Prospective comparison of retrograde and antegrade femoral intramedullary nailing

Predictors of nonunion for transverse femoral shaft fractures treated with intramedullary nailing: a SIGN database study

Introduction

Nonunion is a common postfracture complication resulting in decreased quality of life for patients in resource-limited settings. This study aims to determine how age, sex, injury mechanism, and surgical intervention affect the rate of nonunion in transverse femur fractures treated with a SIGN intramedullary nail (IMN).

Methods

A retrospective study was conducted using the SIGN online surgical database. All patients older than 16 years with simple transverse (<30 degrees), open or closed, femur fractures treated using a SIGN IMN between 2007 and 2021 were included. Our primary outcome of nonunion was measured with the modified Radiographic Union Scale for Tibial fractures (mRUST); scores ≤9 of 16 defined nonunion. The secondary outcome was squat depth. Outcomes were evaluated at follow-up appointments between 240 and 365 days postoperatively. Univariate and multivariate analysis were used for statistical comparison.

Results

Inclusion criteria were met for 182 patients. The overall radiographic union rate was 61.0%, and a high proportion (84.4%) of patients could squat with their hips at or below the level of their knees. Older age, retrograde approach, and fracture distraction were associated with nonunion, but sex, injury mechanism, and other surgical variables were not.

Conclusion

Poor reduction with fracture distraction was associated with a higher rate of nonunion. Loss of follow-up may have contributed to our overall union rate; however, we observed high rates of functional healing using the SIGN IMN.

Level of evidence

IV.

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.

A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

Background

Retrograde intramedullary nailing of the femur is a popular treatment option for femoral shaft fractures. However, this requires accessing the intramedullary canal through the knee, posing a risk of intra-articular infection. The purpose of this study was to examine the rate of intra-articular infection of the knee after retrograde nailing of femoral shaft fractures.

Methods

All patients who underwent retrograde intramedullary nailing for femoral shaft fractures between June 2004 and December 2017 at a level 1 trauma center were reviewed. Six months of follow-up or documented fracture union was required. Records were reviewed for documentation of septic arthritis of the ipsilateral knee during the follow-up period.

Results

A total of 294 fractures, including 217 closed and 77 open injuries, were included. Eighteen had an associated ipsilateral traumatic arthrotomy; 188 cases had an associated ipsilateral lower extremity fracture. No cases of septic arthritis were identified.

Conclusion

There were no cases of septic arthritis in 294 fractures treated with retrograde intramedullary nailing. Retrograde nailing appears safe for risk of postoperative septic arthritis of the knee even in the face of open fractures and traumatic wounds.

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.

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

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures

Objective

To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures.

Design

Retrospective 1:1 matched cohort study.

Setting

Single-level 1 trauma center.

Participants

One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups.

Intervention

Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture.

Main Outcome Measurement

Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores.

Results

Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group.

Conclusions

Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.

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.

Biomechanical behavior of retrograde intramedullary nails in distal femoral fractures

Fractures of the distal femur affect three different groups of individuals: younger people suffering high-energy trauma, elderly people with fragile bones and people with periprosthetic fractures around previous total knee arthroplasty. Main indications of intramedullary nailing are for supracondylar fractures type A or type C of the AO classification. The main objective of the present work is to analyze, by means of FE simulation, the influence of retrograde nail length, considering different blocking configurations and fracture gaps, on the biomechanical behavior of supracondylar fractures of A type. A three dimensional (3D) finite element model of the femur from 55-year-old male donor was developed, and then a stability analysis was performed for the fixation provided by the retrograde nail at a distal fracture with different fracture gaps: 0.5 mm, 3 mm y 20 mm, respectively. Besides, for each gap, three nail lengths were studied with a general extent (320 mm, 280 mm and 240 mm), considering two transversal screws (M/L) at the distal part and different screw combinations above the fracture. The study was focused on the immediately post-operative stage, without any biological healing process. In view of the obtained results, it has been demonstrated new possibilities of blocking configuration in addition to the usual ones, which allows establishing recommendations for nail design and clinical practice, avoiding excessive stress concentrations both in screws, with the problem of rupture and loss of blocking, and in the contact of nail tip with cortical bone, with the problem of a new stress fracture.

Periprosthetic Fracture Resembling Atypical Femoral Fracture After Fixation With Retrograde Intramedullary Nail in Elderly Women: A Report of Two Cases

BACKGROUND/AIM

The number of individuals diagnosed with and requiring medical treatment for osteoporosis continues to increase due to global population aging and the high awareness of osteoporosis. Bone-modifying agents (BMAs) including bisphosphonate and denosumab are widely used for osteoporosis, and atypical femoral fracture (AFF) is also gaining attention as a severe potential side effect of long-term BMA treatment. The definition of AFF excludes periprosthetic femoral fracture; here, we describe two cases of a periprosthetic femoral fracture that resembled AFF.

CASE REPORT

The fractures occurred at the proximal tip of the retrograde femoral nail after an internal fixation for a distal femoral shaft fracture in elderly Japanese women. Each woman had been treated with bisphosphonate therapy for >2 years and had continued the bisphosphonate after undergoing surgery for a distal femoral shaft fracture. Each patient had noticed thigh pain before falling down, and plain radiographs showed a short oblique or transverse fracture with medial spike and localized periosteal reaction of the lateral cortex in each case. The fractures were re-fixed with an antegrade intramedullary nail, and bone union was achieved at >1 year after the second operation. Although these two cases were classified as periprosthetic fractures, they fulfilled the characteristics of AFF.

CONCLUSION

Physicians should conduct a thorough interview of patients with a history of BMA treatment in order to correctly diagnose periprosthetic fractures that resemble AFFs, and they should be aware that symptomatic fractures can be prevented by prophylactic fixation. The discontinuance of BMA therapy and the introduction of another drug such as teriparatide may lead to faster healing of surgically treated AFFs.

