Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial

[Fractures of the shaft of the femur]

The femur is the largest, longest and strongest bone in the human skeleton. Fractures of the shaft of the femur can result from high energy as well as low energy trauma and 30% of patients have multiple injuries. In the clinical diagnostic special attention must be paid to the peripheral neurovascular status as well as the possibility of a compartment syndrome. Fractures of the femur shaft are defined according to the AO classification. Treatment is as a rule operative, except for children up the end of 4 years old. Medullary nailing is nowadays the method of choice and the nails can be implanted in an anterograde or retrograde direction. The introduction of nails after boring out the medullar is associated with an increased healing rate in comparison to non-boring techniques. Various techniques are available for the often promising method of repositioning and the intraoperative controls. Plating is reserved only for special situations. External fixation is of great value in adults for temporary fixation of fractures of the femur shaft. Full weight bearing is possible immediately following the operation depending on the type of fracture and method of treatment. Uncomplicated fracture healing does not result in a reduction in the ability to work. Despite the generally good prognosis and improvement in design and technology of implants, fractures of the femur shaft still represent a special challenge for the treating casualty surgeon.

Intramedullary nailing of femoral shaft fractures: current concepts

Intramedullary nailing is the preferred method for treating fractures of the femoral shaft. The piriformis fossa and greater trochanter are viable starting points for antegrade nailing. Alternatively, retrograde nailing may be performed. Each option has relative advantages, disadvantages, and indications. Patient positioning can affect the relative ease of intramedullary nailing and the incidence of malalignment. The timing of femoral intramedullary nailing as well as the use of reaming must be tailored to each patient to avoid systemic complications. Associated comorbidities, the body habitus, and associated injuries should be considered when determining the starting point, optimal patient positioning for nailing, whether to use reduction aids as well as which to use, and any modifications of standard technique. Intramedullary nailing of diaphyseal femur fractures provides a stable fixation construct that can be applied using indirect reduction techniques. This method yields high union rates and low complication rates when vigilance is maintained during preoperative planning, the surgical procedure, and the postoperative period.

Case report: Patella baja after retrograde femoral nail insertion

Patella baja is a rare condition that can result from conditions involving trauma around the knee. Risk factors are believed to include scar tissue formation in the retropatellar fat pad, extensor mechanism dysfunction, and immobilization in extension. Early recognition and aggressive treatment are critical components in minimizing long-term disability. We present a case report of a woman with a fracture of the femoral diaphysis who underwent retrograde placement of an intramedullary nail. Subsequent followup revealed development of patella baja with resultant disability. The diagnosis was made late and the treatment was ineffective. Although patella baja has been reported in trauma around the knee, causative factors include retrograde femoral nailing. We believe early recognition and institution of treatment are important.

Variability in the assessment of fracture-healing in orthopaedic trauma studies

BACKGROUND

There is a lack of consensus among orthopaedic surgeons in the assessment of fracture-healing. We conducted a systematic review of recent clinical studies of long-bone fracture care that were published in three major orthopaedic journals to identify current definitions of fracture-healing.

METHODS

MEDLINE and the computerized databases for The Journal of Bone and Joint Surgery (American Volume), The Journal of Bone and Joint Surgery (British Volume), and the Journal of Orthopaedic Trauma were searched from January 1996 through December 2006 with use of title, abstract, keyword, and medical subject headings. Therapeutic clinical studies of long-bone fractures of the appendicular skeleton in adults in which fracture-healing was assessed were selected. Two reviewers independently identified articles and extracted data. Any disagreement was resolved by consensus. We qualitatively and quantitatively summarized the definition of fracture union and the reliability of the assessment of radiographic fracture-healing.

