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

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.

Retrograde intramedullary nail for metastatic lesion of the lower tibia

Two cases of distal tibial metastases are presented, and a suggestion is made for a method of treatment.

Treatment of floating knee injuries through a single percutaneous approach

The current study is a review of 20 patients treated by percutaneous stabilization for a floating knee. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. The average Injury Severity Score was 19. Two patients died in the early postoperative period and one patient was lost to followup. The average time to union for the 17 remaining patients with femoral shaft fractures was 14.7 weeks. One patient required dynamization. Four of the 17 patients with tibia fractures required an exchange nailing procedure, one with bone graft, to achieve union. One patient required dynamization and one patient with bone loss required only a bone graft. The average time to union for the tibia fractures was 23 weeks. One patient achieved 115 degrees knee flexion and the remaining 15 patients had full knee motion by 12 weeks, which they were able to maintain. No patient had signs or symptoms of knee pain. This demanding surgical technique using a small incision has yielded good clinical results. Although it is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the mortality and tibial fracture complication rates remain high.

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.

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.