"Ratio of fracture site diameter to isthmus femoral canal diameter" as a predictor of complication following treatment of infra-isthmal femoral shaft fracture with antegrade intramedullary nailing

INTRODUCTION

Fixation of infra-isthmus femoral shaft fracture using antegrade intramedullary (IM) nailing is difficult and is associated with a high complication rate. This study aimed to identify risk factors for complications following this procedure. The ratio of the fracture site diameter to the diameter of the femoral intramedullary canal of the isthmus (FI ratio) was evaluated as a novel parameter to predict complication.

MATERIALS AND METHODS

Patients who underwent antegrade IM nailing for infra-isthmus femoral shaft fracture between January 2008 and December 2018 and had a minimum of 12 months of follow-up were retrospectively reviewed. The primary outcome was occurrence of complication, including non-union, mal-alignment, fixation failure, or progressive loss of reduction. Logistic regression analysis was performed to identify risk factors of complication. The sensitivity and specificity of FI ratio as a predictor of complication was calculated. A receiver operating characteristic (ROC) curve was generated to establish an FI ratio threshold to predict occurrence of complication following antegrade IM nailing.

RESULTS

Sixty-five patients with a mean age of 47.1 years were included. Using univariate logistic regression analysis, comminuted fracture pattern (p=0.026), distance from screws to fracture site (< 3cm) (p=0.002), and higher FI ratio (p=0.001) were associated with complication. Using multivariate logistic regression analysis, FI ratio was identified as an independent risk factor for complication following antegrade IM nailing (p=0.038). ROC curve indicated that FI ratio ≥ 2 had sensitivity and specificity of 0.72 and 0.72, respectively, in predicting complication.

CONCLUSIONS

Our study indicates that wider intramedullary diameter at the fracture site was associated with higher complication rate following antegrade IM nailing in distal infra-isthmal femoral fractures. The FI ratio could be a reliable predictor of complication after antegrade IM nailing for such fracture, and alternative strategies should be considered for patients with higher FI ratio (≥ 2).

Long-term Comparison of Retrograde and Antegrade Femoral Nailing

Antegrade or retrograde nailing for femoral shaft fractures remains the gold standard, but long-term data on functional outcomes after intramedullary nailing are lacking. In a retrospective review of prospectively collected patient registry data, patients with an isolated femoral shaft fracture treated with antegrade or retrograde femoral nailing from 1997 to 2012 were interviewed and their medical records analyzed. Functional reported outcome data were obtained via the visual analog scale (VAS) for pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 5 to 17 years postoperatively. Antegrade and retrograde intramedullary nailing of diaphyseal femur shaft fractures demonstrated a mean WOMAC of 23.5%±23.6% (range, 0%-82.3%) and 29.7%±24.0% (range, 0%-88%), respectively (P=.23). The mean VAS scores of the antegrade vs retrograde intramedullary nailing groups were 2.5±2.6 (range, 0-8) and 3.4±2.8 (range, 0-10), respectively (P=.11). Location of pain differed between groups as well, with the antegrade group noting an increased rate of hip pain (25.6% vs 7.0%, P=.01), but a nonsignificant difference in the rate of thigh pain (27.9% vs 15.5%, P=.15) and knee pain (18.6% vs 26.7%, P=.49) as compared with the retrograde group. Diaphyseal femur fractures are successfully treated with either antegrade or retrograde intramedullary nails without significantly differing long-term functional outcomes, which correlates with other reported findings in the literature at short-term follow-up. [Orthopedics. 2020;43(4):e278-e282.].

Comparative analysis of the biomechanical behavior of anterograde/retrograde nailing in supracondylar femoral fractures

Supracondylar femoral fractures account for a noticeable percentage of the femoral shaft fractures, affecting two etiological groups: high energy trauma in young men, with good bone quality, and older women with osteoporotic femur. Surgical treatment of those kind of fractures remains controversial, with different surgical options such as plate and sliding barrel locking condylar plate, less invasive stabilization system (LISS) or intramedullary nailing, which has emerged as a new fixation choice in the treatment of that type of fractures. The present work performs a comparative study about the biomechanical behavior of anterograde and retrograde nailing in supracondylar femoral fractures type A, in order to determine the best choice of nailing and locking configuration. A three-dimensional finite element model of the femur was developed, modeling femoral supracondylar fracture and different nailing configurations, both for anterograde and retrograde nails. The study was focused on the immediately post-operative stage, verifying the appropriate stability of the osteosynthesis. The obtained results show a better biomechanical behavior for anterograde nails, providing a better stability from the point of view of global movements, lower stresses in screws, and less stress concentration in cortical bone. So, for the analyzed fractures and osteosyntheses types, anterograde nailing has demonstrated to be a better surgical option, being an excellent indication in supracondylar fractures of femur, with clear benefits compared to retrograde nailing, providing a better stabilization which enables for a more satisfactory fracture healing.

Impact of Surrounding Canal Size on Time to Union After Intramedullary Nailing of Femur Fractures: Are 10-mm Nails All We Need?

OBJECTIVE

To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures.

DESIGN

Retrospective review.

SETTING

Two Level 1 and 1 Level 2 trauma centers.

PATIENTS

Two hundred eighty-seven patients met the criteria and were included in the study.

INTERVENTION

Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm.

MAIN OUTCOME MEASUREMENTS

Nonunion rates, mean time to union.

RESULTS

Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups.

CONCLUSION

Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory.

LEVEL OF EVIDENCE

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

Effect of Nail Size, Insertion, and Δ Canal-Nail on the Development of a Nonunion After Intramedullary Nailing of Femoral Shaft Fractures

OBJECTIVE

To determine whether intramedullary nail (IMN) diameter, antegrade versus retrograde insertion, or the difference between the canal and IMN diameter affect femoral shaft fracture healing.

DESIGN

Retrospective analysis of a prospective database.

SETTING

Level One Regional Trauma Center.

PATIENTS/PARTICIPANTS

Seven hundred thirty-three femoral shaft fractures (OTA/AO 32) treated with an IMN between 1999 and 2017. After exclusion criteria, 484 fractures remained in the final analysis.

INTERVENTION

Closed section, cannulated, interlocked, titanium alloy IMN using a reamed insertion technique.