RESULTS

One hundred and twenty-three studies proved to be eligible. Union was defined on the basis of a combination of clinical and radiographic criteria in 62% of the studies, on the basis of radiographic criteria only in 37%, and on the basis of clinical criteria only in 1%. Twelve different criteria were used to define fracture union clinically, and the most common criterion was the absence of pain or tenderness at the fracture site during weight-bearing. In studies involving the use of plain radiographs, eleven different criteria were used to define fracture union, and the most common criterion was bridging of the fracture site. A quantitative measure of the reliability of the radiographic assessment of fracture union was reported in two studies.

CONCLUSIONS

We found a lack of consensus with regard to the definition of fracture-healing in the current orthopaedic literature. Without valid and reliable clinical or radiographic measures of union, the interpretation of fracture care studies remains difficult.

Anatomy of the greater trochanteric 'bald spot': a potential portal for abductor sparing femoral nailing?

Soft tissue injury occurs when using a piriformis portal for femoral nailing. Standard trochanteric portals also can injure the gluteus medius and external rotator tendons, which may be a source of hip pain after nailing. On the lateral facet of the greater trochanter, a "bald spot" may exist that is devoid of tendon insertion. This may be a potential portal for intramedullary nail insertion. We defined the dimensions and location of this region. Cadaveric specimens were dissected to expose the tendon insertions on the greater trochanter. A computer navigation system was used with a stylus and bone morphing to determine the tendon insertions and bald spot anatomy. The greater trochanteric bald spot is covered by the subgluteus medius bursa and has no tendon insertions. Its center lies 11 mm distal to the tip of the greater trochanter and 5 mm anterior to the midline. The shape is ellipsoid with a diameter of 21 mm. This region is large enough to accommodate the size of most nailing system reamers without tendon footprint infringement. Use of this modified entry site may reduce soft tissue injury with nailing procedures and minimize subsequent hip pain.

Hand prehension recovery after brachial plexus avulsion injury by performing a full-length phrenic nerve transfer via endoscopic thoracic surgery

Object

The functional recovery of hand prehension after complete brachial plexus avulsion injury (BPAI) remains an unsolved problem. The authors conducted a prospective study to elucidate a new method of resolving this injury.

Methods

Three patients with BPAI underwent a new procedure during which the full-length phrenic nerve was transferred to the medial root of the median nerve via endoscopic thoracic surgery support. All 3 patients were followed up for a postoperative period of > 3 years.

Results

The power of the palmaris longus, flexor pollicis longus, and the flexor digitorum muscles of all 4 fingers reached Grade 3–4/5, and no symptoms of respiratory insufficiency occurred.

Conclusions

Neurotization of the phrenic nerve to the medial root of the median nerve via endoscopic thoracic surgery is a feasible means of early hand prehension recovery after complete BPAI.

Infecção pós-estabilização intramedular das fraturas diafisárias dos membros inferiores: protocolo de tratamento

O tratamento das infecções pós-estabilização intramedular das fraturas dos membros inferiores apresenta uma grande variedade de opções, desde a limpeza cirúrgica com manutenção da haste até a retirada da haste e colocação de fixador externo. O espaçador diafisário ainda é uma técnica pouco utilizada para o tratamento desse tipo de infecção, existindo poucos relatos na literatura sobre sua aplicação. No IOT HCFMUSP, esta técnica vem sendo empregada de maneira crescente e, no presente trabalho, temos o objetivo de descrever o protocolo de tratamento utilizado em nossa instituição, bem como a apresentação de nossa casuística inicial. O protocolo consiste na antibioticoterapia endovenosa, retirada da haste intra-medular, desbridamento cirúrgico do canal medular e colocação do espaçador diafisário. Revisamos retrospectivamente o prontuário de 11 pacientes com 13 fraturas, sendo cinco femorais e oito tibiais, submetidos à técnica apresentada. O tempo de seguimento variou de 6 a 36 meses, média de 14,27 meses, com resultados satisfatórios ocorridos em dez das treze fraturas estudadas, representando uma taxa de eficácia de 76,93%. Concluímos que o método representa uma boa alternativa para o tratamento destes casos, necessitando ainda novos trabalhos comparativos para a avaliação de suas vantagens e para difundir o uso do método.

