Retrograde reamed femoral nailing

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Retrograde intramedullary nailing of the femur: identifying the true anatomic axis for the ideal start point

PURPOSE

Retrograde femoral intramedullary nailing (IMN) is commonly used to treat distal femur fractures. There is variability in the literature regarding the ideal starting point for retrograde femoral IMN in the coronal plane. The objective of this study was to identify the ideal starting point, based on radiographs, relative to the intercondylar notch in the placement of a retrograde femoral IMN.

METHODS

A consecutive series of 48 patients with anteroposterior long-leg radiographs prior to elective knee arthroplasty from 2017 to 2021 were used to determine the femoral anatomic axis. The anatomic center of the isthmus was identified and marked. Another point 3 cm distal from the isthmus was marked in the center of the femoral canal. A line was drawn connecting the points and extended longitudinally through the distal femur. The distance from the center of the intercondylar notch to the point where the anatomic axis of the femur intersected the distal femur was measured.

RESULTS

On radiographic review, the distance from the intercondylar notch to where the femoral anatomic axis intersects the distal femur was normally distributed with an average distance of 4.1 mm (SD, 1.7 mm) medial to the intercondylar notch.

CONCLUSION

The ideal start point, based on radiographs, for retrograde femoral intramedullary nailing is approximately 4.1 mm medial to the intercondylar notch. Medialization of the starting point for retrograde intramedullary nailing in the coronal plane aligns with the anatomic axis. These results support the integration of templating into preoperative planning prior to retrograde IMN of the femur, with the knowledge that, on average, the ideal start point will be slightly medial. Further investigation via anatomic studies is required to determine whether a medial start point is safe and efficacious in patients with distal femur fractures treated with retrograde IMNs.

Heterotopic ossification in the knee following retrograde nailing of a femur fracture

BACKGROUND

Heterotopic ossification (HO) is a pathologic bone formation in extra skeletal tissue and articular space. This was an objection to nailing of femur fractures across the knee; however, this has not been the case in many thousands of cases. Nonetheless, we present a patient in who placement of a retrograde nail resulted in calcification in the knee requiring excision.

CASE PRESENTATION

A 42-year-old male presented to the clinic complaining of pain, popping, clicking, and mocking in the right knee, especially in the patellar region. Nine months prior he suffered an ipsilateral femur fracture that was treated with a retrograde intramedullary nail. X-ray and CT scan were used to confirm the presentation of a heterotopic bone mass in the Hoffa area of the right knee. The patient underwent an arthrotomy for excision of the bone mass. The bone mass was excised, but bone in the ACL was not removed. The patient experienced pain relief and improved range of motion following excision.

CONCLUSION

Intraarticular heterotopic ossification is an infrequent event. We present a case of heterotopic ossification in the knee following retrograde nailing. The patient experienced improved symptoms and range of motion after excision of the intraarticular heterotopic bone mass.

Retrograde Nailing for Extremely Proximal Fractures of the Femoral Shaft

OBJECTIVES

To report the results of retrograde intramedullary nailing (RIMN) for the treatment of extremely proximal femur fractures.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

63 patients with femoral shaft fractures involving the anatomic region within 10 centimeters of the inferior border of the lesser trochanter, which were treated with retrograde intramedullary nailing.

INTERVENTION

Retrograde intramedullary femoral nail.

MAIN OUTCOME MEASUREMENTS

Time to union, nonunion, malunion, and unplanned reoperation.

RESULTS

Between 2009 and 2020, 63 fractures were followed up to fracture union, reoperation, or a minimum of 1 year clinically. The mean follow-up was 32 months, and 48 (76%) of the patients were followed up beyond 1 year clinically. The mean patient age was 34 years (range 18-84 years), and the mean BMI was 27 (range 14-45) kg/m 2 . Forty (64%) patients were polytraumatized. Clinical and radiographic union was achieved in 59 (94%) fractures after index operation at a mean time to union of 22 weeks (range 9-51 weeks). Delayed union requiring nail dynamization occurred in 1 (2%) instance. Malreduction was noted in 1 (2%) patient with a 12-degree flexion deformity that resulted in nonunion. In total, there were 3 (5%) nonunions requiring revision surgery, 1 treated with retrograde exchange nailing and 2 revised to cephalomedullary nails; all were united after revision.

CONCLUSIONS

Retrograde intramedullary nailing can be an effective treatment strategy for extremely proximal femur fractures when necessary. Our series demonstrated a high rate of union and a low rate of malalignment and complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous Intramedullary Nailing of Complex Humeral Shaft Fractures: A Retrospective Case Series

BACKGROUND

Humeral diaphyseal fractures have been traditionally stabilized with plates and screws. However, surgical morbidity can be quite extensive, particularly in more complex segmental and comminuted fracture patterns. An intramedullary nail (IMN) has the biomechanical advantage of being a load-sharing device and can be placed with a more minimally invasive technique. The purpose of this study was to evaluate the clinical and radiographic outcomes of complex humeral shaft fractures treated with an IMN utilizing a percutaneous surgical technique.

METHODS

A retrospective review was performed on a consecutive series of patients who underwent treatment of a complex humeral shaft fracture with an IMN placed with a percutaneous technique. Clinical outcome scores and radiographic analysis were performed at a minimum one-year follow-up.

RESULTS

Of the 14 patients included, 12 had clinical and radiographic follow-ups at one year. The majority (64%) were obese and involved polytrauma (50%), and 79% were AO Foundation/Orthopaedic Trauma Association (AO/OTA) type C fractures. Union after the index procedure was 93%, with one nonunion requiring a secondary operation. The average operative time was 103 minutes. There were no other complications or additional procedures. The mean clinical outcome scores included American Shoulder and Elbow Society (ASES): 78.2, Constant Score: 72.1, Single Assessment Numerical Evaluation (SANE): 81.9, and Penn Shoulder Score: 82.7.

CONCLUSION

This study demonstrates complex comminuted and segmental humeral shaft fractures in a higher-risk patient population can be effectively managed with IMN. Percutaneous placement of an IMN should be considered as a treatment option in complex humeral shaft fractures, particularly in patients with secondary comorbidities such as obesity and polytrauma.

Initial definitive treatment of open femoral shaft fractures with retrograde nailing - is it safe? A retrospective analysis comparing antegrade to retrograde nailing

INTRODUCTION

Treatment of severe open femoral fractures with retrograde intramedullary nailing, raises concerns of septic arthritis of the knee due to its intra-articular entrance point. There is little evidence concerning the safety of retrograde femoral nailing (RFN) usage in these cases, and what evidence there is does not necessarily include severe open fractures. Furthermore, the outcome of ballistic injuries treated in this manner and a comparison with antegrade femoral nailing (AFN), is yet to be established. The aim of this study was to examine the outcome of primary retrograde femoral nailing in high-grade open fractures and compare our results with similar fractures treated with AFN.

