Retrograde reamed femoral nailing

Supracondylar femur fractures treated percutaneously

One hundred twenty-five supracondylar fractures in 118 patients treated with the Green-Seligson-Henry supracondylar intramedullary nail were evaluated. One hundred four patients (111 fractures) were followed up to fracture union. The percutaneous technique was compared with open reduction and internal fixation using the same device. The mean operative time was greater for the open reduction technique when compared with the percutaneous technique (176 minutes versus 76.6 minutes, respectively), as was the mean estimated blood loss (229 cc versus 96.2 cc). The incidence of delayed union was approximately the same for patients who were treated with both techniques. However, the nonunion rate was significantly higher in the patients treated with open reduction and internal fixation than the patients treated with the percutaneous technique (5.6% versus 2.6%). Twenty-nine (39%) patients who were treated with open reduction and internal fixation required bone grafting versus only three (7%) patients who were treated with the percutaneous technique. Additionally, the percutaneous technique did not produce a higher incidence of malalignment and resulted in a greater postoperative range of motion than the open technique. The current study shows that percutaneous treatment of supracondylar femur fractures is possible and can decrease operative times, blood loss, the need for bone grafting, increase rates of union, and improve functional outcomes.

Retrograde nailing of femur fractures in patients with myelopathy and who are nonambulatory

The authors studied 10 consecutive patients with closed femoral shaft or supracondylar fractures who were nonambulatory and who were treated by reamed retrograde intramedullary nailing via an intercondylar notch approach. The study consisted of five women and five men with an average age of 60.7 years (range, 40-89 years). Six patients had spinal cord lesions, one had a brain injury, one had cerebral palsy, one had multiple sclerosis, and one had progressive myelopathy. Three fractures were supracondylar, and seven fractures involved the mid-distal diaphysis. The average time of surgery was 110 minutes (range, 70-225 minutes) with an average estimated blood loss of 288 mL (range, 150-400 mL). There were two postoperative deaths (at 15 days and 2 months, respectively) after the procedure that were attributable to pneumonia. The remaining eight patients were observed for an average of 13 months (range, 6-20 months) after surgery. All fractures healed as evaluated radiographically. Retrograde intramedullary nailing is a simple, safe, and effective alternative to nonoperative treatment for femoral shaft or supracondylar fractures in patients who are nonambulatory. Stabilization by this method allows fracture healing and rapid return of patients to their previous level of function. There were no nonunions, malunions, significant shortening, implant failure, or wound infections.

A biomechanical comparison of the antegrade inserted universal femoral nail with the retrograde inserted universal tibial nail for use in femoral shaft fractures

Femoral shaft fractures with and without bony contact were simulated in cadaver specimens fixed with one of two different types of intramedullary locked nail systems; conventional antegrade nail fixation of the femur with the universal AO femoral nail or retrograde insertion in the femur with the universal tibial nail (a smaller diameter slotted nail) were utilized. Mechanical testing simulated one leg stance, and resultant deformation was measured in bending, torsion, and shortening. In stable fractures, fracture stability was similar to both devices, while in unstable fractures, the larger femoral nail was more stable. Furthermore, the simulation of single leg stance led to a coupled deformation of varus bending, axial shortening, and external rotation, which was dependent on bone geometry.

Treatment of femoral shaft fracture using unreamed interlocked nails

OBJECTIVE

To evaluate healing rates of femoral shaft fractures treated with interlocked nails inserted without reaming.

STUDY DESIGN

Review of prospectively collected data.

SETTING

Level I trauma center.

METHODS

From the trauma registry, 159 patients with 164 femoral shaft fractures were identified who had been treated from March 1993 through December 1995 with femoral nails inserted without reaming in either an antergrade or retrograde manner. Fractures were classified according to the AO/OTA method. Patients were followed for a minimum of one year with clinical and radiographic examinations.

RESULTS

One hundred twenty-one patients with 125 fractures were available for review. Average follow-up was 18.3 months (range 12 to 59 months). One hundred sixteen of the 125 fractures (93 percent) healed after the index procedure. Type A fractures healed at an average of 3.8 months (range 2 to 8 months), Type B fractures at 4.8 months (range 2 to 16 months), and Type C fractures at 6.2 months (range 3 to 12 months). There were no increases in complication rates or differences in ranges of knee and hip motion as compared with other published series. Overall, there was no difference in the length of time to union between antegrade or retrograde nailings, and the healing rates for the two methods showed only a small statistical difference.