Retrograde cement removal in periprosthetic fractures following hip arthroplasty

INTRODUCTION

Revision of cemented hip arthroplasty after periprosthetic fractures of the femur is a demanding procedure. Many different technical devices have been developed for this purpose. This paper presents a new surgical technique of cement removal avoiding excessive exposure of the fracture site.

MATERIALS AND METHODS

In six patients with periprosthetic fractures of the femur following hip arthroplasty (Johansson Type II and III) cement removal was performed by means of advancing a retrograde nail through the intercondylar notch of the knee.

RESULTS

In all cases the cement was removed completely. Intraoperative complications or significant knee problems were not observed.

CONCLUSION

The intracondylar approach provides a simple, rapid and less invasive technique for cement removal in revision hip arthroplasty.

Retrograde bridging nailing of periprosthetic femoral fractures

A retrograde femoral nail was designed to slide over the tip of the femoral stem. Eighteen patients (4 male symbol, 14 female symbol) were treated with this retrograde nail between 1995 and 2003. The mean age was 81.4 years (range 61-96) with a mean follow-up of 21 months (range 4-61 months). Eight patients suffered from severe comorbidity. Mean surgical time was 91 min. Fourteen patients regained their preoperative functional level. Six patients died within the first post-operative year of natural causes. Their knee- and hip-function were reasonable considering the age group and co-morbidity. One revision was required and one patient had a protruding nail. In all patients radiological union of the fracture was seen between 4 and 12 months after surgery. Retrograde bridging nailing of the periprosthetic fractured femur is a therapeutic option in geriatric or impaired patients and can serve as a definitive implant.

Principles of free tissue transfer in orthopaedic practice

Free tissue transfer is a vital adjunct to orthopaedic practice; it may optimize the treatment of many emergency and elective conditions that require soft-tissue or bone augmentation. Consultation with a colleague trained in microsurgery is often necessary in undertaking free tissue transfer techniques. A two-team approach frequently is used to maximize efficiency and minimize fatigue. Flaps with reliable pedicle anatomy are preferred. Flaps typically are raised using an open technique, but endoscopic techniques can be utilized to decrease donor-site scarring. Free tissue transfer is a demanding procedure; careful preoperative planning is essential to ensure optimal results. Free tissue transfer inevitably results in some donor morbidity, and flaps are carefully chosen to minimize this. The most serious complication is failure of the flap. Free muscle flaps used in soft-tissue reconstruction today result in little loss of function.

Prevalence of long-bone non-unions

Despite the enormous progress made during recent decades in the treatment of long-bone fractures, fracture healing is still haunted by complications and above all non-unions. Non-unions represent a particular challenge, and the difficulties surrounding their management are frequently underestimated. Knowledge of the epidemiology of long-bone non-union can assist the treating surgeon in the application of the optimum fracture treatment.

Retrograde nailing for distal third femoral shaft fractures: a prospective study

PURPOSE

To evaluate the postoperative knee function and results of unreamed retrograde nailing for distal third femoral shaft fractures.

METHODS

Between January 2002 and 2003 inclusive, a consecutive series of 27 patients (with 28 fractures) who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified Knee Society Knee Score. Correlations between union time and other variables were also studied.

RESULTS

In these patients 26 (93%) of the 28 fractures achieved union, of which 5 underwent dynamisation; the mean union time for the other 21 fractures was 4.4 months. Angular malalignment was present in 4 patients and shortening in 4 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 26 patients. 19 patients had anterior knee pain and 10 had instability. By the end of one year, excellent or good scores for pain and function were recorded in 77% and 73% respectively, of the 26 patients.

CONCLUSION

In view of such favourable union rates but significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.

Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures

INTRODUCTION

Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures.

MATERIALS AND METHODS

Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture.

RESULTS

The average time for union of femoral shaft fractures was 27.3 (14-60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8-12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman-Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty.

CONCLUSION

Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.