PATIENTS AND METHODS

A retrospective analysis of treated high-grade open femoral fractures, was performed at an academic level one trauma centre between 2006 and 2016. Included were all open femur shaft fractures treated with either RFN or AFN as primary fixation. We analysed both patient groups and compared outcomes including the infection rate, non-union rate and secondary interventions. Presence of knee pain and long-term function, was evaluated using the Short-Form 12 (SF-12) questionnaire.

RESULTS

Forty-nine patients with open femoral shaft fractures whose primary treatment was intramedullary nailing (IMN), were included in the cohort. Thirty patients were treated with RFN and 19 with AFN. No septic arthritis of the knee was detected in either group. One patient in the RFN group and two in the AFN had a deep surgical wound infection. Excluding reoperations for locking screw removal due to local irritation, the reoperation rate was 22% with two patients treated for non-union in the RFN group and two in the AFN. When comparing outcome measures, including SF-12 scores and the reported knee pain rates of AFN and RFN groups, no significant differences were observed.

CONCLUSION

Our study showed that retrograde femoral nailing as initial definitive treatment in high-grade open femoral shaft fractures, resulted neither in septic arthritis of the knee nor in an unacceptable infection rate. General outcomes regarding complications and reoperations, was similar to antegrade femoral nailing performed in our centre for similar injuries.

Assessment of clinical and radiographic outcomes following retrograde versus antegrade nailing of infraisthmic femoral shaft fractures without the use of intraoperative fluoroscopy in Tanzania

To compare clinical and radiographic outcomes following antegrade versus retrograde intramedullary nailing of infraisthmic femoral shaft fractures.

Design

Secondary analysis of prospective cohort study.

Setting

Tertiary hospital in Tanzania.

Participants

Adult patients with infraisthmic diaphyseal femur fractures.

Intervention

Antegrade or retrograde SIGN intramedullary nail.

Outcomes

Health-related quality of life (HRQOL), radiographic healing, knee range of motion, pain, and alignment (defined as less than or equal to 5 degrees of angular deformity in both coronal and sagittal planes) assessed at 6, 12, 24, and 52 weeks postoperatively.

Results

Of 160 included patients, 141 (88.1%) had 1-year follow-up and were included in analyses: 42 (29.8%) antegrade, 99 (70.2%) retrograde. Antegrade-nailed patients had more loss of coronal alignment (P = .026), but less knee pain at 6 months (P = .017) and increased knee flexion at 6 weeks (P = .021). There were no significant differences in reoperations, HRQOL, hip pain, knee extension, radiographic healing, or sagittal alignment.

Conclusions

Antegrade nailing of infraisthmic femur fractures had higher incidence of alignment loss, but no detectable differences in HRQOL, pain, radiographic healing, or reoperation. Retrograde nailing was associated with increased knee pain and decreased knee range of motion at early time points, but this dissipated by 1 year. To our knowledge, this is the first study to prospectively compare outcomes over 1 year in patients treated with antegrade versus retrograde SIGN intramedullary nailing of infraisthmic femur fractures.Level of Evidence: III.

Patterns, Management, and Outcome of Traumatic Femur Fracture: Exploring the Experience of the Only Level 1 Trauma Center in Qatar

Background: Femur is the most fractured long bone in the body that often necessitates surgical fixation; however, data on the impact of the mechanism of injury (MOI), age, and timing of intervention are lacking in our region of the Arab Middle East. We aimed to describe the patterns, management, and outcome of traumatic femoral shaft fractures. Methods: A retrospective descriptive observational study was conducted for all trauma patients admitted with femoral shaft fractures between January 2012 and December 2015 at the only level 1 trauma center and tertiary hospital in the country. Data were analyzed and compared according to the time to intervention (intramedullary nailing; IMN), MOI, and age groups. Main outcomes included in-hospital complications and mortality. Results: A total of 605 hospitalized cases with femur fractures were reviewed. The mean age was 30.7 ± 16.2 years. The majority of fractures were unilateral (96.7%) and 91% were closed fractures. Three-fourths of fractures were treated by reamed intramedullary nailing (rIMN), antegrade in 80%. The pyriform fossa nails were used in 71.6% while trochanteric entry nails were used in 28.4%. Forty-five (8.9%) fractures were treated with an external fixator, 37 (6.1%) had conservative management. Traffic-related injuries occurred more in patients aged 14–30 years, whereas fall-related injuries were significantly higher in patients aged 31–59. Thirty-one patients (7.8%) had rIMN in less than 6 h post-injury, 106 (25.5%) had rIMN after 6–12 h and 267 (66.8%) had rIMN after more than 12 h. The implant type, duration of surgery, DVT prophylaxis, in-hospital complications, and mortality were comparable among the three treatment groups. Conclusions: In our center, the frequency of femoral fracture was 11%, and it mainly affected severely injured young males due to traffic-related collisions or falls. Further multicenter studies are needed to set a consensus for an appropriate management of femur fracture based on the MOI, location, and timing of injury.

Extreme Nailing or Less Invasive Plating of Lower Extremity Periarticular Fractures

Periarticular fractures of the lower extremity can be difficult injuries to stabilize effectively. Modern advances in technique and implant design now allow many of these fractures to be fixed with an extreme intramedullary nail. When nailing is not possible, less invasive plating through percutaneous incisions is a reliable option. The decision to perform extreme nailing is multifactorial and is based on the fracture pattern, the condition of the soft tissues, the medical condition of the patient, and the importance of earlier or immediate weightbearing.

Proximal Cortical Breach After Retrograde Femoral Nailing for Femoral Shaft Fracture: A Case Report

CASE

A case of a distal third femoral shaft fracture treated with retrograde nailing complicated by proximal cortical breach is presented. The proximal fracture was detected intraoperatively and treated with plating.

CONCLUSION

Although rare, clinicians should be cognizant of the risk for proximal femur fractures secondary to retrograde femoral nailing in elderly patients.

Long Segment Blocking Screws Increase the Stability of Retrograde Nail Fixation in Geriatric Supracondylar Femur Fractures: Eliminating the "Bell-Clapper Effect"

OBJECTIVES

To determine the change in stiffness and horizontal translations of a geriatric supracondylar femur fracture model with the addition of distal segment blocking screws versus proximal (long) segment blocking screws to the standard retrograde intramedullary nail construct.

