Comparison of knee function in patients with a healed fracture of the femoral shaft fixed with retrograde and antegrade intramedullary nailing

Locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, fracture table and power reaming: retrograde affords greater procedural efficiency than antegrade approach

PURPOSE

To compare the intraoperative procedural efficiency of antegrade and retrograde locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, power reaming devices and fracture tables.

METHODS

A secondary analysis of prospectively collected data was conducted on 238 isolated diaphyseal femur fractures fixed with SIGN Standard and Fin nails within three weeks of injury. The data included baseline patient and fracture characteristics, nail type and diameter, fracture reduction methods, operative times and outcome measures.

RESULTS

There were 84 and 154 fractures in the antegrade and retrograde groups respectively. Both groups were similar vis-a-vis baseline patient and fracture characteristics. Closed reduction of the fractures was significantly easier for retrograde than an antegrade approach. The retrograde approach more readily permitted the use of Fin nails. The mean nail diameter used for retrograde was significantly larger than that for antegrade. The time taken to achieve retrograde nailing was significantly lesser than that of antegrade. There was no statistically significant difference between the outcomes of the two groups.

CONCLUSION

In the absence of expensive fracture-surgery gadgets, retrograde nailing offers many procedural advantages over antegrade, such as easier closed reduction and canal reaming, the greater possibility of using the Fin nail with fewer interlocking screws and shorter operative times. However, we acknowledge the lack of randomisation and the presence of an unequal number of fractures in the two groups as limitations of this study.

The application of a hollow trephine in femoral retrograde intramedullary nailing technique

PURPOSE

The purpose of this study was to describe and evaluate the use of a specially designed hollow trephine to create the entry point through the femoral condyle during retrograde interlocking intramedullary nailing for femoral fractures.

METHODS

From June 2019 to December 2021, we treated 11 patients (5 men, 6 women; mean age, 64 years; age range 40-77 years) with mid-distal femoral fractures by retrograde intramedullary femoral nailing using a self-designed hollow trephine for femoral condyle reaming and cancellous bone harvesting. The mode of all the nails is static. Patients were followed up at 1, 4, 8, and 12 weeks and for at least 6 months after surgery. The healing process and heterotopic ossification were evaluated by imaging. Partial weight bearing was permitted during the recovery period and complete weight bearing was permitted after clinical healing of the fracture displayed by X-ray.

RESULTS

The operation was successful in all patients. Over mean follow-up of 9.3 months (range, 6.0-12.0 months), all patients achieved clinical healing within three months. There were no complications such as knee joint infection, heterotopic ossification, knee joint adhesion and wedge effect.

CONCLUSION

The use of the hollow trephine during femoral retrograde intramedullary nailing helps avoid postoperative complications such as heterotopic ossification, knee joint adhesions, and wedge effect. It also facilitates bone graft harvesting.

Effect of nailing technique on length of stay in isolated ballistic femoral shaft fractures

PURPOSE

The purpose of this study was to investigate length of stay, postoperative mobilization and discharge disposition following intramedullary nailing of ballistic femoral shaft fractures stratified by nailing technique.

METHODS

All adult patients with isolated ballistic femoral shaft fractures between May 1, 2018, and September 1, 2021, were reviewed. The final cohort included 69 ballistic femur fractures in 69 patients. Of the 69 patients included, 29 were treated with retrograde nailing while 40 were treated with antegrade nailing.

RESULTS

The average length of stay of patients treated with antegrade nailing was 2.55 days (SD 1.3 days) compared with 3.45 days (SD 2.3 days) for patients treated with retrograde nailing; this was statistically significant (P = 0.04). Median steps on POD1 for antegrade nailing were 20 and 8 for retrograde. There was no significant difference in VAS pain scores between the two cohorts. All patients were discharged home.

CONCLUSION

The average length of stay for patients who underwent antegrade nailing was significantly shorter when compared with the retrograde nailing. Patients in the antegrade cohort mobilized further than the retrograde cohort in the immediate postoperative setting. We found no significant difference in VAS pain scores between the two cohorts.

LEVEL OF EVIDENCE: 3

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.

3D printed navigation template-guided minimally invasive percutaneous plate osteosynthesis for distal femoral fracture: A retrospective cohort study

OBJECTIVE

To evaluate functional and radiological outcomes in distal femoral fracture patients (distal femoral shaft fractures or metaphyseal fractures) receiving indirect reduction and internal fixation with the minimally invasive percutaneous plate osteosynthesis (MIPPO) assisted by 3D printing navigation templates.

METHODS

This retrospective study included all adult (≥18 years) patients who underwent MIPPO for distal femoral fracture (AO32/33) at PLA 960 Hospital, Jinan, China between January 1, 2013 and December 31, 2016. 3D printed navigation templates were used to assist surgery. Functional assessment was performed using the Knee Society Score (KSS) and the Functional Knee Society Score (FKSS). Postoperative deformity was assessed with 3D-CT reconstruction using contralateral (non-fracture) side as the reference.