MAIN OUTCOME MEASUREMENTS

Nonunion, IMN size (10, 11.5, and 13 mm), antegrade versus retrograde insertion, Δ canal-nail diameter (ΔD) after reaming (<1, 1-2, or >2 mm).

RESULTS

IMN diameters used were as follows: 314/10 mm (64%), 137/11.5 mm (28%), and 33/13 mm (8%). Forty-five percent were placed in antegrade versus 55% retrograde. Four hundred fifty-six fractures (94.2%) healed uneventfully. There were no IMN failures. 10/484 IMNs (2%) had broken interlocking screws; only 4 were associated with a NU. Average time to union was 23 weeks (12-119). Twenty-eight (5.8%) developed NU. There was no statistical correlation between (1) the NU rate and IMN diameter: 10 mm, 6.3%; 11.5 mm, 5.1%; 13 mm, 3% (P = 0.8, power = 0.85), (2) the NU rate and ΔD: 7.1% <1 mm, 5.6% 1-2 mm, 20% >2 mm (P = 0.36), (3) the NU rate and fracture location: Prox = 11%, Mid = 5%, Dist = 3% (P = 0.13), or (4) the NU rate and antegrade (7.2%) versus retrograde (4.2%) insertion (P = 0.24).

CONCLUSION

Similar healing rates occurred regardless of IMN diameter, Δ canal-nail diameter after reaming, or insertion site. This indicates that a closed section, cannulated, interlocked, titanium alloy IMN with a diameter of 10 mm can be considered the standard diameter for the treatment of acute femoral shaft fractures, regardless of entry point. This should be associated with less reaming and therefore shorter operative times, and possibly less hospital implant inventories as well. Larger diameter IMN should be reserved for revision surgery.

LEVEL OF EVIDENCE

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

Predictive Factors of Death after Surgery for Treatment of Proximal Femoral Fracture

Objective  To evaluate predictive factors of death in patients aged ≥ 70 years old with proximal femoral fracture (PFF) submitted to surgical treatment. Methods  An analysis of medical records by creating a retrospective cohort with a 6-month follow-up. A total of 124 charts were analyzed after applying the inclusion and exclusion criteria. All of the patients were treated by a single orthopedic surgeon under uniform conditions. Results  The mortality rate was of 34.7%, and the most common profile was female, 85 years old, and with at least 1 comorbidity. Patients > 85 years old, hospitalized for > 7 days, with at least 1 comorbidity, and staying at the intensive care unit (ICU) had a higher risk of death (2, 2.5, 4, and 4 times higher, respectively). Conclusion  Regarding the death outcome, although we did not find a statistically significant difference in the topography of the lesion and in its behavior in its coexistence with ICU hospitalization, we believe that further investigations under this perspective are required in a population with the studied profile.

Can the use of femoral notch view alone decrease measurement error of distal interlocking screws after retrograde femoral nailing

OBJECTIVES

Determine if using different fluoroscopic views of the knee (Notch or Tangential) improves accuracy of screw lengths assessment compared to the standard posteroanterior (PA).

PARTICIPANTS AND METHODS

Orthopaedic surgeons at three ACGME-accredited residency programs were asked via survey to assess screw lengths on PA, femoral notch, and tangential radiographic views.

RESULTS

Responders correctly identified screw length using PA, femoral notch, and medial tangential views at rates of 46.75%, 52.27%, and 44.37% respectively. Respondents detected overall screw length discrepancies most accurately using the femoral notch view (Odds Ratio 1.26; 95% confidence interval: 1.07-1.47; P < 0.005). There was no statistical difference between the residents and faculty cohort in ability to detect screw length discrepancy.

CONCLUSION

Differentiating distal interlocking screw lengths on traditional imaging (AP/Notch/Tangential) is poor. The femoral notch view significantly improves accuracy in radiographic determination of screw length. The femoral notch view should be used in conjunction with the traditional PA view to maximize sensitivity and specificity for detecting prominent screws.

Influence of Hip Fracture on Knee Pain During Postoperative Rehabilitation

Objective

To investigate whether fracture type, surgical procedure, or fracture grade affect knee pain during postoperative rehabilitation after a hip fracture.

Methods

We conducted a retrospective case-controlled study of 139 patients during postoperative rehabilitation after surgery for hip fractures. Patients were divided into two groups: patients experiencing knee pain during the first week of postoperative rehabilitation, and patients without knee pain. We compared the types of fracture, surgical procedure, and fracture grade between the two groups.

Results

We enrolled 52 patients (37.4%) with knee pain during the first weeks of postoperative rehabilitation. For type of fracture, knee pain was more common with intertrochanteric fracture than with femur neck fracture (48.8% vs. 21.1%, respectively; p=0.001). For the surgical procedure, there was no significant difference between the groups. For the fracture grade, the grades classified as unstable fractures were more common in the group of intertrochanteric fracture patients with knee pain than in those without knee pain (74.1% vs. 36.4%, respectively; p=0.002).

Conclusion

Intertrochanteric fracture affected knee pain after hip fracture surgery more than did femur neck fracture, particularly in unstable fractures. Furthermore, there was no difference in each fracture type according to the surgical procedure. Careful examination and management for knee pain is needed in patients with hip fracture surgery.

Treatment of infra-isthmal femoral fracture with an intramedullary nail: Is retrograde nailing a better option than antegrade nailing?

INTRODUCTION

Antegrade intramedullary (IM) nailing is ideal for femoral shaft fractures, but fixing the fracture distal to the isthmal level may be difficult because of medullary canal widening and the proximity of fracture location from the distal femoral joint line. This study aimed to compare treatment results between antegrade and retrograde nailing for infra-isthmal femoral shaft fracture, and to identify influencing factors of nonunion and malalignment.

MATERIALS AND METHODS

Sixty patients with infra-isthmal femoral shaft fractures treated with IM nailing and followed-up for > 1 year were enrolled in this retrospective study, 38 in the antegrade nailing group, and 22 in the retrograde nailing group. The two groups had no significant differences in age, sex, and fracture location (p = 0.297, Mann-Whitney test). Radiological evaluation was performed, and functional result was assessed using the Knee Society scoring system. Complications were analyzed in accordance with fracture location, fracture type, and operative method.