CONCLUSIONS

The use of femoral nails inserted in an unreamed manner in this series produced healing rates comparable with historic standards using reamed insertion. Smaller diameter nails inserted without reaming did not compromise fracture management and produced no increase in complication rates. The causes for delayed union or nonunion appear to be multifactorial, and secondary procedures should be considered if fractures have demonstrated little or no healing by three months.

A new era in orthopedic trauma care

The previous 20 years have truly opened a new era of orthopedic trauma care. Rapid advances in the development of systems for internal and external fixation have been made. Improvements in technology and surgical technique have allowed fracture reduction and fixation to be achieved with less-invasive surgical approaches. This has reduced postoperative morbidity, decreased hospitalization, and expedited the recovery of function. A new understanding of processes at the cellular and molecular levels offers the possibility, for the first time, of directly influencing the biology of fracture union and soft-tissue healing. Transitional research has introduced new therapies that are moving rapidly from the laboratory to biotech industry and the clinical arena. Given the present state of scientific acceleration, orthopedic trauma care in the new millennium will be shaped by important developments that physicians can now only imagine.

Biomechanical analysis of supracondylar femoral fractures fixed with modern retrograde intramedullary nails

OBJECTIVES

Several new retrograde supracondylar intramedullary nails have been developed to specifically address fractures of the distal femur. The nails appear clinically effective, but there are few biomechanical data documenting the stability of the fixation or the mechanical stiffness of the different designs. The goal of this study was to assess the torsional and bending stiffness of four designs of intramedullary nails developed for this application.

METHODS

Four nail designs were tested in torsion and bending to determine system stiffness: Ace supracondylar, Richards "five hole" and "multi-hole" supracondylar, and Biomet retrograde. The nails were inserted into cadaveric femurs in which a one-centimeter distraction osteotomy had been created seven centimeters proximal to the condyles. The constructs were then tested on an Instron biaxial testing system.

RESULTS

There were no statistically significant differences in bending stiffness among the groups of nails (range 0.79 to 1.18 newtons/meter; p > 0.1). However, the Ace nails (1.10 newtonmeters/degree) did exhibit a statistically lower torsional stiffness compared with the other nails (2.20 to 2.21 newton-meters/ degree; p < 0. 1). No differences were noted as a function of the number of locking holes.

CONCLUSIONS

The bending stiffness of four currently available designs of retrograde intramedullary nails does not appear to be dependent on design variations. The torsional stiffness did vary among the four designs, but this was not determined by the number of fixation holes provided. It appears that a well-placed retrograde supracondylar nail of modern design should have sufficient stiffness to support the femur and provide stability during fracture healing.

Retrograde nailing of the femoral shaft

Retrograde intramedullary nailing of fractures of the femoral shaft with use of a distal intercondylar intra-articular entry portal is a relatively new surgical technique. This method of nailing represents a modification of the previously described procedure in which an extra-articular entry portal in the medial femoral condyle was used. The earlier procedure was plagued by technical difficulties, which limited its use; these problems were mainly related to the fact that the entry portal was not in line with the intramedullary canal, as well as to the fact that purpose-specific implants and instrumentation were not available. Modification of this technique, by using the intercondylar entry portal and a nail designed for retrograde insertion, has proved very effective in clinical studies. There have been theoretical concerns regarding postoperative knee function and intraoperative injury to important anatomic structures, such as branches of the femoral nerve; however, laboratory and clinical findings have dispelled many of these concerns and have provided firm support for continued use of the technique. Nonetheless, further study is required to delineate the long-term outcome of knee joint function. Current indications for use of this technique include multisystem injuries, multiple fractures (including ipsilateral lower-limb combination injuries), ipsilateral vascular injuries, periprosthetic fractures, and morbid obesity.

Intraarticular heterotopic ossification in the knee following intramedullary nailing of the fractured femur using a retrograde method

The cases of a forty-five-year-old woman and a twenty-year-old man who developed severe intraarticular and periarticular heterotopic ossification around the knee following intramedullary nailing of a femur fracture using a retrograde technique. The association of musculoskeletal heterotopic ossification with closed head injuries seems well established and can occur in and around the knee following retrograde intramedullary nailing. This complication may occur more often than has been reported.

Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation

OBJECTIVE

To determine the patellofemoral contact areas as well as mean and maximal pressures after retrograde intramedullary nailing in a cadaveric model.

STUDY DESIGN

Pressure-sensitive film was used to analyze patellofemoral joint pressures after insertion of a retrograde femoral nail in a cadaveric specimen.

