures is by open reduction and internal fixation.2 However conventional blade plate devices are often unsatisfactory especially in pathological fractures because of loss of fixation.3 Heiple and colleagues2 report a significant rate of failure of the fixation device using long blade plates. The Zickel nail was designed specifically to fix securely both proximal and distal fragments of subtrochanteric fractures. Figure 2A and B shows views of Zickel device before and after assembly. Studies of the use of this device for subtrochanteric fractures, both traumatic and pathological, have been encouraging (Mickleson et al 1976: Zickel et al 1976).3,4 The purpose of this paper is to describe our results using Zickel nail fixation for the treatment of seventeen patients who had either traumatic or pathological fractures in this region of femur.