RESULTS

According to the AO/OTA classification, 35, 16, and 9 cases were type A (A1: 1, A2: 11, A3: 23), B (B1: 2, B2: 7, B3: 7), and C fractures (C2: 4, C3: 5), respectively. The mean follow-up duration was 29.5 months. In the antegrade and retrograde nailing groups, the primary bony union rates were 73.7% in 20.7 weeks (range 12-41) and 86.4% in 17.4 weeks (range 12-30), respectively. The two groups showed no significant differences in union rate (p = 0.251, Pearson's Chi-square test) and union time (p = 0.897, Mann-Whitney test). No cases of malalignment of > 10° in any plane were found in both groups. The mean Knee Society scores were 92 (range 84-100) and 91 (range 83-95) in the antegrade and retrograde nailing groups, respectively, showing no significant difference (p = 0.297, Pearson's Chi-square test). Although fracture location was not significantly related to union rate (p = 0.584, Mann-Whitney test), patients with an effective working length of the distal segment of < 0.75 were prone to nonunion (p = 0.003, Pearson's Chi-square test).

CONCLUSIONS

Although no significant difference was found in IM nail type, the IM nail with a shorter working length distal to the fracture showed a strong relationship with nonunion.

The Aberdeen Weight-Bearing Test (Knee): a new objective test for anterior knee discomfort

Purpose

We present the Aberdeen Weight-Bearing Test (Knee), an objective test specific for anterior knee discomfort assessed via load bearing. We assess its validity by performing it on normal subjects with no knee symptoms and subjects who had undergone anterograde tibial nailing.

Methods

Two scales are placed parallel on the floor with the dials concealed from the subject. The subject then kneels with one knee on each scale. The weight through each knee is recorded at 0, 15, 30, 45, and 60 s. The proportion of total body weight on each leg at each timepoint is calculated, and a ratio calculated from the values. A value of 1 equates to equal weight on each leg. The test was performed on 53 normal subjects and 38 subjects who had undergone tibial nailing.

Results

In the normal group, no significant difference in mean ratio of weight distribution (left:right) was seen at any timepoint (mean ratio range = 0.98–0.99, p value range = 0.18–0.64). In the tibial nail group, a difference was observed in mean ratio of weight distribution (injured:uninjured) favouring the uninjured leg, reaching significance at 0, 15, 30, and 45 s (mean ratio range = 0.88–0.94, p value range = 0.01–0.02). At 60 s, the mean ratio was 0.93 (p = 0.09).

Conclusion

The Aberdeen Weight-Bearing Test (Knee) is an objective, easily reproducible, specific test for anterior knee discomfort. It produces different results in individuals who have undergone anterograde tibial nailing compared to individuals with no knee symptoms.

The Resolution Axis Method (RAM) for lengthening of the femur with or without associated frontal plane deformity (a new method)

INTRODUCTION

Femoral lengthening with or along intramedullary (IM) nails will occur along the axis of the nail coincident with the anatomical axis of the bone. In the femur particularly, such lengthening often creates lateral mechanical axis deviation as the knee is driven medially. In cases where shortening is associated with frontal plane deformity the surgeon needs to correct the deformity intra-operatively, however, subsequent lengthening along the anatomical axis will create deformity. Thus, planning for lengthening of the femur with or along IM nails, whether shortening is associated with frontal plane deformity or not, requires a completely different planning strategy. The author questioned if a resolution anatomical axis can be identified and used for planning when lengthening the femur along or with IM nails while still applying the same classic CORA deformity analysis method.

METHODS

In a prospective study, the author included eight patients who needed femoral lengthening, five with associated frontal plane deformity and three without. The author identified a method to determine the trajectory of the nail in the lower femoral segment. It was done by calculating the angle enclosed between this resolution anatomical axis and the mechanical axis, also known as the anatomical-mechanical angle.

RESULTS

This new method has proven to be effective in achieving normal alignment after lengthening is completed.

CONCLUSION

The Resolution Axis Method is a new and alternative method providing a solution for planning when lengthening the femur along the anatomical axis using an IM nail, whether a deformity is present or not.

Effect of Blocking Screws on Union of Infraisthmal Femur Fractures Stabilized With a Retrograde Intramedullary Nail

OBJECTIVE

To investigate the effect of blocking screws (BS) on the union rate and stability of infraisthmal femur fractures treated with retrograde intramedullary nail (RIMN) insertion.

DESIGN

Retrospective cohort study.

SETTING

A single level 1 trauma center.

PATIENTS/PARTICIPANTS

All patients with an infraisthmal femur fracture treated with a RIMN from 2005 to 2012 were included.

INTERVENTION

All fractures were treated with a RIMN. BS were used at the discretion of the treating surgeon.

MAIN OUTCOME MEASUREMENTS

(1) Radiographic time to union, (2) initial postoperative sagittal and coronal angulation, and (3) final sagittal and coronal angulation.

RESULTS

Neither the average time to union (BS 21.1 weeks vs. 21.8 weeks), nor union rates (BS 61% vs. 77%) were statistically different between BS and non-BS constructs. No significant alignment differences existed whether BS were used or not.

CONCLUSIONS

In this study, we were not able to verify our hypothesis. In fact, we did not find any significant advantages when BS were added to a RIMN construct for distal femur fractures with respect to union time, union rate, or improvements in alignment. Additional studies are needed to determine the actual benefit of BS in the treatment of infraisthmal femoral shaft fractures treated with retrograde intramedullary nailing.

LEVEL OF EVIDENCE

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

Retrograde Femoral Nailing Using Percutaneous Reduction Techniques

Femoral shaft fractures are commonly treated with closed reduction and reamed intramedullary nailing. However, some reductions are difficult to obtain or maintain, especially in muscular or large patients. When closed methods fail to achieve reduction, percutaneous techniques are extremely useful. In addition, the use of either permanent or temporarily placed blocking implants offer a minimally invasive option for improving sagittal and coronal plane alignment. In the accompanying video, we describe our method of percutaneous reduction techniques in the setting of a comminuted femoral shaft fracture treated with a retrograde femoral intramedullary nail.

