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Alzahrani MM, Aljamaan Y, Alsayigh J, Alghamdi S, Alqahtani SM, Papp SR. Optimal entry point for antegrade and retrograde femoral intramedullary nails. Chin J Traumatol 2023; 26:249-255. [PMID: 37031048 PMCID: PMC10533528 DOI: 10.1016/j.cjtee.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/27/2023] [Accepted: 03/25/2023] [Indexed: 04/10/2023] Open
Abstract
Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.
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Affiliation(s)
- Mohammad M Alzahrani
- Orthopedic Surgery Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Yousef Aljamaan
- Orthopedic Surgery Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Jaffar Alsayigh
- Orthopedic Surgery Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Shahad Alghamdi
- Orthopedic Surgery Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Saad M Alqahtani
- Orthopedic Surgery Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Steven R Papp
- Division of Orthopaedic Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
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Chouhan D, Behera P, Ansari MT, Digge VK. Posterior hip dislocation associated with concomitant ipsilateral femoral head and shaft fractures: an unusual combination of injuries. BMJ Case Rep 2021; 14:e244453. [PMID: 34446518 PMCID: PMC8395262 DOI: 10.1136/bcr-2021-244453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/04/2022] Open
Abstract
The combination of posterior hip dislocation with an ipsilateral femoral head and shaft fractures is unusual. While cases of concomitant fractures of femoral head and shaft have been previously reported, the treatment of such injuries is challenging. Presence of an associated hip dislocation further complicates the matter. A timely diagnosis and treatment are crucial to have a good outcome.We are presenting the case of a 20-year-old man who sustained a traumatic posterior hip dislocation with ipsilateral femoral shaft and femur head fractures. After reducing the hip, we fixed the femoral shaft with a retrograde femur nail and the femoral head by the trochanteric flip approach in the same sitting. The patient returned to his pre-injury occupation after 4 months. He has been doing well until his last follow-up, 1 year after the surgery, thus emphasising the utility of following basic principles of trauma management in the management of unusual injuries.
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Affiliation(s)
- Deepak Chouhan
- Department of Orthopaedics, Kashmiri hospital and Heart care centre, Sunam, Punjab, India
| | - Prateek Behera
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Mohammed Tahir Ansari
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Kumar Digge
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Kubik JF, Bornes TD, Klinger CE, Dyke JP, Helfet DL. The effect of calcar femoral neck plating on vascularity of the femoral head and neck. Bone Jt Open 2021; 2:611-617. [PMID: 34378395 PMCID: PMC8384446 DOI: 10.1302/2633-1462.28.bjo-2021-0099.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Aims Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck. Methods A Hueter approach and capsulotomy were performed bilaterally in six cadaveric hips. In the experimental group, a one-third tubular plate was secured to the inferomedial femoral neck at 6:00 on the clockface. The contralateral hip served as a control with surgical approach and capsulotomy without fixation. Pre- and post-contrast MRI was then performed to quantify signal intensity in the femoral head and neck. Qualitative assessment of the terminal arterial branches to the femoral head, specifically the inferior retinacular artery (IRA), was also performed. Results Quantitative MRI revealed a mean reduction of 1.8% (SD 3.1%) of arterial contribution in the femoral head and a mean reduction of 7.1% (SD 10.6%) in the femoral neck in the plating group compared to non-plated controls. Based on femoral head quadrant analysis, the largest mean decrease in arterial contribution was in the inferomedial quadrant (4.0%, SD 6.6%). No significant differences were found between control and experimental hips for any femoral neck or femoral head regions. The inferior retinaculum of Weitbrecht (containing the IRA) was directly visualized in six of 12 specimens. Qualitative MRI assessment confirmed IRA integrity in all specimens. Conclusion Calcar femoral neck plating at the 6:00 position on the clockface resulted in minimal decrease in femoral head and neck vascularity, and therefore it may be considered as an adjunct to laterally-based fixation for reduction and fixation of femoral neck fractures, especially in younger patients. Cite this article: Bone Jt Open 2021;2(8):611–617.
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Affiliation(s)
- Jeremy F Kubik
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Troy D Bornes
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Craig E Klinger
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Jonathan P Dyke
- Citigroup Biomedical Imaging Center and Weill Medical College of Cornell University, New York, New York, USA
| | - David L Helfet
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
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Treatment of Ipsilateral Femoral Neck and Shaft Fractures With Cannulated Screws and Antegrade Reconstruction Nail. J Orthop Trauma 2020; 34:e176-e180. [PMID: 31688439 DOI: 10.1097/bot.0000000000001689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ipsilateral femoral neck and shaft fractures are challenging injuries, and there are different fixation options but no consensus on a superior construct. Our preferred method is cannulated screw fixation of the femoral neck and antegrade reconstruction nailing of the shaft. Compressive fixation of the femoral neck fracture with cancellous lag screws followed by reconstruction nail placement provides compressive fixation and fixed angle support of the neck fracture while allowing for more optimal treatment of femoral shaft fractures at or above the isthmus. The purpose of this submission is to describe the surgical decision-making, surgical technique, and all surgically related complications of this technique.