METHODS

Unstable supracondylar femur fractures (OTA/AO 33-A3) were created; all specimens were instrumented with a retrograde intramedullary nail. Specimens were divided into 2 groups (6 matched pairs per group). Group 1 compared the standard construct (1 proximal screw and 3 distal screws) to a distally augmented construct, with blocking screws placed in the distal metaphyseal segment. Group 2 compared the distally augmented construct to one in which blocking screws were placed just proximal to the fracture (long segment blocking screws). Specimens were then axially loaded and cycled to failure or run-out.

RESULTS

There was no significant difference in baseline stiffness, survival through cyclic loading, stiffness after cyclic loading, or cycles to failure between femurs treated with distal blocking screws and femurs treated without blocking screws (group 1). Femurs with blocking screws in the long proximal segment had significantly greater baseline stiffness, stiffness after cyclic loading, and less horizontal translation at the fracture site (group 2). There was no difference in survival through cyclic loading or cycles to failure.

CONCLUSION

Long segment blocking screws are biomechanically superior to blocking screws in the distal segment or no blocking screws initially and after cyclic loading in an unstable geriatric supracondylar femur fracture model treated with intramedullary nail.

CLINICAL RELEVANCE

Surgeons may use blocking screws to aid in fracture alignment during retrograde nail fixation. In addition, the placement of long segment blocking screws can help resist failure of fixation in geriatric patients by eliminating the "Bell-clapper effect."

Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and meta-analysis

BACKGROUND

There are several different techniques commonly used to perform intramedullary (IM) nailing of the femur to fix femoral fractures. We sought to identify significant differences in outcomes of studies comparing 1) trochanteric and piriformis entry and 2) antegrade and retrograde entry in IM nailing of the femur.

METHODS

We searched MEDLINE, Cochrane and Embase databases and the Orthopaedic Trauma Association and American Academy of Orthopaedic Surgeons websites for comparative studies published from inception to November 2015. Criteria used to select articles for detailed review included use of antegrade and retrograde entry point or use of trochanteric and piriformis entry point for IM nailing of the femur in adult patients. Functional and technical outcomes were extracted from accepted studies.

RESULTS

We identified 483 potential studies, of which 52 were eligible. Of these, we included 13 publications and 2 abstracts (2 level I, 7 level II and 6 level III studies). Trochanteric entry significantly reduced operative duration by 14 min compared with piriformis entry (p = 0.030). Retrograde nailing had a greater risk of postoperative knee pain than antegrade nailing (p = 0.05). On the other hand, antegrade nailing had significantly more postoperative hip pain (p = 0.003) and heterotopic ossification (p < 0.001) than retrograde nailing. No significant differences in functional outcomes were observed.

CONCLUSION

Although some significant differences were found, the varying quality of studies made recommendation difficult. Our meta-analysis did not confirm superiority of either antegrade over retrograde or trochanteric over piriformis entry for IM nailing of the femur.

LEVEL OF EVIDENCE

Level III therapeutic.

Subtrochanteric fractures after retrograde femoral nailing

Secondary fractures around femoral nails placed for the management of hip fractures are well known. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. Only a few reports in the existing literature have described these fractures. Two young men after sustaining a fall presented to us with pain, swelling and deformity in the upper thigh region. On enquiring, examining and radiographing them, peri-implant fractures of subtrochanteric nature through the distal interlocking screws were revealed in both patients who also had histories of previous falls for which retrograde intramedullary nailing was performed for their respective femora. Both patients were managed with similar surgical routines including removal of the existing hardware, open reduction and ace cephallomedullary antegrade nailing. The second case did show evidence of delayed healing and was additionally stabilized with cerclage wires. Both patients had uneventful postoperative outcomes and union was evident at the end of 6 mo postoperatively with a good range of motion at the hip and knee. Our report suggests that though seldom reported, peri-implant fractures around the subtrochanteric region can occur and pose a challenge to the treating orthopaedic surgeon. We suggest these be managed, after initial stabilization and resuscitation, by implant removal, open reduction and interlocking intramedullary antegrade nailing. Good results and progression to union can be expected in these patients by adhering to basic principles of osteosynthesis.

Is There an Optimal Proximal Locking Screw Length in Retrograde Intramedullary Femoral Nailing? Can We Stop Measuring for These Screws?

Insertion of locking screws through the proximal thigh while locking retrograde femoral nails is arguably more difficult and traumatic to local tissues than locking at other intramedullary nail sites. The purpose of this study was to evaluate whether a "standard" screw length for proximal interlocking of retrograde nails is possible, therefore assessing whether the act of measuring for these screws can be omitted. This article retrospective evaluates screw position and estimated proximal locking screw length in patients undergoing retrograde nailing using a large radiographically measured computed tomography cohort, with validation through a smaller clinical cohort. According to these data, it seems reasonable to skip depth gauge measurement during anteroposterior interlocking of retrograde femoral nails and insert a standard length screw based on location relative to the lesser trochanter. This should decrease the amount of local trauma to the patient at the locking screw site while increasing operating room efficiency by avoiding what can often become a difficult step during the procedure.

Retrograde versus antegrade intramedullary nailing for femoral fractures: a meta-analysis of randomized controlled trials

OBJECTIVES

To conduct a meta-analysis of randomized controlled trials assessing the effect on clinical outcomes of intramedullary nailing for femoral fractures via a retrograde or antegrade approach.

DATA SOURCES

Randomized controlled trials using PubMed, Embase, and the Cochrane Library databases.

STUDY SELECTION

We used the following search terms with no language or study type restrictions: femoral shaft fractures, internal fixation, treatment outcome, intramedullary nailing, and retrograde or antegrade approach.

DATA EXTRACTION

Two independent authors extracted the data and we assessed the quality of the included studies based on Jadad score; allocation concealment; similarity of baseline characteristics; eligibility criteria; blinding; completeness of follow-up; and intention-to-treat analysis. Our primary outcome measure was the union rate and the secondary outcome measures were nonunion, knee pain, and heterotopic ossification. A total of 240 patients from three randomized controlled trials were included.

DATA SYNTHESIS

Risk ratios (RRs) and 95% confidence intervals (CIs) were computed for dichotomous variables, and weighted mean differences and 95% CIs for continuous variables. Heterogeneity among studies was assessed using the I (2) statistic, with I (2 )> 50% considered significant. If heterogeneity was not significant, a fixed effects model was chosen to assess the overall estimate. Otherwise, a random effects model was used. We used Egger's regression asymmetry test and Begg's adjusted-rank correlation to assess publication bias.

CONCLUSIONS

Both retrograde and antegrade intramedullary nailing produced high union rates. We found no significant difference in union rate between the retrograde nailing group and the antegrade nailing group for femoral fractures (RR 1.02, 95% CI: 0.94-1.11, p = 0.59, I (2 )= 0%).

Electromagnetic navigation reduces surgical time and radiation exposure for proximal interlocking in retrograde femoral nailing

OBJECTIVES

To compare the time required for proximal locking screw placement between a standard freehand technique and the navigated technique, and to quantify the reduction in ionizing radiation exposure.