Radiographic predictors of symptomatic screw removal after retrograde femoral nail insertion

INTRODUCTION

Removal of symptomatic implants is a common procedure performed by orthopaedic trauma surgeons. No guidance is available regarding which factors contribute to the likelihood of an implant becoming symptomatic. Our objective was to determine whether radiographic parameters associated with distal interlocks in retrograde femoral nails are associated with the rate of symptomatic screw removal.

PATIENTS AND METHODS

We conducted a retrospective review at a Level I trauma center. Study patients (n=442) had femoral fractures treated with retrograde intramedullary nails from 2007 to 2014 and at least 1year of follow-up. The main outcome measurement was symptomatic distal screw removal as predicted by radiographic parameters.

RESULTS

Symptomatic screw removal occurred in 12% of the patients. Increased distance between the most distal screw and the articular surface of the femur significantly reduced likelihood of symptomatic screw removal. A cutoff of 40mm from the articular block was predictive of removal (≥40mm, 0% removal; <40mm, 18% removal, p<0.0001). In patients with distal screws placed within 40mm of the articular surface of the femur, a ratio of screw length to distance between medial and lateral femoral cortices that was ≥1 was a strong predictor of symptomatic screw removal (area under Receiver Operating Characteristic curve, 0.75; p<0.0001).

CONCLUSIONS

More distal screws and screws that radiographically extend to or beyond the medial cortex are more likely to cause pain and require removal in femoral fractures treated with retrograde intramedullary nails. We identified a specific distance from the joint (<40mm) and a ratio of screw length to bone width (≥1) that significantly increased the likelihood of symptomatic screw removal. Clinicians can use these data to inform patients of the likely risk of implant removal and perhaps to better guide placement and length of screws when the clinical scenario allows some flexibility in location and length of screws.

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.

Retrograde intramedullary fixation of long bone fractures through ipsilateral traumatic amputation sites

The technique of retrograde intramedullary fixation of fractures through open traumatic amputations has not been previously described. We performed a retrospective case series at a tertiary-care military hospital setting. Ten patients met inclusion criteria. All were male, and all were injured through improvised explosive device. Outcome measures included the incidence of fracture nonunion, osteomyelitis or acute infection, heterotopic ossification (HO), as well as successful prosthesis fitting and ambulation. Average time to fixation after injury and amputation closure was 11.7 and 12.2 days, respectively. Follow-up averaged 20.2 months. The radiographic union rate was 100%, and time to osseous union averaged 7.5 months. One patient had an amputation site infection requiring revision, but none of the nails was removed for infectious reasons. HO occurred in 7 patients, and 2 patients required revision for symptomatic HO. All patients were successfully fitted with prostheses and able to ambulate. To our knowledge, this is the only series in the literature to specifically describe retrograde intramedullary fixation of long bone fractures through the zone of traumatic amputation sites. The infectious risk is relatively low, whereas the union rate (100%) and successful prosthesis fitting are high. For patients with similar injuries, retrograde intramedullary fixation through the zone of amputation is a viable treatment option.

Femur fractures in professional athletes: a case series

OBJECTIVE

To discuss return to play after femur fractures in several professional athletes.

BACKGROUND

Femur fractures are rare injuries and can be associated with significant morbidity and mortality. No reports exist, to our knowledge, on return to play after treatment of isolated femur fractures in professional athletes. Return to play is expected in patients with femur fractures, but recovery can take more than 1 year, with an expected decrease in performance.

TREATMENT

Four professional athletes sustained isolated femur fractures during regular-season games. Two athletes played hockey, 1 played football, and 1 played baseball. Three players were treated with anterograde intramedullary nails, and 1 was treated with retrograde nailing. All players missed the remainder of the season. At an average of 9.5 months (range, 7-13 months) from the time of injury, all athletes were able to return to play. One player required the removal of painful hardware, which delayed his return to sport. Final radiographs revealed that all fractures were well healed. No athletes had subjective complaints or concerns that performance was affected by the injury at an average final follow-up of 25 months (range, 22-29 months).

UNIQUENESS

As the size and speed of players increase, on-field trauma may result in significant injury. All players returned to previous levels of performance or exceeded previous statistical performance levels.

CONCLUSIONS

In professional athletes, return to play from isolated femur fractures treated with either an anterograde or retrograde intramedullary nail is possible within 1 year. Return to the previous level of performance is possible, and it is important to develop management protocols, including rehabilitation guidelines, for such injuries. However, return to play may be delayed by subsequent procedures, including hardware removal.

Femoral lengthening and deformity correction using the Fitbone motorized lengthening nail

BACKGROUND

This study reports our results with retrograde Fitbone insertion in patients with femoral shortening and deformity. We also present our experience regarding the benefits, complications, and factors associated with complications of the Fitbone technique.

METHODS

Twelve males and ten females had femoral shortening and deformities treated using the retrograde Fitbone technique between 2009 and 2012. The etiologies were post-traumatic in 12 patients, poliomyelitis in four, cosmetic in two, congenital hypoplasia in two, achondroplasia in one, and Perthes sequela in one.

RESULTS

The follow-up time was 30.8 months. The mean lengthening was 5.8 (range 2-14) cm. The degree of acute angular correction was 9° (5-22°) in nine cases. The time to full weight-bearing was 5.9 months. The consolidation index was 1.07 (0.75-1.62) months/cm. Complete consolidation was obtained in all cases except two. Running back was observed in two cases.

CONCLUSIONS

The Fitbone technique allows accurate deformity correction. The rigid reamers allow the surgeon to use the Fitbone even in patients with a narrow medullary canal. As this might result in poor bone regeneration, thinner lengthening nails should be considered.

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%).