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Rollick NC, Gadinsky NE, Klinger CE, Kubik JF, Dyke JP, Helfet DL, Wellman DS. The effects of dual plating on the vascularity of the distal femur. Bone Joint J 2020; 102-B:530-538. [PMID: 32228080 DOI: 10.1302/0301-620x.102b4.bjj-2019-1776] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. METHODS A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. RESULTS Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. CONCLUSION Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530-538.
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Affiliation(s)
- Natalie C Rollick
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Naomi E Gadinsky
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Craig E Klinger
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Jeremy F Kubik
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Jonathan P Dyke
- Citigroup Biomedical Imaging Center and Weill Medical College of Cornell University, New York, New York, USA
| | - David L Helfet
- Orthopaedic Trauma Service, Hospital for Special Surgery, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - David S Wellman
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Gadinsky NE, Klinger CE, Sculco PK, Helfet DL, Lorich DG, Lazaro LE. Femoral Head Vascularity: Implications Following Trauma and Surgery About the Hip. Orthopedics 2019; 42:250-257. [PMID: 31355905 DOI: 10.3928/01477447-20190723-03] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/28/2019] [Indexed: 02/03/2023]
Abstract
Traumatic injury and surgical intervention about the hip joint place the arterial supply to the femoral head (FH) at risk. Compromised perfusion may lead to FH ischemia, cell death, and osteonecrosis. Progression to FH collapse may lead to pain, functional impairment, and decreased quality of life, especially in younger patients. This review describes the arterial supply to the FH, analyzes the impact of femoral neck fractures on FH vascularity, and explores the vascular implications of various surgical interventions about the hip, offering specific techniques to minimize iatrogenic damage to the vessels supplying the FH. [Orthopedics. 2019; 42(5):250-257.].
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Gruskay JA, Fragomen AT, Rozbruch SR. Idiopathic Rotational Abnormalities of the Lower Extremities in Children and Adults. JBJS Rev 2019; 7:e3. [PMID: 30624306 DOI: 10.2106/jbjs.rvw.18.00016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Donders JCE, Klinger CE, Shaffer AD, Lazaro LE, Thacher RR, Dyke JP, Wellman DS, Helfet DL, Lorich DG. Quantitative and Qualitative Assessment of the Relative Arterial Contributions to the Calcaneus. Foot Ankle Int 2018; 39:604-612. [PMID: 29346737 DOI: 10.1177/1071100717749229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to quantitatively and qualitatively assess relative arterial contributions to the calcaneus. METHOD Fourteen cadaveric ankle pairs were used. In each specimen, the posterior tibial artery, peroneal artery, and anterior tibial artery were cannulated and used for contrast-enhanced magnetic resonance imaging (MRI) and computed tomography (CT). Quantitative MRI analysis of the pre- and postcontrast MRI scans facilitated assessment of relative arterial contributions. In addition, postcontrast MRIs were used to measure all perfused arterial entry points and scaled to a 3-dimensional calcaneus model. Contrast-enhanced CT imaging was assessed to further delineate the extraosseous arterial course. Two pairs underwent infusion of diluted BaSO4 through a constant-pressure pump using extended infusion duration. RESULTS Quantitative MRI findings indicated the peroneal artery provided 52.6% of the calcaneal arterial supply, 31.6% from the posterior tibial artery, and 15.8% from the anterior tibial artery. The cortical entry points were found in fairly consistent patterns along calcaneal cortical surfaces. All specimens demonstrated intraosseous anastomoses between lateral and medial entry points at common locations. CONCLUSIONS The peroneal artery was found to provide the largest calcaneal arterial contribution, followed by the posterior tibial artery and anterior tibial artery. A rich anastomotic arterial network was found supplying the calcaneus. CLINICAL RELEVANCE This study provides quantitative and qualitative findings of the relative arterial contribution of the calcaneus. This knowledge can help expand our understanding of calcaneal vascularization, demonstrate the vascular impact of calcaneal fracture and surgery, and facilitate future research on the arterial anatomy of the calcaneal soft tissue envelope.