Arthroscopically-assisted removal of retrograde intramedullary femoral nails

Retrograde nailing of femoral shaft fractures has become more prevalent as a result of its growing acceptance and familiarity to orthopaedic surgeons. Nail removal is occasionally indicated, which may require a formal arthrotomy. We describe an arthroscopic removal technique that has several advantages. The percutaneous technique imparts less morbidity than a more extensive arthrotomy. More importantly, additional intra-articular pathology can be thoroughly assessed and treated, such as meniscal tears and chondral injury, which may have occurred at the time of injury. These are potential causes of knee pain, which usually cannot be properly diagnosed without arthroscopy. Our findings also support the existence of a stable fibrous cap, which forms over the entry portal of a well-seated retrograde femoral nail as well as no evidence of intra-articular metallosis.

Derotation of post-traumatic femoral deformities by closed intramedullary sawing

Different techniques and devices have been used for correction osteotomies of bones in patients with malalignments. The most frequently used technique for rotational deformities of the femur and tibia is open osteotomy with an oscillating saw and pre-drilled holes with all well-known drawbacks of open surgery. An intramedullary device with an adapted minimal-invasive surgical technique allows intramedullary osteotomy of the bone preserving the surrounding soft tissue. We performed femoral osteotomies with an intramedullary saw followed by static interlocking nailing in 14 patients with post-traumatic rotational deformity in the femur. Twelve patients had an external rotational deformity of the femur ranging between 26 and 63 degrees , one had an additional leg-shortening of about 4 cm. Two patients had internal rotational deformities. In two patients with delayed fracture healing union was achieved within one year without secondary surgery. Post-operative clinical assessment and CT-scans revealed good derotation results with deformities of less than 4 degrees in all cases. No device-related complications were observed. Therefore, we conclude that "closed" osteotomy with an intramedullary saw is a minimal-invasive, safe and reliable option for derotation procedures in the femur.

Adult traumatic brachial plexus injuries

Adult traumatic brachial plexus injuries are devastating, and they are occurring with increasing frequency. Patient evaluation consists of a focused assessment of upper extremity sensory and motor function, radiologic studies, and, most important, preoperative and intraoperative electrodiagnostic studies. The critical concepts in surgical treatment are patient selection as well as the timing and prioritizing of restoration of function. Surgical techniques include neurolysis, nerve grafting, neurotization, and free muscle transfer. Results are variable, but increased knowledge of nerve injury and repair, as well as advances in microsurgical techniques, allow not only restoration of elbow flexion and shoulder abduction but also of useful prehension of the hand in some patients.

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.

Early patellofemoral osteoarthritis caused by an osteochondral defect after retrograde solid nailing of the femur in sheep

BACKGROUND

Retrograde femoral nailing (RFN) is an increasingly used technique for internal fixation of femoral fractures. Geometrically and empirically, the nail entry zone is close to the center of the femoral groove, causing concern about the development of patellofemoral osteoarthritis.

METHODS

We studied the effect of opening the distal femur through the femoral groove on the development of osteoarthritis in sheep after retrograde reamed insertion of a solid titanium nail into the femoral canal. Knees were radiographically and macroscopically studied for the presence of osteophytes and signs of cartilage degeneration. Controls underwent the same procedure without opening the femoral groove.

RESULTS

The study group showed time-dependent macroscopic and radiographic signs of osteoarthritis with predominant involvement of the patellofemoral joint.

CONCLUSION

RFN can cause patellofemoral osteoarthritis. Care should be exercised to use RFN in isolated supracondylar or shaft fractures of the femur in healthy young adults.

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.