Decreased muscle strength is associated with impaired long-term functional outcome after intramedullary nailing of femoral shaft fracture

PURPOSE

To examine the long-term outcome after intramedullary nailing of femoral diaphysial fractures measured as disease-specific patient reported function, walking ability, muscle strength, pain and quality of life (QOL).

METHODS

Cross-sectional study. Retrospective review and follow-up with clinical examination of 48 patients treated with intramedullary nailing after femoral shaft fracture between 2007 and 2010. The patients underwent a clinical examination and assessment of walking ability, maximal muscle strength during knee flexion and extension and hip abduction. Hip disability and Osteoarthritis Outcome Score (HOOS) and questionnaire evaluating QOL (Eq5D-5L) were completed by patients.

RESULTS

Fourty-eight patients agreed to participate. Mean time for follow-up was 4.7 years. The mean HOOS scores were 84.9 (Pain), 86.6 (ADL), 85.0 (Symptoms), 72.6 (QOL), and 69.1 (Sport). The mean muscle strength of knee flexion with the injured leg (226.0 N) was significantly lower then knee flexion with the non-injured leg (259.5 N, P < 0.0001). Likewise for knee extension (335.2 vs 406.4 N, P < 0.001) and hip abduction (129.2 vs 156.0 N, P < 0.001). Significant association between HOOS and an increase in the difference in muscle strength were observed as well as between worse HOOS outcome and increasing body mass index.

CONCLUSION

This study showed that decreased muscle strength for knee flexion, knee extension and hip abduction was associated with worse long-term functional outcome measured with a disease-specific questionnaire (HOOS) after intramedullary nailing of femoral shaft fracture.

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.

"Push-past" reaming as a reduction aid with intramedullary nailing of metadiaphyseal and diaphyseal femoral shaft fractures

Eccentric reaming of cortical bone near a fracture site can introduce malalignment when an intramedullary nail is placed. The authors describe a technique of reaming metadiaphyseal and diaphyseal femur fractures in which maintaining reduction at the fracture site is not necessary to obtain an excellent alignment of long bone fractures after intramedullary nailing. They have found that central reaming proximal and distal to, but not at, the fracture site allows for excellent reduction of long bone fractures when the intramedullary nail is passed. The reamer is stopped just before the fracture site and then "pushed" across the fracture prior to resumption of reaming. The authors present "push-past" reaming as a technical trick to facilitate reduction of femoral fractures treated with intramedullary nails and a consecutive series of 18 cases in which excellent postoperative alignment was achieved.

Biomechanical analyses of static and dynamic fixation techniques of retrograde interlocking femoral nailing using nonlinear finite element methods

Femoral shaft fractures can be treated using retrograde interlocking nailing systems; however, fracture nonunion still occurs. Dynamic fixation techniques, which remove either the proximal or distal locking screws, have been used to solve the problem of nonunion. In addition, a surgical rule for dynamic fixation techniques has been defined based on past clinical reports. However, the biomechanical performance of the retrograde interlocking nailing systems with either the traditional static fixation technique or the dynamic fixation techniques has not been investigated by using nonlinear numerical modeling. Three-dimensional nonlinear finite element models were developed, and the implant strength, fixation stability, and contact area of the fracture surfaces were evaluated. Three types of femoral shaft fractures (a proximal femoral shaft fracture, a middle femoral shaft fracture, and a distal femoral shaft fracture) fixed by three fixation techniques (insertion of all the locking screws, removal of the proximal locking screws, or removal of the distal locking screws) were analyzed. The results showed that the static fixation technique resulted in sufficient fixation stability and that the dynamic fixation techniques decreased the failure risk of the implant and produced a larger contact area of the fracture surfaces. The outcomes of the current study could assist orthopedic surgeons in comprehending the biomechanical performances of both static and dynamic fixation techniques. In addition, the surgeons could also select a fixation technique based on the specific patient situation using the numerical outcomes of this study.

[Retrograde nailing in a tibial fracture]

We describe a case of a severely comminuted type iiia open tibial fracture, with distal loss of bone stock (7 cm), total involvement of the tibial joint surface, and severe instability of the fibular-talar joint. The treatment performed consisted of thorough cleansing, placing a retrograde reamed calcaneal-talar-tibial nail with proximal and distal blockage, as well as a fibular-talar Kirschner nail. Primary closure of the skin was achieved. After 3 weeks, an autologous iliac crest bone graft was performed to fill the bone defect, and the endomedullary nail, which had protruded distally was reimpacted and dynamized distally. The bone defect was eventually consolidated after 16 weeks. Currently, the patient can walk without pain the tibial-astragal arthrodesis is consolidated.

Retrograde versus antegrade intramedullary nailing of gunshot diaphyseal femur fractures

BACKGROUND

The use of retrograde nailing for gunshot wound femur fractures is controversial due to concerns of knee sepsis after this procedure since the knee is entered to introduce the nail into the canal.

QUESTIONS/PURPOSES

We compared retrograde and antegrade nailing for gunshot femur fractures to determine whether (1) knee sepsis or other adverse events were more likely to complicate procedures using retrograde nails, (2) there were differences in surgical time or blood loss, and (3) there were differences in radiographic union.

METHODS

We retrospectively reviewed our prospective trauma database from 1999 to 2012 for patients with a diagnosis of gunshot and femur fracture. We performed a detailed review of medical records and radiographs for those patients with OTA Classification Type 32 femur fractures secondary to gunshot injury treated with either retrograde or antegrade femoral nailing. Eighty-one patients were treated with intramedullary nailing (53 retrograde and 28 antegrade). We reviewed elements of the operative treatment (procedure, anesthesia time, operative time, and estimated blood loss) for all 81 patients. For clinical and radiographic review, followup was adequate for 43 and 25 patients with retrograde and antegrade nailing, respectively. Minimum followup was 3 months for both groups (retrograde: mean, 41 months; range, 3-148 months; antegrade: 26 months: range, 3-112 months).

RESULTS

No patients in either group developed knee sepsis. No significant differences were found between groups with regard to operative time, blood loss, or radiographic union.