METHODS

A retrograde femoral nail was inserted into seven cadaveric knees. Pressure-sensitive film was placed into the patellofemoral joint and physiologic loads (700 newtons) were applied to the knee joint at 90 degrees and 120 degrees of flexion. Testing was performed with the nail three millimeters deep to the cartilage (In), flush with the cartilage (Flush), and one millimeter prominent (Out). The intact knee served as the Control.

RESULTS

The mean contact areas showed no statistical differences among the four groups. There was a significant increase in mean pressure at 120 degrees and maximum pressure at 90 degrees and 120 degrees for the Out group when compared with the Control, In, and Flush groups (p < 0.001).

CONCLUSIONS

There were no significant differences in mean contact pressure, contact area, or maximum pressure among the Control, three-millimeter insertion depth, or flush insertion groups. There was, however, a significant increase in mean and maximum pressures with the nail one millimeter prominent. These results indicate that placement of a retrograde femoral intramedullary nail is critical, but that proper placement should not significantly influence the biomechanics of the patellofemoral joint.

Retrograde intramedullary nailing of femoral diaphyseal fractures

OBJECTIVES

To prospectively evaluate the results of retrograde intramedullary nailing of femoral shaft fractures.

DESIGN

Prospective, consecutive series.

PATIENTS AND SETTING

All patients with a femoral shaft fracture admitted at an urban Level 1 trauma center from December 1995 to December 1996 were treated with a retrograde femoral intramedullary nail.

INTERVENTION

Retrograde femoral intramedullary nailing was performed on a radiolucent operating room table. Through a three-centimeter medial parapatellar incision, a reamed ten-millimeter retrograde nail was inserted.

METHODS

From the time of injury until union, the following parameters were assessed: operative time, blood loss, extent of comminution, open grade, associated injuries, Injury Severity Score, body mass index, time to union, secondary procedures, range of motion in the knee. and complications.

RESULTS

Fifty-seven patients with sixty-one fractures were available for follow-up, which averaged 43.1 weeks. Fifty-two percent of fractures demonstrated Winquist Type 3 or 4 comminution. Twenty-six percent of the fractures were open. Fifty-two fractures healed after the initial nailing, five of seven dynamized nails healed, and one patient with bone loss requiring bone graft united yielding a final union rate of 95 percent. Of the three nonunions (5 percent), two healed with exchange nailing and one remains asymptomatic at seventy-one weeks. One patient developed a late septic knee that resolved with treatment. Excellent range of motion in the knee was obtained by those patients who did not have other ipsilateral limb injuries.

CONCLUSIONS

This consecutive series had a 95 percent union rate after nailing and dynamization as necessary. No knee problems were associated with the retrograde femoral intramedullary nailing technique. The one septic knee raises concerns about the use of retrograde nailing in severe open femoral shaft fractures. Retrograde femoral nailing should be given serious consideration as an alternative to antegrade femoral nailing.

Length of operative procedures: reamed femoral intramedullary nailing performed with and without a fracture table

OBJECTIVES

To determine whether performing reamed intramedullary nailing of the femur without the use of a fracture table decreases the length of operation.

DESIGN

Retrospective.

SETTING

Level 1 trauma center, Nashville. Tennessee.

PATIENTS/PARTICIPANTS

Consecutively treated patients with fractures of the femoral shaft were treated with intramedullary nails from June 1986 to March 1996.

INTERVENTION

Reamed intramedullary nailing of the femoral shaft was performed with the use of a fracture table or with the leg draped free on a radiolucent table.

MAIN OUTCOME MEASUREMENTS

Length of anesthesia time, prep and drape time (from the point the anesthetized patient is turned over to the surgeons until incision), and intramedullary nailing time (from incision until end of surgery) for reamed intramedullary nailing of the femoral shaft performed with and without the use of a fracture table were compared.

RESULTS

Univariate analysis showed statistically significant decreases in the length of prep and drape time, operative time, and anesthetic time when fractures were treated without the use of a fracture table. Multivariate analysis showed that use of a fracture table prolongs prep and drape time (plus twenty minutes), operative time (plus seventeen minutes), and anesthesia time (plus seventy-three minutes) when the covariates of age, sex, fracture location, learning curve, position of the patient, nail brand, and number of distal bolts are controlled.

CONCLUSIONS

Reamed intramedullary nailing of the femoral shaft performed without the use of a fracture table is significantly faster than when the procedure is performed with a fracture table.

Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails

OBJECTIVE

To evaluate the neurovascular structures at risk with the placement of anterior-posterior locking screws in the proximal femur.

DESIGN

Cadaveric study.