Posttraumatische Achsabweichungen und funktionelle Untersuchungen nach ante- bzw. retrograder Marknagelung des distalen Femurdrittels

Previous studies have compared the functional outcome and torsional differences following closed intramedullary nailing of femoral fractures. Rotational deformity following intramedullary nailing may cause symptoms and require surgical correction by osteotomy. Until now studies were designed to evaluate the correct torsional differences by examining every patient following antegrade or retrograde femoral nailing. The series included 13 women and 28 men, average age 44.5 years, who suffered a fracture of the distal femoral diaphysis. Postoperatively we established the diagnosis by three-dimensional determination of the torsion and length of the lower extremities by ultrasound measurement. Furthermore, we performed the clinical examination according to the Tegner and Lysholm score and the Merle d'Aubigne score. There were no significant differences in torsional deformity and length found. The functional outcome showed no significant differences between the two groups. The functional examination exhibited a reduction of flexion in knee motion in the retrograde group. In the antegrade group the motion of the hip was decreased. A correlation between the functional outcome and the torsional deformity was not found. The possible advantage of positioning by using the retrograde femoral nail was not verified.

The effects of femoral shaft malrotation on lower extremity anatomy

OBJECTIVE

To determine how axial rotation around the anatomic axis of the femur, as would occur with malrotation of a femoral fracture, affects frontal and sagittal plane alignment and knee joint orientation.

DESIGN

Computer-generated models of the lower extremity were constructed using standardized dimensions. To simulate a malrotated fracture, these models were rotated in the shaft around the anatomic axis in 15 degrees increments from 60 degrees internal to 60 degrees external rotation. Rotation was performed at the proximal fourth, mid-shaft, and distal fourth.

MAIN OUTCOME MEASUREMENTS

At each rotational position, the mechanical axis deviation in millimeters and the changes in mechanical lateral distal femoral angle in degrees were measured to quantify frontal plane malalignment and malorientation, respectively. The mechanical axis deviation in millimeters in the sagittal plane was also measured at each rotatory position.

RESULTS

Femoral shaft malrotation greater than 30 degrees internal rotation of a subtrochanteric fracture or more than 45 degrees of a midshaft fracture or external rotation of 30 degrees or greater of a supracondylar fracture resulted in frontal plane malalignment. External rotation of a supracondylar fracture of 45 degrees or more results in knee joint malorientation. Any external rotation at all 3 fracture levels caused posterior displacement of the weight-bearing axis in the sagittal plane.

CONCLUSIONS

Malrotation of a femoral shaft fracture is not just a cosmetic problem. Internal and external rotation causes malalignment and malorientation in the frontal plane, depending on the level of the fracture and the magnitude of malrotation. External rotation of any degree at the proximal fourth, mid-shaft, and distal fourth causes a posterior shift of the weight-bearing axis in the sagittal plane.

Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion

Object

The authors report the functional outcomes after functioning free muscle transfer (FFMT) for restoration of the upper-extremity movement after brachial plexus injury (BPI).

Methods

The authors conducted a retrospective review of 36 gracilis FFMT procedures performed in 27 patients with BPI between 1990 and 2000. Eighteen patients underwent a single gracilis FFMT procedure for restoration of either elbow flexion (17 cases) or finger flexion (one case). Nine patients underwent a double free muscle transfer for simultaneous restoration of elbow flexion and wrist extension (first muscle) and finger flexion (second muscle), combined with direct triceps neurotization. The results obtained in 29 cases of FFMT in which the follow-up period was 1 year are reported.

Neurotization of the donor muscle was performed using the musculocutaneous nerve (one case), spinal accessory nerve (12 cases), or multiple intercostal motor nerves (16 cases). Two second-stage muscle flaps failed secondary to vascular insufficiency. Mean electromyography-measured reinnervation time was 5 months. At a minimum follow-up period of 1 year, five muscles achieved less than or equal to Grade M2, eight Grade M3, four Grade M4, and 12 Grade M5. Transfer for combined elbow flexion and wrist extension compared with elbow flexion alone lowered the overall results for elbow flexion strength. Seventy-nine percent of the FFMTs for elbow flexion alone (single transfer) and 63% of similarly innervated muscles transferred for combined motion achieved at least Grade M4 elbow flexion strength.