METHODS

A fresh frozen cadaver model was used for 48 proximal interlocking screw procedures. Each procedure consisted of insertion of 2 anteroposterior locking screws. Standard fluoroscopic technique was used for 24 procedures, and an electromagnetic navigation system was used for the remaining 24 procedures. Procedure duration was recorded using an electronic timer and radiation doses were documented.

RESULTS

Mean total insertion time for both proximal interlocking screws was 405 ± 165.7 seconds with the freehand technique and 311 ± 78.3 seconds in the navigation group (P = 0.002). All procedures resulted in successful locking screw placement. Mean ionizing radiation exposure time for proximal locking was 29.5 ± 12.8 seconds.

CONCLUSIONS

Proximal locking screw insertion using the navigation technique evaluated in this work was significantly faster than the standard fluoroscopic method. The navigated technique is effective and has the potential to prevent ionizing radiation exposure.

Blocking screws for the treatment of distal femur fractures

Intramedullary nailing is one of the most convenient biological options for treating distal femoral fractures. Because the distal medulla of the femur is wider than the middle diaphysis and intramedullary nails cannot completely fill the intramedullary canal, intramedullary nailing of distal femoral fractures can be difficult when trying to obtain adequate reduction. Some different methods exist for achieving reduction. The purpose of this study was determine whether the use of blocking screws resolves varus or valgus and translation and recurvatum deformities, which can be encountered in antegrade and retrograde intramedullary nailing. Thirty-four patients with distal femoral fractures underwent intramedullary nailing between January 2005 and June 2011. Fifteen patients treated by intramedullary nailing and blocking screws were included in the study. Six patients had distal diaphyseal fractures and 9 had distal diaphyseo-metaphyseal fractures. Antegrade nailing was performed in 7 patients and retrograde nailing was performed in 8. Reduction during surgery and union during follow-up were achieved in all patients with no significant complications. Mean follow-up was 26.6 months. Mean time to union was 12.6 weeks. The main purpose of using blocking screws is to achieve reduction, but they are also useful for maintaining permanent reduction. When inserting blocking screws, the screws must be placed 1 to 3 cm away from the fracture line to avoid from propagation of the fracture. When applied properly and in an adequate way, blocking screws provide an efficient solution for deformities encountered during intramedullary nailing of distal femur fractures.

Analysis of retrograde femoral intramedullary nail placement through traumatic knee arthrotomies

OBJECTIVES

To analyze the rate of postoperative infection after retrograde femoral nail placement in the setting of traumatic knee arthrotomy (KA).

DESIGN

Retrospective.

SETTING

Level-I trauma center.

PATIENTS

A review of all adult femur fractures (N = 1748) treated with an intramedullary nail over a 10-year period identified 34 retrograde nails with traumatic KA as the study group and 23 antegrade nails with traumatic KA as a control group. The retrograde femoral traumatic KA group was also compared with a 4:1 matched control group of 136 patients with retrograde femoral nails without traumatic KA.

INTERVENTION

Retrograde femoral nail placement with traumatic KA.

MAIN OUTCOME MEASUREMENTS

Occurrence of postoperative infection.

RESULTS

The traumatic KA groups treated with retrograde and antegrade femoral nails were similar across all recorded patient variables. No infections occurred in the retrograde traumatic KA group versus 1 infection (4.3%) in the antegrade traumatic KA group (P = 0.404). Four nonunions (11.8%) occurred in the retrograde traumatic KA group versus 1 nonunion (4.3%) in the antegrade traumatic KA group (P = 0.638). The matched control group of retrograde nails did not significantly differ when compared with the retrograde traumatic KA group for infection or nonunion (P = 1.000 and 0.261).

CONCLUSIONS

This is the first study to investigate retrograde nail placement through traumatic KA with comparison to control groups, with no differences found in infection rates. Furthermore, no infections (knee or fracture) occurred in those patients who were treated using a retrograde femoral nail with traumatic KA. This study documents the relative safety associated with retrograde femoral nailing in the setting of a concurrent traumatic KA with surgical debridement.

Risk of septic knee following retrograde intramedullary nailing of open and closed femur fractures

Background

One potential complication of retrograde femoral nailing in the treatment of femur fractures is the risk of septic knee. This risk theoretically increases in open fractures as a contaminated fracture site has the potential to seed the instrumentation being passed in and out of the sterile intraarticular starting point. There are few studies examining this potential complication in a relatively commonly practiced technique.

Methods

All patients who received a retrograde femoral nail for femur fracture between September 1996 and November 2006 at a Level 1 trauma center were retrospectively reviewed. This yielded 143 closed fractures, 38 open fractures and 4 closed fractures with an ipsilateral traumatic knee arthrotomy. Patient follow-up records were reviewed for documentation of septic knee via operative notes, wound culture or knee aspirate data, or the administration of antibiotics for suspected septic knee.

Results

No evidence of septic knee was found in the 185 fractures examined in the dataset. Utilizing the Wilson confidence interval, the rate of septic knee based on our population was no greater than 2%, with that of the open fracture group alone being 9%.

Conclusions

Based on these results and review of the literature, the risk of septic knee in retrograde femoral nailing of both open and closed femoral shaft fractures appears low but potentially not insignificant.

Funding

There was no outside source of funding from either industry or other organization for this study.

Anatomical structures at risk with the proud retrograde femoral nail

BACKGROUND

Post-operative knee pain is common following retrograde nailing, with its etiology often multifactorial although a well-established cause is nail protrusion from the intercondylar notch. The aim of this study was to assess the structures at risk if the nail is left proud of the femoral articular surface.

METHODS

A retrograde femoral nail (Synthes Distal Femoral Nail) was inserted into the distal femur of 15 cadaveric lower limbs using the standard technique. The nail was left 10 mm proud of the articular surface and locked in this position. The knee was then put through a full range of movement while recording the intra-articular structures that came into contact with the distal end of the nail as well as the position of the knee when this occurred. This was repeated with the nail 5 mm proud.

RESULTS

With the nail 10 mm proud, it impinged on the anterior horn of the medial meniscus in 14 cases and the anterior horn of the medial meniscus as well as the tibial insertion of the ACL in one case at 15° of flexion. At 70° of flexion the nail came into contact with the distal margin of the patellar articular surface in the midline in all 15 cases. With the nail 5 mm proud, it impinged on the anterior horn of the medial meniscus in seven cases and the tibial insertion of the ACL as well as the anterior horn of the medial meniscus in eight cases as the knee was brought into full extension. In flexion the distal margin of the patellar articular surface in the midline came into contact with the nail at 70° of flexion in all 15 cases.