MAIN OUTCOME MEASURE

Anatomic relationships.

RESULTS

The femoral artery lies medial to the femur, and its branches cross the anterior femur more than four centimeters distal to the lesser trochanter. Branches of the femoral nerve cross the anterior femur proximal to the lesser trochanter and start four centimeters distal to the piriformis fossa.

CONCLUSIONS

Risks to the neurovascular structures during anterior-posterior locking in the proximal femur are diminished if locking is performed above the level of the lesser trochanter.

Unreamed retrograde intramedullary nailing of fractures of the femoral shaft

OBJECTIVE

To evaluate the efficacy of unreamed retrograde intramedullary (IM) nailing of fractures of the femoral shaft in a second series of patients using modifications suggested from our initial study.

DESIGN

Prospective.

SETTING

Level I trauma center.

METHODS

Based on the findings of a previous study, we began a clinical series incorporating changes consisting of (a) inclusion of any patient with a femoral shaft fracture amenable to IM nailing (i.e., closed physes), (b) primary use of a split patellar tendon intercondylar distal femoral entry portal, and (c) the use of a full-length femoral implant having variable size availability and dynamization capability. Over a twelve-month period, thirty-four patients with thirty-five femoral shaft fractures were treated. The protocol called for planned dynamization in statically locked stable fractures and unstable fractures showing minimal healing at six to twelve weeks. Functional outcome was assessed by using the Knee Society clinical rating system.

RESULTS

Incorporating the concepts of canal fill and early dynamization, there were only two nonunions (6 percent) in this series as compared with 14 percent in the previously reported series with an overall shorter time to union (12.6 versus 15 weeks). There were no infections or malunions. Postoperative complaints of knee pain were minimal (knee score average: 98 points) and knee function was excellent (knee score average: 97 points).

CONCLUSIONS

Although not advocated as a replacement for other techniques, unreamed retrograde nailing is presented as a safe and beneficial fracture fixation method that should be added to the orthopaedic surgeon's treatment armamentarium. The operative technique is quick and simple, and blood loss is minimal. Early nail dynamization and early weight-bearing are important in minimizing the risk of nonunion.

Femoral and cruciate blood flow after retrograde femoral reaming: a canine study using laser Doppler flowmetry

OBJECTIVE

To determine the effect of retrograde femoral reaming on the blood flow of the distal femur and the cruciate ligaments.

DESIGN

Canine experimental study.

SETTING

Tertiary referral and teaching hospital in Toronto, Canada.

PARTICIPANTS

Thirteen skeletally mature, cross-bred dogs.

MAIN OUTCOME MEASURE

Red cell flux (RCF) was measured by using a laser Doppler flowmetry probe at three bone sites in the distal femur (trochlear groove, medial condyle, and lateral condyle) and at the midportion of both the anterior and posterior cruciate ligaments before and after retrograde femoral reaming.

RESULTS

There was a significant increase in the mean postreaming RCF at all the bone sites of the distal femur compared with prereaming values: trochlear groove (p = 0.0247), medial condyle (p = 0.0440), and lateral condyle (p = 0.0042). We also found a significant decrease in the mean postreaming RCF at both cruciate ligament sites compared with prereaming values (anterior cruciate, p = 0.0004; posterior cruciate, p = 0.0006).

CONCLUSIONS

Retrograde femoral reaming and intramedullary nailing has become a popular option for the treatment of distal femoral and some femoral shaft fractures, but concerns regarding the effect of reaming through an intraarticular entry portal have been raised. Our experimental study found that after reaming perfusion of the anterior cruciate ligament decreased by 52 percent and perfusion of the posterior cruciate ligament decreased by 49 percent. Diminished perfusion after reaming may delay healing or exacerbate existing injury to the cruciate ligaments and adversely affect rehabilitation of the knee after femoral fracture.

Retrograde nailing of the femur using an intercondylar approach

The standard of care for femoral fractures is an intramedullary nail, placed in an antegrade approach. This has produced high rates of healing and low complication rates. The use of retrograde nailing for femoral shaft fractures is a relatively new technique, previously described as an extraarticular approach. Forty-one patients with 45 fractures were available for assessment after retrograde femoral nailing using an intracondylar approach. There were 2 nonunions, which healed with revision surgery, in addition to 5 other complications including: reflex sympathetic dystrophy, an ileus, deep vein thrombosis, skin loss about the knee, and malrotation noted after initial nailing. There were no postoperative infections, no arthrosis was noted, and flexion of the knee averaged 129 degrees. Retrograde femoral nailing may be used to treat fractures in patients who present with multisystem trauma; multiskeletal trauma, especially peritrochanteric and acetabular injuries; floating knee fractures; bilateral femur fractures; and patients with morbid obesity.