CONCLUSIONS

With the numbers available, immediate retrograde nailing appears as safe and effective as antegrade nailing for gunshot femur fractures. Immediate retrograde nailing is as safe as antegrade nailing for gunshot femur fractures.

Blocking screws: an adjunct to retrograde nailing for distal femoral shaft fractures

PURPOSE. To review records of 11 patients who underwent retrograde nailing in conjunction with blocking screws to aid fracture reduction for distal femoral shaft fractures. METHODS. Records of 8 men and 3 women aged 27 to 60 (mean, 41) years who underwent retrograde nailing with the use of blocking screws for distal femoral shaft fractures were reviewed. Two of the fractures were open and graded as Gustilo-Anderson grade II. The mean surgical delay was 2 (range, 1-5) days. RESULTS. All fractures united after a mean of 14 (range, 11-16) weeks without malalignment. There was no screw breakage, screw bending, or wound infection. CONCLUSION. Blocking screws increase the stability of the construct and thereby minimise macro-motion at the fracture site.

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.

Outcomes of nails versus plates for humeral shaft fractures: a Medicare cohort study

OBJECTIVES

This study was performed to determine (1) the incidence of humeral shaft fractures within the Medicare noncancer population, (2) the trends in utilization of humeral shaft fixation techniques by plate-and-screw devices and intramedullary nails, (3) differences in procedure times, and (4) the outcomes of individuals as measured by rate of secondary operations and 1-year mortality.

DESIGN/SETTING

Retrospective comparative cohort analysis. A cancer-free Medicare part B claims sample derived from a 5% sample from the years 1993 to 2007 was analyzed.

PATIENTS/INTERVENTION

Our cohorts were generated by diagnostic and procedural codes for humeral shaft fractures.

MAIN OUTCOME MEASUREMENT

The incidence of humeral shaft fracture and trend in operative fixation were evaluated for all years of data. Surgical times were assessed by anesthesia Current Procedural Terminology codes. Outcomes and complications were assessed by Current Procedural Terminology codes. The proportion of individuals experiencing complications and 1-year mortality were compared by proportion hazards.

RESULTS

We identified 1385 claims for humeral shaft fractures over 15 years, with an adjusted rate of between 12.0 and 23.4 fractures per 100,000 beneficiaries. We identified 511 individuals who received surgical treatment for humeral shaft fractures, 451 of whom had complete 1-year follow-up data. Nail fixation was more prevalent than plate fixation most years and had shorter anesthesia time by 27.1 minutes (P < 0.0001). There were no significant differences in the complication rates between the 2 groups as measured by incidence of secondary operations and 1-year mortality.

CONCLUSIONS

Intramedullary nails are used for the majority of operative humeral shaft fractures among Medicare beneficiaries. Nailing has a shorter mean operative time. The 2 surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality.

LEVEL OF EVIDENCE

: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

[Minimally invasive treatment of geriatric and osteoporotic femur fractures with polyaxial locking implants (NCB-DF®)]

BACKGROUND

Periprosthetic femur fractures in elderly patients are a challenging surgical procedure. The aim of this study was a prospective evaluation of minimally invasive implantation of non-contact bridging (NCB-DF®) plates.

PATIENTS AND METHODS

A total of 30 osteosynthesis procedures in 29 patients (average age 76 years and mean ASA 2.9) with complex femur fractures were registered, 19 fractures were periprosthetic and osteoporosis was present in 17 bones. In 25 patients a minimally invasive percutaneous procedure was performed using a standardized technique. An x-ray examination and clinical follow-up were performed after 6, 12 and 24 weeks.

RESULTS

The early complications (14% in total) included 1 plate breakage after 16 weeks as well as 3 minor revisions for screw length correction. The x-ray follow-up after 24 weeks showed a secondary extension deficit of 10° and 15° in the knee joint in 2 patients, respectively.

CONCLUSION

The NCB-DF® implantation using a standardized minimally invasive technique in periprosthetic femur fractures is a safe alternative in elderly patients. In this very sensitive population the early revision rate within the first 24 weeks is noticeable lower compared to similar procedures.

NCB-plating in the treatment of geriatric and periprosthetic femoral fractures

BACKGROUND

The aim of this study is the presentation of the polyaxial locking NCB-plate in the treatment of femoral fractures, especially in elderly patients and in proximity of a prosthetic implant. The reduction and fixation of these fractures is a challenging surgical procedure with high complication rates reported up to 40%.

PATIENTS AND METHODS

A total of 72 patients with femoral fractures had polyaxial locking plate osteosynthesis. Indications included fractures of the shaft and around an implant. Concerning surgical procedures, three different standardized techniques were performed: (1) minimally invasive with percutaneous distal insertion using a targeting device; (2) mini-open with additional cerclage wire via the same approach and (3) a conventional open reduction and internal fixation. Data collection included intraoperative data and early complications at 6, 24 and 52 weeks. Fifty-two patients had an implant or prosthesis in situ. Thirty-three patients were treated by technique (1), 32 patients had mini-open surgery and seven patients conventional open surgery.

RESULTS

Thirty-nine patients attended clinical follow-up after 52 weeks. Twenty-two patients were interviewed by telephone, two were untraceable and nine patients had died. Bony consolidation without secondary loss of reduction was confirmed after 52 weeks in all patients but two. Plate breakage occurred in these two at 25 and 31 weeks after surgery due to non-union. Implant related complications (17% in total) lead to surgical revision in five other cases: two deep wound infections as well as three minor revisions. When itemizing complications according to surgical technique used, most major complications occurred following open surgery.

CONCLUSION

The availability of polyaxial locking implants widened the range of indications for plate fixation in femoral fractures. The advantages of the polyaxial locking implant combined with minimally invasive surgical technique contribute to successful management of this population category. Early revision rate is noticeably lower compared to similar procedures.

LEVEL OF EVIDENCE

IV retrospective series.

Long-term functional outcome following intramedullary nailing of femoral shaft fractures

BACKGROUND

The management of femoral shaft fractures using intramedullary nailing is a popular method. The purpose of this study was to evaluate the long-term functional outcome after antegrade or retrograde intramedullary nailing of traumatic femoral shaft fractures. We further determined predictors of these functional outcome scores.