CONCLUSION

Correct positioning of a retrograde femoral nail is of paramount importance to avoid further iatrogenic injury to intra-articular structures.

Intra- and periarticular heterotopic ossification in the knee after a low-velocity gunshot wound treated with retrograde intramedullary nailing of the femur

This is a case of a 32-year-old man who developed intra- and periarticular heterotopic ossification (HO) after sustaining a low-velocity gunshot wound to the femur treated with intramedullary nailing of the fracture using a retrograde technique. The association between HO after a high-velocity gunshot wounds is well established. In addition, there have been two case reports of intra-articular HO after retrograde intramedullary femoral nailing. However, HO in and around the knee after a low-velocity gunshot wound has not been reported and may be more common than initially thought.

Management of femur shaft fractures in obese patients

Given the ongoing epidemic of obesity, femoral fracture management in the population affected by this condition is likely to become more frequent. Fracture treatment in obese patients poses a special challenge given greater difficulty in establishing an accurate diagnosis and confirming associated injuries. Adequate intraoperative positioning and obtaining accurate reduction and stable fixation may require special considerations. Obese patients have a high predisposition for complications such as compartment syndrome, nerve injuries, and pressure ulcers, and are at increased risk for medical complications given the high prevalence of comorbidities. A thorough understanding of the risks associated with obesity and the diagnostic and therapeutic challenges involved with femoral shaft fractures in this setting is paramount to achieve adequate results.

Analysis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures

OBJECTIVES

Retrograde nailing of open femoral fractures has presumed increased risk of knee sepsis. Our hypothesis was that the incidence of secondary knee infection after retrograde nailing of open femoral fractures is low.

DESIGN

Retrospective, multicenter.

SETTING

Four Level I trauma centers.

PATIENTS AND METHODS

A retrospective review of prospective trauma registries and fracture databases identified all open femoral fractures treated with retrograde intramedullary nailing from January 1, 2003, through February 15, 2007. Patients with ballistic injuries and those with less than 1 month follow up were excluded. Ninety-three open femoral fractures were identified in 90 patients. We defined a septic knee as a knee with infection that required reoperation with arthrotomy or arthroscopy. Infections at an open fracture site were defined as those treated with local irrigation and débridement and intravenously and/or orally administered antibiotics.

INTERVENTION

Open femoral shaft fractures treated with a retrograde approach.

MAIN OUTCOME MEASUREMENTS

Occurrence of an ipsilateral postoperative septic knee.

RESULTS

One acute septic knee was identified (1.1%; 95% confidence interval, 0.0%-3.2%) noted at time of repeat irrigation and débridement of a massive degloving wound that left no skin coverage over the knee. We also observed one late knee sepsis 2.5 years after the index procedure occurring after quadricepsplasty. The nail had been removed 1.5 years before surgery, so we did not include that case in our knee sepsis rate. Two additional infections at the open wound site did not involve the knee.

CONCLUSIONS

Previous publications have argued that retrograde nailing of open femoral fractures provides a potential conduit for knee infection. Our data show that risk of a septic knee as a direct result of retrograde nailing of an open femoral fracture is relatively low (1.1%; 95% confidence interval, 0.0%-3.2%). To our knowledge, this is the first case series to document the relative safety associated with retrograde nailing of open femoral fractures.

Comparison of knee function after antegrade and retrograde intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation

OBJECTIVE

To evaluate knee function in patients having femoral diaphyseal fractures treated with antegrade or retrograde intramedullary nail insertion.

DESIGN

Prospective.

SETTING

Level I referral center.

PATIENTS AND METHODS

Seventy patients having 71 OTA 32 fractures were randomly allocated into 2 groups to be treated with either antegrade or retrograde intramedullary nails inserted with reaming.

INTERVENTION

Antegrade nail in 41 fractures and retrograde femoral intramedullary nails in 30 fractures.

MAIN OUTCOME MEASURES

Postoperative knee range of motion, Lysholm Knee Score, and isokinetic knee muscle function testing at least 6 months after documented fracture healing, minimum 1 year postoperatively.

RESULTS

Groups had similar data with regard to demographics and injury patterns. Mean follow-up time was 44 (range: 25-80) months. Mean knee flexion angle was 132 and 134 degrees, and mean Lysholm Score was 84 and 83.1 in antegrade and retrograde groups, respectively (P = 0.893 and P = 0.701). Isokinetic evaluation revealed similar results for peak torque deficiencies at 30 and 180 degrees per second and total work deficiencies at 180 degrees per second (P > 0.05). Age affected the knee functioning as the higher the age of the patient is, the lower the Lysholm Score and knee flexion angle (r = -0.449, P = 0.0321 and r = -0.568, P = 0.001, respectively).

CONCLUSIONS

Knee function seems to have similar clinical results after either antegrade or retrograde nail insertion for femoral diaphyseal fractures when knee range of motion, Lysholm Scores, and isokinetic knee evaluation are considered as outcome measures. With increasing patient age, a decrease in knee functioning should be anticipated in patients with femoral fractures treated with intramedullary nails regardless of technique.

Distal third femur fractures treated with retrograde femoral nailing and blocking screws

Retrograde femoral nailing is a widely used treatment for fractures involving the distal third of the femur. Angular malunion of these fractures after retrograde intramedullary nailing is a known complication. We report our surgical technique and experience using blocking screws to aid in reduction and augment the stability of the fixation when using a retrograde intramedullary nail for distal femoral fractures.

Retrograde intramedullary nailing in treatment of bilateral femur fractures

OBJECTIVE

The purpose of this study was to evaluate the use of retrograde nailing to treat patients with bilateral femur fractures.

DESIGN AND SETTING

A retrospective review of prospectively obtained trauma databases was completed at 9 Level 1 trauma centers.

PATIENTS

In all, 3767 patients with femur fractures were identified. Of those, 89 (46 males, 43 females) had bilateral femur fractures treated with reamed, retrograde intramedullary nails within 48 hours after injury. The charts were reviewed for pertinent data.

RESULTS

The average cohort age was 30 years (16-63 years). The average Injury Severity Score was 21 (9-50). Eighty-five patients (96%) had associated injuries. Thirteen patients (14.6%) developed adult respiratory distress syndrome; 8 had thoracic injuries. There were 4 patients (4%) with fat embolism syndrome, 2 were delayed longer than 24 hours to the operating room. There were 5 deaths (5.6% mortality) in the retrograde nailing group. Thoracic injury was found to be associated with death rate (P < 0.07).