Ipsilateral fractures of the femur and tibia: treatment with retrograde femoral nailing and unreamed tibial nailing

Between 1989 and 1995 a total of 47 patients with 50 fractures of the ipsilateral femoral and tibial shafts without significant articular involvement were treated at Tampa General Hospital. Within this group were 24 patients with 26 fractures who were treated with intramedullary fixation of both bones using a technique of retrograde insertion of a femoral nail and unreamed insertion of an interlocking tibial nail. Information concerning the injuries, treatments, and much of the follow-up was gleaned from a trauma registry. Five of the femoral fractures (19%) and 14 of the tibial fractures (54%) were open. Associated injuries were present in 18 of the 24 patients (75%) with injuries of the pelvis, other extremities, and head being most prevalent. The average Injury Severity Score was 14 (range 9-32). The femoral nails were placed either through the medial femoral condyle (n = 14) or the intercondylar notch of the distal femur (n = 12). Twenty patients with 22 extremities had sufficient follow-up at an average of 20 months (range 4-60) postinjury to be included in the review. One patient had died, and three were completely lost to follow-up. Both fractures in 14 extremities had healed or were healing uneventfully at final review. Seven of the tibiae and three of the femora had complications after initial hospitalization. Two patients developed problems in both bones. Three patients had electrical stimulation of a tibia fracture, one of which underwent simultaneous nail dynamization. A total of 18 additional operative procedures were necessary after the primary treatment in six problematic extremities. Thirteen additional operative procedures were required in five complicated tibiae (one nail dynamization, six debridement procedures, five bone grafts, and one muscle flap) after the initial hospitalization. Five additional operative procedures were required in the three complicated femora (two nail dynamizations, one bone graft, and two exchange nailing procedures). Functional results were good or excellent in 13 of the 20 patients (65%) and 15 of the 22 extremities (68%) available at final review. No significant knee problem related to the femoral nailing technique was identified. This method of treatment can be performed using a standard radiolucent table and a single medial parapatellar incision. It is expedient and allows other procedures to be performed simultaneously in this group of severely injured patients.

Unreamed intramedullary nailing of femoral shaft fractures: operative technique and early clinical experience with the standard locking option

Nailing techniques have changed in recent years in ways which are not just limited to omitting the reaming process. These changes concern positioning patients, techniques of reduction and selecting implants. Techniques of approach and exposure have been modified to new, less-invasive procedures to fulfill technical, functional and cosmetic requirements. In addition, techniques have been developed to avoid fragment diastasis, rotational and sagittal malalignment, and leg-length discrepancy. Finally, simple algorithms have been elaborated for the management of specific fracture patterns (bilateral shaft fractures, ipsilateral tibial fractures or associated femoral neck fractures) and to determine the number and location of locking bolts. We developed these algorithms, techniques and procedures in a series of 133 femoral shafts, which were stabilized with the AO unreamed femoral nail (URFN) in a prospective study between 1991 and 1994. Of these, the first 57 cases with a mean follow-up of 17.9 months (range, 5-44) after injury were reviewed. Fractures were classified according to Müller's 1990 system: 12 type A, 29 type B and 16 type C. Closed soft-tissue injuries were classified by our classification of 1982: 17 type C 0/I, 42 type C II. Of 15 open fractures, six were OI, six OII, two OIIIA and one was OIIIB by Gustilo's classification of 1984. The major complications were two broken locking bolts, one nail breaking after 9 weeks, one case of osteitis and one of intra-operative lung embolism.

Retrograde intramedullary nailing, without reaming, of fractures of the femoral shaft in multiply injured patients

Twenty consecutive multiply injured patients who had a total of twenty-two fractures of the femoral shaft were managed with intramedullary nailing without reaming. A retrograde technique through the intercondylar notch of the knee was used. All patients were followed for at least one year or until union of the fracture. The operative time for the nailing averaged seventy-five minutes (range, thirty-five to 105 minutes). Union of the fracture occurred at an average of fifteen weeks. There were three non-unions and one rotational malunion. There were no infections, and no nail or screw failed. Normal motion of the knee was regained by all patients, except one who had had an ipsilateral dislocation of the knee. On the basis of these preliminary results, we concluded that retrograde nailing is a safe and effective technique for multiply injured patients. The apparently higher prevalence of non-union compared with that reported with antegrade nailing with reaming warrants additional study.