METHODS

In a retrospective study, patients with a femoral shaft fracture but no other injuries to the lower limbs or pelvis were included. A total of 59 patients met the inclusion criteria. Functional outcome scores (Short Musculoskeletal Functional Assessment (SMFA), Western Ontario and McMaster University Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and the Lysholm knee function scoring scale) were measured at a mean of 7.8 years (± 3.5 years) postoperatively. The Visual Analogue Scale (VAS) was used to determine pain complaints of the lower limb.

RESULTS

The range of motion (ROM) of the hip and knee joints was comparable between the injured and uninjured leg, regardless of the nailing technique. Correlation between ROM and the final outcome scores was found to be fair to moderate. Even years after surgery, 17% of the patients still reported moderate to severe pain. A substantial correlation was observed between VAS and the patient-reported outcome scores. The most significant predictor of functional outcome was pain in the lower limb.

CONCLUSIONS

Our findings suggest that the ROM of hip and knee returns to normal over time, regardless of the nailing method used. However, pain in the lower limb is an important predictor and source of disability after femoral shaft fractures, even though most patients achieved good functional outcome scores.

Retrograde intramedullary nailing of open femoral shaft fractures: a retrospective case series

BACKGROUND

Nailing of open femur fractures has been described, but the literature on this subject often used antegrade nailing techniques. A retrograde nailing technique carries the risk of contamination and infection of the knee, infection, and nonunion. The purpose of this study was to have a case series examining the intermediate term outcome of retrograde nailing of open femur fractures.

METHODS

A retrospective review of all open femur fractures treated between 2008 and 2010 at a Level II trauma center was performed. Demographic and injury patterns were reviewed for the 35 patients who were treated with retrograde nailing. The main outcome measures evaluated were infection (knee or femur) and nonunion.

RESULTS

There were 11 grade I, 18 grade II, and 6 grade IIIA fractures (no IIIB or IIIC injuries). Healing occurred in 34 of 35 fractures with 1 (3%) nonunion and 2 (6%) deep infections, both occurring in IIIA fractures. There were no cases of knee joint infections, but two patients (6%) developed arthrofibrosis requiring manipulation. Implant removal of a prominent screw was required in one patient.

CONCLUSION

Early retrograde nailing of open femur fractures has infection and healing rates consistent with existing literature. There seems to be little risk for knee infection, but the increased incidence of arthrofibrosis requiring manipulation is higher than previously published. These findings suggest that early retrograde nailing may be considered an acceptable treatment option for open femur fractures.

LEVEL OF EVIDENCE

IV, case series.

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.

Functional outcome following intramedullary nailing of the femur: a prospective randomized comparison of piriformis fossa and greater trochanteric entry portals

BACKGROUND

The purpose of the study was to prospectively compare the functional outcome of intramedullary nailing of the femur performed with use of a trochanteric and a piriformis fossa entry portal.

METHODS

One hundred and ten patients with a femoral shaft fracture were enrolled in a prospective, randomized study. Fifty-four patients were randomized to Group A (piriformis fossa portal) and fifty-six to Group B (trochanteric portal). Outcome measures included the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index hip function score, pain, and blinded functional evaluation by a physical therapist.

RESULTS

Most measures of hip function did not differ between the two groups. The WOMAC score at three, six, and twelve months did not differ significantly between the piriformis fossa and trochanteric nailing groups. Functional tests included the chair stand test and the timed up and go test. Patients in Group B had significantly better scores on the chair stand test (13.3 compared with 11.1 in Group A, p = 0.04) at six months postoperatively, but there was no difference at twelve months (14.0 compared with 13.6). The two groups did not differ significantly on the timed up and go test at either six or twelve months. The two groups also did not differ on the muscle strength testing. Intraoperative parameters differed significantly between the groups with respect to operative time, fluoroscopy time, and incision length, with the difference favoring Group B for each parameter. Analog pain scale values were similar in Group A (2.49) and Group B (2.15) at twelve months postoperatively.

CONCLUSIONS

Patients in our prospective randomized study who were treated with trochanteric nailing did not differ in hip function at one year postoperatively compared with patients treated with intramedullary nailing through the piriformis fossa. The values of several intraoperative parameters were significantly better in the trochanteric nailing group. Our data indicate that the functional hip outcome of femoral intramedullary nailing performed through the greater trochanter is equal to that of intramedullary nailing performed through the piriformis fossa.

Influence of femoral malrotation on knee joint alignment and intra-articular contract pressures

INTRODUCTION

The standard treatment of femoral diaphyseal fractures is intramedullary nailing. Torsion error remains a largely unsolved problem. We hypothesized that femoral malrotation would change the coronal alignment of the lower extremity and the center of force (COF) in the tibiofemoral joint as compared to the native state.

METHOD

Ten cadaveric legs were used. Intraarticularly placed sensor foil was used to measure contact pressures for each condyle. The resultant pressure of this two-force measurement was calculated as the COF for the joint. Mechanical axis was defined by the navigation system. Two novel devices were used: (1) to simulate bodyweight with leg attachment and fixation to the anterior pelvis and (2) to fix the femur at various degrees of malrotation. A mid-diaphyseal osteotomy was performed and the distal fragment was rotated both internally and externally in 5° increments to a maximum of 25°. COF and axial alignment were assessed at each step with application of a half-bodyweight specific to each specimen.

RESULTS

Internal rotation resulted in valgus deviation of the mechanical axis and a shift in COF towards the lateral condyle (P < 0.05). External rotation caused varus deviation and switched COF towards the medial condyle (P < 0.05). This study shows that femoral malrotation has a significant effect on mechanical axis alignment and force vectors within the knee. Correlation with clinical outcomes is necessary and further research into minimizing such errors of torsion is warranted.

CONCLUSION

Torsion errors are not merely cosmetic issues, but may result in further morbidity, such as varus or valgus deformity and shifting of the COF, which may lead to joint arthrosis.