Conclusions

Functioning free muscle transfer is a viable reconstructive option for restoration of upper-extremity function in the setting of severe BPI. It is possible to achieve good to excellent outcomes in terms of muscle grades with the simultaneous reconstruction of two functions by one FFMT, making restoration of basic hand function possible. More reliable results are obtained when a single FFMT is performed for a single function.

Significance of shoulder function in the reconstruction of prehension with double free-muscle transfer after complete paralysis of the brachial plexus

Reconstruction of shoulder stability and movement in cases with complete paralysis of the brachial plexus was performed to improve the outcomes for universal function of prehension after double free-muscle transfer (Doi's procedure). In cases in which the C5 or C6 nerve root was available as a donor, neurotization of the supra-scapular nerve was performed with a nerve graft. If the C5 or C6 nerve root was not available, then the contralateral C7 nerve root was chosen as the donor motor nerve and was transferred to the suprascapular nerve by using a vascularized ulnar nerve graft. Seven cases with ipsilateral C4, C5, or C6 nerve root transfer to the suprascapular nerve and one with contralateral C7 transfer were evaluated, and the functional outcomes for the range of shoulder motion were compared with those for patients who had undergone arthrodesis of the humeroscapular joint or had undergone no procedures for shoulder function reconstruction. The patients who underwent supra-scapular nerve repair demonstrated statistically significantly better ranges of motion for flexion and abduction of the shoulder, compared with the other two groups. Shoulder function is important for achieving prehensile function among patients with complete paralysis of brachial function, when they undergo double free-muscle transfer.

Ilizarov compression over a nail for aseptic femoral nonunions that have failed exchange nailing: a report of five cases

OBJECTIVE

To evaluate a new operative treatment of femoral nonunion following failed exchange nailing.

DESIGN

Retrospective review, consecutive series. SETTING Office-based orthopaedic practice.

PATIENTS

Five consecutive patients (ages 31-67 years) were referred in with a femoral nonunion following exchange nailing an average of 28 months (range 11-55) after the initial traumatic injury. The patients had undergone an average of 5 (range 2-8) previous surgeries on the femur. No patient had signs or history of bone infection or segmental bone loss at presentation. All patients had diaphyseal or diaphyseal-metaphyseal oligotrophic nonunions and had failed an average of 2 (range 1-3) previous exchange nailings.

INTERVENTION

Slow compression (0.25 to 0.50 mm per day) of the nonunion site over a new, smaller diameter nail using an Ilizarov external fixator.

MAIN OUTCOMES MEASUREMENTS

Clinical and radiographic evidence of bone union, ambulation, pain, residual deformity, or shortening.

RESULTS

All nonunions healed without the need for further nonunion surgery. The external fixator was removed at an average of 133 days (range 86-238 days). No deep infections occurred in any patient. All patients experienced some degree of pin site irritation. At the most recent follow-up (average 45 months; range 12-75 months), all patients had improved their functional ambulatory status and had discontinued or decreased the use of assistive devices to walk. All patients were full weight bearing. Average pain, as rated on a 0 to 10 Visual Analogue Scale, decreased from 8 of 10 before treatment to 1 of 10 after treatment. No patient experienced a clinically significant worsening of leg length discrepancy.

CONCLUSIONS

Slow compression over an intramedullary nail using external fixation successfully promotes the healing of problematic femoral nonunions that have failed one or more prior exchange nailings.

Femoral shaft fractures

Femoral shaft fractures are not only significant injuries in their own right but also often a marker for multiple, serious injuries elsewhere. The treatment in adults is usually surgical. The results are for the most part good, but are dependent on the degree of injury to the local soft tissues and on the presence or absence of other distant injuries.

An aid to femoral nail removal

We describe a novel technique to aid the removal of a proximally inserted femoral nail by using a guide wire and the starter reamer. By reaming through the scar tissue, a cylindrical track is created and the threaded top end of the nail is exposed. The soft tissue dissection is therefore limited to the absolute minimum with no further damage to the hip abductors.

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.