CONCLUSIONS

Bilateral femur fractures are indicative of severe injuries with mortality rates as high as 40%. There are no specific studies addressing the outcomes of bilateral femur fractures treated with retrograde nailing. In this largest retrospective study to date, the overall death rate of 5.6% was significantly lower than historical controls. The effect of timing and duration of surgery and other injuries is not completely known. In conclusion, retrograde nailing of bilateral femur fractures is an acceptable treatment for bilateral femur fractures.

An alternative direction for proximal locking in retrograde femoral nails

Lateral-to-medial proximal interlocking screw insertion for retrograde femoral nails avoids potential neurovascular injury while maintaining stable interlocking mechanics.

Retrograde femoral nailing: an understanding of the intercondylar insertion site

BACKGROUND

: The intercondylar starting site for retrograde femoral nailing has been selected to avoid damage to the articular weight-bearing surface. This starting point assumes that implants will adapt to the femoral radius of curvature. Implant-femur radius mismatch may result in postoperative fracture angulations, translation, or increase in hoop stress.

METHODS

: Twenty cadaveric femurs were analyzed. The posterior cruciate ligament (PCL) was preserved. Two different femoral nails were analyzed. After creating an osteotomy at the superior level of the lesser trochanter, a cannulated nail was inserted to the level of the articular surface of the distal femur. A pointed guide wire was advanced through the nail and driven through the articular surface of the distal femur. The exact location of the guide wire exiting the articular surface was anatomically and radiographically determined.

RESULTS

: The mean anterior distance of the wire to the PCL was 20.4 mm for the ACE nail and 13.9 mm for the Synthes Femoral Nail (SFN). A Student's t test showed a significant difference between the two implants (p = 0.0002). The mean medial distance of the guide wire exit compared with the PCL was 4.2 mm for the ACE and 4.1 mm for the SFN nail and showed no significant difference.

CONCLUSIONS

: The tested nails require a more anterior insertion site than what has been described to match the femur curvature. Of the two nail designs evaluated, the SFN was more compatible with the currently recommended starting point.

Results of femoral intramedullary nailing in patients who are obese versus those who are not obese: a prospective multicenter comparison study

OBJECTIVES

Antegrade femoral nailing through a piriformis fossa starting point in patients who are obese has been demonstrated to be problematic. Retrograde femoral nailing therefore has been advocated in this patient population, but little data exist to support such a recommendation. The purpose of this study was to evaluate and compare antegrade and retrograde femoral nailing technique in both patients who are and are not obese.

DESIGN

Prospective, multicenter, nonrandomized, internal review board (IRB)-approved study.

SETTING

Four Level 1 trauma centers.

PATIENTS

Patients (151) with a femoral shaft fracture (OTA 32) treated with intramedullary nailing were studied. Thirty-two with a body mass index (BMI) of >or=30 comprised the obese group (OG), and 119 with a BMI of <30 comprised the nonobese group (NOG). Antegrade nailing was performed in 15 patients from the OG and 84 from the NOG. Retrograde nailing was performed in 17 patients from the OG and 35 from the NOG.

INTERVENTION

Reamed intramedullary nailing of a femoral shaft fracture.

MAIN OUTCOME MEASURES

Patient and fracture characteristics, operative time, fluoroscopy time, healing, complications, and functional outcome based on the lower extremity measure (LEM) were evaluated.

RESULTS

Antegrade technique in the OG was associated with a 52% greater average operative time (94 minutes) compared with antegrade nailing in the NOG (62 minutes; P < 0.003). For retrograde nailing technique, there was no difference in the average operative time between the OG (67 minutes) and NOG (62 minutes; P = 0.51). Antegrade technique in the OG was associated with a 79% greater average radiation exposure time (247 seconds) compared with antegrade nailing in the NOG (135 seconds; P < 0.03). For retrograde nailing technique, average fluoroscopy time was similar between the OG (76 seconds) and the NOG (63 seconds; P = 0.44). Within the OG, antegrade nailing required 40% greater average operative time (94 minutes versus 67 minutes, P < 0.02) and more than 3 times more average fluoroscopy time (242 seconds versus 76 seconds, P < 0.002) than retrograde nailing. Thirty-eight patients from the original cohort were not available for follow-up. Of the 113 patients followed (average 9 months, range: 4 to 25 months), healing complications occurred similarly between the 2 groups, with 1 nonunion and 2 delayed unions in the OG (12%), and 3 nonunions and 9 delayed unions in the NOG (14%).

CONCLUSIONS

This study provides evidence, in the form of decreased operative and radiation exposure times, to support the use of retrograde nailing technique for the treatment of femoral shaft fractures in patients who are obese. Also, antegrade nailing was found to require significantly more operative and radiation exposure time in the patient who is obese as opposed to the patients who is not obese. Although having similar baseline functional scores, patients who are obese recovered at a slower rate and more incompletely than patients who are not obese.

The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature

The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6 degrees . The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6 degrees . The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union.

Ein neues retrogrades Femurmarknagelsystem mit durchleuchtungsfreier proximaler Verriegelung

INTRODUCTION

Conventional retrograde nailing of the femur causes two important disadvantages: the proximal locking of the nail is difficult because of the anatomic conditions and a chondral defect was left into the knee.

MATERIAL AND METHODS

After the retrograde implantation the new nail was lead through the greater trochanter. An additional proximal aiming device for proximal interlocking can be fixed. The entrance portal will be sealed by an osteochondral cylinder. 50 cases of femur fractures were selected for the prospective study. We recorded all intraoperative complications and technical difficulties. The cases were followed up for 52 weeks, both clinical and radiology examinations were performed.

RESULTS

The mean follow up was 15.5+/-5 months. All fractures were healed. Knee movement was 125+/-14 degrees. The Leung Score was 84+/-12.6 points; HSS Score was 90+/-9 points. In two cases wound infections were developed. Mal-union was observed in three cases, in two cases nail brake down.

CONCLUSIONS

The new retrograde interlocking nail could be used to manage femur fractures successfully. Two aiming devices enable a easy interlocking. Replacement of the osteochondral cylinder into the entry portal reduces cartilage damage.

One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening

OBJECTIVE

To assess the effectiveness of a one-stage lengthening using a locked nail technique for the treatment of distal femoral shaft nonunions associated with shortening.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS AND METHODS

During a 6-year period, 36 distal femoral shaft nonunions associated with shortening (>1.5 cm) were treated by the one-stage lengthening technique. Indications for this technique were distal femoral shaft aseptic or quiescent infected nonunions, 1.5-5 cm shortening, and a fracture level suitable for the insertion of two distal locked screws. The surgical technique involved skeletal traction using the femoral condyle, local débridement, lengthening by <or=4 cm aided by a laminar spreader, insertion of a static locked nail, and grafting of corticocancellous bone. Mize's classification for clinical function was used for final patient evaluation.