RESULTS

A total of 54 patients underwent MIPPO for distal femoral fracture during the review period (34 and 20 for conventional and template-guided MIPPO, respectively). At 10-14 months, the KSS score was 160.6 ± 18.1 and 167.5 ± 17.2 in the conventional and template-guided MIPPO groups, respectively (p = 0.18). The FKSS was 77.6 ± 9.4 in the conventional MIPPO group vs. 81.0 ± 8.5 in the template-guided MIPPO group (p = 0.15). Femoral length difference was smaller in template-guided MIPPO group (3.31 ± 1.53 vs. 9.50 ± 4.49 mm in the control; p < 0.01). Template-guided MIPPO group also had smaller anatomic lateral distal femoral angle (aLDFA) difference (1.57° ± 0.72° vs. 3.89° ± 1.72° in the control; p < 0.01), anatomic posterior distal femoral angle (aPDFA) difference (1.95° ± 0.78° vs. 5.04° ± 1.78°; p < 0.01), and anteversion angle difference (2.52° ± 1.00° vs. 8.23° ± 4.07°; p < 0.01). The rate of length discrepancy (>20 mm), coronal angulation deformity (aLDFA difference >5°), sagittal angulation deformity (aPDFA difference >10°), and rotational malalignment (anteversion angle >10°) was 5.9%, 20.5%, 2.9%, and 32.4% in the control group. No patients in the template-guided MIPPO group had deformity of any type.

CONCLUSIONS

MIPPO assisted by 3D printing navigation templates could practically improve surgical accuracy and eliminate postoperative rotational deformity in patients with distal femoral fractures.

Improve the Efficiency of Surgery for Femoral Shaft Fractures with A Novel Instrument: A Randomized Controlled Trial

Objective

To improve the efficacy of closed reduction and wire guiding during intramedullary nail internal fixation in femoral shaft fractures.

Methods

A novel instrument was designed and manufactured. Sixty-eight patients were enrolled from February 2011 to December 2013. The instrument designed was used during the operation in the experimental group, but not in the control group.

Results

All patients exhibited fracture union, excluding 1 patient in the experimental group and 2 in the control group who had non-union; all of whom achieved fracture union with reoperation. There were no statistically significant differences in operative blood loss or duration of hospital stay between the groups (P > 0.05). The operative time, frequency of wire drilling, and number of open reduction cases, were significantly smaller in the experimental group than in the control group (P < 0.05).

Conclusion

Femoral shaft fractures are difficult to reduce using general methods; the novel instrument showed high clinical value and proved effective and safe in assisting with closed reduction and intramedullary nail fixation for femoral shaft fractures.

Trial Registration

ChiCTR ChiCTR-ICR-15007335

Femoral Condyles Tangential Views: An Effective Method to Detect the Screw Penetration of Femoral Condyles After Retrograde Nailing

Background:

Postoperative knee soft tissue irritation is a common complication after retrograde nail fixation of femoral fractures. Distal locking screw prominence is one of the causes for soft tissue irritation. This study aimed to determine whether the use of the femoral condyles tangential views improve the diagnostic accuracy compared with anteroposterior (A-P) view in detecting distal locking screw penetrations during retrograde femoral nailing.

Methods:

The angle between the sagittal plane and lateral aspect of the condyle and the angle between the sagittal plane and medial aspect of condyle were measured on computed tomography (CT) images. After the angles were measured and recorded, cadaveric femurs were used in a simulated surgical procedure. The retrograde femoral nail was inserted into the femur and placed distal locking screws, which were left 2, 4, and 6 mm proud of the medial and lateral condyles for each femur. A-P view, lateral condyle tangential view and medial condyle tangential view were obtained. All fluoroscopic images were recorded and sent to three observers blinded to the experimental procedure to determine whether screws penetrated the condyle cortex or not.

Results:

According to the results of CT scan, the lateral condyle view was 20.88 ± 0.98° and the medial condyle view was 40.46 ± 3.14°. In the A-P view, we detected 0% at 2 mm penetration, 16.7% (lateral condyle screw) and 25.0% (medial condyle screw) at 4 mm, and 41.7% (lateral condyle screw) and 58.3% (medial condyle screw) at 6 mm. In the lateral tangential view, we detected 91.7% at 2 mm penetration of the lateral condyle and 100% at 4 mm and 6 mm. In the medial tangential view, we detected 66.7% at 2 mm penetration of the medial condyle and 100% at 4 mm and 6 mm. The femoral condyle tangential views provided significant improvement in detecting screw penetrations at all lengths (2, 4, and 6 mm) compared with the A-P view (P < 0.05).

Conclusions:

The femoral condyles tangential views increased the accuracy of detecting screw penetrations on the medial and lateral condyles. Routine clinical use of the femoral condyles tangential views has the potential to increase accuracy in detecting distal locking screw penetration during retrograde femoral nailing.