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Affiliation(s)
- Johanna C E Donders
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
| | - Craig E Klinger
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
| | - Andre D Shaffer
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
| | - Lionel E Lazaro
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
| | - Ryan R Thacher
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
| | - Jonathan P Dyke
- 3 Citigroup Biomedical Imaging Center, Weill Cornell Medicine, New York, NY, USA
| | - David S Wellman
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
| | - David L Helfet
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
| | - Dean G Lorich
- 1 Hospital for Special Surgery and New York Presbyterian Hospital, New York, NY, USA.,2 Weill Cornell Medicine, New York, NY, USA
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Assaghir Y. Retrograde entry portal for femoral interlocking nailing in femoral nonunion after plate failure: a prospective comparative study with antergrade portal. J Orthop Traumatol 2016; 18:77-82. [PMID: 27439956 PMCID: PMC5310996 DOI: 10.1007/s10195-016-0416-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/26/2016] [Indexed: 11/25/2022] Open
Abstract
The piriformis fossa is the ideal portal of entry for antegrade interlocking nailing. Localizing this portal can be difficult and its eccentricity leads to complications. This prospective comparative study was designed to compare an innovative way to obtain the ideal portal from inside the medullary canal in cases of plate failure and compare it to the classic antegrade portal. It included 41 cases (19 antegrade and 22 retrograde). The retrograde portal was significantly better in terms of entry time, radiation time, blood-loss, and wound length. The proper portal was rapidly and easily achieved in all retrograde cases without complications; while four in antegrade cases had complications. Minimum follow-up was 2 years. Level of evidence III.
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Affiliation(s)
- Yasser Assaghir
- Orthopaedic Department, Sohag Faculty of Medicine, Sohag University, Sohâg, 82425, Egypt.
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Kim JW, Oh JK, Byun YS, Shon OJ, Park JH, Oh HK, Shon HC, Park KC, Kim JJ, Lim SJ. Incidence of Avascular Necrosis of the Femoral Head After Intramedullary Nailing of Femoral Shaft Fractures: A Multicenter Retrospective Analysis of 542 Cases. Medicine (Baltimore) 2016; 95:e2728. [PMID: 26844518 PMCID: PMC4748935 DOI: 10.1097/md.0000000000002728] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The goal of this study was to determine the incidence of avascular necrosis of the femoral head (AVNFH) after intramedullary nailing of femoral shaft fractures and to identify risk factors for developing AVNFH.We retrospectively reviewed all patients with femoral shaft fractures treated with antegrade intramedullary nailing at 10 institutions. Among the 703 patients enrolled, 161 patients were excluded leaving 542 patients in the study. Average age was 42.1 years with average follow-up of 26.3 months. Patient characteristics and fracture patterns as well as entry point of femoral nails were identified and the incidence of AVNFH was investigated. Patients were divided into 2 groups according to open versus closed physis, open versus closed fractures, and age (<20 versus ≥20 years).Overall incidence of AVNFH was 0.2% (1 of 542): the patient was 15-year-old boy. Of 25 patients with open physis, the incidence of AVNFH was 4%, whereas none of 517 patients with closed physis developed AVNFH (P < 0.001). The incidence of AVNFH in patients aged < 20 versus ≥20 years was 1.1% (1 of 93) and 0.0% (0 of 449), respectively (P = 0.172), which meant that the incidence of AVNFH was 0% in adult with femur shaft fracture. Of 61 patients with open fractures, the incidence of AVNFH was 0%. The number of cases with entry point at the trochanteric fossa or tip of the greater trochanter (GT) was 324 and 218, respectively, and the incidence of AVNFH was 0.3% and 0.0%, respectively (P = 0.412).In patients aged ≥20 years with isolated femoral shaft fracture, there was no case of AVNFH following antegrade intramedullary nailing regardless of the entry point. Therefore, our findings suggest that the risk of AVNFH following antegrade femoral nailing is extremely low in adult patients.
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Affiliation(s)
- Ji Wan Kim
- From the Haeundae Paik Hospital, Inje University, Busan (JWK); Korea University Guro Hospital, Seoul (J-KO); Daegu Fatima Hospital (Y-SB); Yeungnam University Hospital, Yeungnam University, Daegu (O-JS); Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul (JHP); Ilsan Paik Hospital, Inje University, Koyang (HKO); Chungbuk National University Hospital, Chungbuk National University, Cheong-Ju (HCS); Hanyang University Guri Hospital, Hanyang University, Guri (KCP); Asan Medical Center, University of Ulsan, Seoul, Republic of Korea (JJK); and Samsung Medical Center, Sungkyunkwan University School of Medicine(S-JL), Seoul, Republic of Korea
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