RESULTS

A total of 32 nonunions were followed-up for at least 1 year (median 3.8 years; range 1.2-6.9 years), and 29 fractures healed. The median union period was 4.5 months (range 3-6 months). Three fractures persistently failed to heal. One was treated successfully with exchange nailing, and the remaining two patients were followed annually and had no symptoms. At the latest follow-up, all 32 patients had achieved a satisfactory outcome. The average lengthening was 2.5 cm (range 1.5-3.5 cm).

CONCLUSIONS

One-stage lengthening using the locked nailing technique to treat distal femoral shaft nonunions associated with shortening can achieve a high success rate and low complication rate. The key to successful treatment is the patient's complete cooperation with strictly protected weight bearing until the fracture has healed.

Identification of the Optimal Intercondylar Starting Point for Retrograde Femoral Nailing: An Anatomic Study

BACKGROUND

Retrograde nailing of femoral shaft fractures is an effective and increasingly more popular method of fracture fixation. However, concern remains regarding the effect of the intercondylar entry-portal location on knee function.

METHODS

The optimal entry-portal location was identified in cadaver femurs. Approximating the clinical intraoperative situation, a threaded guidewire was inserted into each of 26 distal femur specimens and positioned in the center of the femoral shaft as determined by anteroposterior and lateral fluoroscopic imaging. Each guidewire was then overdrilled with a 12-mm cannulated drill bit. All entry-portal locations were recorded relative to the posterior cruciate ligament attachment and the intercondylar groove and mapped relative to the known patellofemoral contact area.

RESULTS

The starting holes averaged 6.21 mm anterior to the posterior cruciate ligament attachment and 2.67 mm medial to the intercondylar groove. Overall, 100% of starting portals were located in safe areas relative to the patellofemoral contact area.

CONCLUSION

In the vast majority of femurs, the optimal entry portal for retrograde femoral nailing (in line with the long axis of the femur) is located in the expected safe position, anterior to the posterior cruciate ligament insertion and slightly medial to center of the intercondylar groove. However, because of anatomic variability, the ideal starting position occasionally may be located in a patellofemoral contact area. Potential compromise of the patellofemoral contact area by the retrograde nail entry portal can and should be recognized before nailing, allowing the surgeon the option of altering the surgical technique.

Noncontiguous fractures of the femoral neck, femoral shaft, and distal femur

BACKGROUND

Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale.

METHODS

This was a retrospective study conducted at a Level I trauma center.

RESULTS

Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures.

CONCLUSION

This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.

Optimal entry point for retrograde femoral nailing

OBJECTIVE

The purpose of this study is to identify the optimum entry point for retrograde femoral nailing, defined as that point which will provide adequate fracture alignment while minimizing soft-tissue and articular cartilage injury.

DESIGN

Cadaveric study.

SETTING

Biomechanics laboratory.

MAIN OUTCOME MEASURE

Anatomic relationships and fracture reduction. METHODS Eleven cadaveric femori with attached knee joints underwent retrograde femoral nailing with a Synthes femoral nail (Synthes, Paoli, PA, U.S.A.). After placement of the nail, the specimens underwent an osteotomy 3 inches proximal to the articular surface. Multiple entry points were tested to determine fracture alignment and extent of articular cartilage injury. Medial-lateral and anterior-posterior displacements, in addition to any soft-tissue or articular surface trauma, were recorded for these various points of entry.

RESULTS

An entry point of 1.2 cm anterior to the femoral origin of the posterior cruciate ligament resulted in the least anterior-posterior displacement of the femoral shaft following fracture. In the coronal plane, an entry point at the midpoint of the intercondylar sulcus was identified as minimizing the displacement following fracture. This ideal position allows for proper seating of the nail within the intercondylar sulcus, resulting in minimal damage to the articular cartilage and posterior cruciate ligament and minimal disruption of the patella femoral joint.

CONCLUSION

Retrograde femoral nailing should be used cautiously in select patients, when conventional antegrade nailing cannot be used, due to the unavoidable injury to the knee articular surface associated with this technique. The optimum entry point of 1.2 cm anterior to the femoral posterior cruciate ligament origin and centered in the intercondylar sulcus provides the optimal balance of fracture reduction and knee joint sparing. It may be difficult to target this site with a percutaneous technique and may require direct visualization of the intercondylar sulcus for ideal nail placement.

The floating hip injury: patterns of injury

OBJECTIVE

To evaluate the relationship between mechanism of injury, type of femoral fracture and type of acetabular fracture in floating hip injury.

DESIGN

Historical retrospective.

PATIENTS

Twenty consecutive patients who sustained a floating hip injury, i.e. simultaneous ipsilateral fracture of the acetabulum and the femur.

INTERVENTION

Statistical analysis of the correlation between the mechanism of injury and fracture type.

RESULTS

Two main patterns of floating hip injury were observed. The first is the posterior type, which occurs due to a longitudinal force along the femur that causes first, a posterior type fracture of the acetabulum and thereafter, a midshaft femoral fracture. The second pattern is the central type, caused by a lateral blow to the greater trochanter, which then causes a central fracture-dislocation of the acetabulum and a proximal fracture of the femur.

CONCLUSIONS

This observation explains the biomechanical nature of this injury and has treatment related implications.

Retrograde femoral interlocking nail in complex fractures

Retrograde interlocking nail was used as the method of fixation in 35 different cases of combination of complex femoral fractures. We performed this procedure in fractures of femoral shaft associated with fracture neck femur, pathological fractures of proximal third of femur with trochanteric pathology, ipsilateral fracture of femur and tibia in polytrauma cases with multiple other injuries, in highly obese patients with fracture shaft femur. This technique was also used in cases of pregnancy with fracture shaft femur and in unstable pelvic fracture or dislocation hip associated with fracture shaft femur. Operative technique involved with retrograde insertion of un-reamed, non-cannulated custom made nail through entrance portal in intercondylar notch was applied for fixation of the shaft femur fracture. The other associated fracture around hip was stabilized separately using suitable implant according to type of fracture. In cases of ipsilateral fracture of femur and tibia, femur was stabilized by retrograde interlocking nail and tibia was stabilized by antigrade interlocking nail through same incision at the same sitting. The case was followed up for three years; the average union time was 12 to 18 weeks. Out of 35 cases, 31 cases regained full knee movement. Out of the remaining 4 cases, 2 cases could regain up to 90 degrees of movement, these were old fractures and non-cooperative patients. In one case, patellofemoral arthritis was developed because of an operative error where a nail was not put inside the articular surface. Mal-union was observed in an early case of the series and implant failure was nil. Retrograde interlocking nail was used as the method of fixation in complex fracture problems. Multiple fractures of long bones can be stabilized in one stage, preventing multiple operations at different stages in polytraumatized patients. This resulted in early recovery, lesser hospital stay, and early rehabilitation of patient with good results and is economical also.

Vascular compromise after insertion of a retrograde femoral nail: case report and review of the literature

The authors describe entrapment of the popliteal artery within fragments of an open supracondylar femur fracture after reduction and stabilization with a retrograde femoral nail. At the time of fracture fixation, the loss of pedal pulses was noted, and an exploration of the popliteal vessels was performed. The popliteal artery was easily identified and dissected free after extension of the patient's lateral thigh wound. Following thrombectomy, blood flow to the distal extremity was restored and no postoperative vascular sequelae were encountered.

Potential of increased risk of neurovascular injury using proximal interlocking screws of retrograde femoral nails in patients with acetabular fractures

OBJECTIVES

Neurologic and vascular structures are at risk of iatrogenic injury from proximal interlocking screw insertion after retrograde nailing. This risk may increase in the presence of acetabular fractures because of the displacement of soft tissues resulting from hematoma. The purpose of this study was to establish and compare the relative safe zones (RSZs) for interlocking screw insertion in adults with and without concomitant acetabular fractures.

MATERIALS AND METHODS

Thirty pelvic computed tomography scans of patients with acute unilateral acetabular fracture and magnetic resonance imaging scans of five healthy legs were used to evaluate the course of the femoral sheath, neurovascular complex, and the sciatic nerve as they course through the proximal thigh in sixty-five limbs.

RESULTS

The anatomy of the neurovascular structures on the fractured side was statistically different from that of the normal side. On the normal side, the RSZ at the lesser trochanteric level was identified from +7 degrees medial to +20 degrees lateral to the sagittal axis (27-degree angle zone) for anteroposterior screw placement. These values for the fractured side, respectively, changed to +1 degrees and +14 degrees (13-degree angle zone), a 52 percent decrease. The RSZ for lateral-medial screw placement was 28 degrees anterior to 39 degrees posterior to the coronal axis (67-degree angle zone) for the normal side, which changed, respectively, to 32 degrees and 41 degrees (73-degree angle zone) for the fractured side. At the level of the lesser trochanter, rotation in the femoral shaft was mimicked only in part (approximately 50 percent) by the neurovascular structures.

CONCLUSION

Lateral-medial screw insertion is safer than anteroposterior insertion. Anteroposterior screw insertion becomes even more critical if the acetabulum is fractured. Femoral external rotation after rod insertion, but before screw insertion, will enlarge the safe zones.

Retrograde versus antegrade nailing of femoral shaft fractures

OBJECTIVES

To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing.

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05).

INTERVENTION

Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques.

MAIN OUTCOME MEASURES

Union, delayed union, nonunion, malunion, and complication rates.

RESULTS

After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05).

CONCLUSIONS

Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.

Angular malalignment after intramedullary nailing of femoral shaft fractures

OBJECTIVES

To determine factors associated with angular malalignment of femoral shaft fractures treated with intramedullary nails and to determine differences in the incidence of angular malalignment based on fracture location, fracture comminution, and method of treatment (i.e., antegrade or retrograde).

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Three hundred sixty patients with 374 femoral shaft fractures were identified from a prospectively obtained orthopaedic trauma database. Complete sets of immediate postoperative anteroposterior and lateral radiographs were available for 355 (95 percent) of the 374 fractures.

INTERVENTION

Patients were treated with antegrade (183 cases) or retrograde (174 cases) intramedullary femoral nailing.

MAIN OUTCOME MEASURE

Goniometric measurements were made on all immediate postoperative radiographs to determine the coronal plane and sagittal plane angular alignments. A multiple linear regression statistical analysis was used to determine factors associated with increasing angular malalignment. The incidence of malalignment was determined using more than 5 degrees of deformity in any plane as the definition of malalignment.

RESULTS

Proximal fracture location, distal fracture location, and unstable fracture pattern were associated with increasing fracture angulation (p < 0.001). Fracture location in the middle third, stable fracture pattern, method of treatment (i.e., antegrade or retrograde), and nail diameter were not associated with increasing fracture angulation (p > 0.05). The incidence of malalignment was 9 percent for the entire group of patients, 30 percent when the fracture was of the proximal third of the femoral shaft, 2 percent when the fracture was of the middle third, and 10 percent when the fracture was of the distal third. The incidence of malreduction was 7 percent for patients with stable fracture patterns and 12 percent for those with unstable fracture patterns.

CONCLUSIONS

Patients with fractures of the proximal third of the femoral shaft treated with intramedullary nails are at highest risk for malalignment. Proximal fracture location, distal fracture location, and unstable fracture pattern are associated with increasing fracture angulation.

Arterial injury during retrograde femoral nailing: a case report of injury to a branch of the profunda femoris artery

The management of femoral shaft fractures by retrograde intramedullary nailing is becoming more widespread. There have been no reported intraoperative neurovascular injuries to the surrounding anatomy using the retrograde femoral nailing technique. We report a case of injury to a branch of the profunda femoris artery during placement of the anteroposterior proximal locking screw.

Prospective comparison of retrograde and antegrade femoral intramedullary nailing

OBJECTIVE

To prospectively compare the results, function, and complications of antegrade and retrograde femoral nailing for femoral shaft fractures.

DESIGN

Prospective, randomized.

SETTING

Urban Level 1 trauma center.

PATIENTS

One hundred consecutive femoral shaft fractures. Fifty-four nails inserted retrograde and forty-six inserted antegrade.

INTERVENTION

Ten-millimeter antegrade or retrograde nail inserted for a femoral shaft fracture after reaming.

OUTCOME MEASUREMENTS

A comparison of the outcomes after antegrade and retrograde nailing of the femur. Data were collected for analysis on comminution, set-up and starting point times, open grade, location of fracture, injury severity score, body mass index, time to union, knee pain and motion, hip and thigh pain, and nail to intramedullary canal diameter difference. A linear regression model was employed.

RESULTS

Knee motion was 120 degrees in all but one knee in each group. The antegrade nailed femurs healed faster than those treated retrograde (A = 14.4, R = 18.1 weeks, p = 0.0496). More patients required dynamization for union in the retrograde insertion group (17 percent versus 5 percent, p = 0.10, NS). In a linear regression model, a nail-to-canal-diameter difference and retrograde nailing had an association with an increased time to union. Knee pain was equal in both groups; however, thigh pain was higher in the antegrade group (p = 0.0108). All of the antegrade nailed femurs healed (100 percent), and 98 percent (one nonunion) of the retrograde femurs healed after secondary procedures.

CONCLUSIONS

Both antegrade and retrograde nailing yielded high union rates. Each insertion technique has its own advantages and disadvantages. The two insertion modes appear to be relatively equal for the treatment of femoral shaft fractures.