Entry point soft tissue damage in antegrade femoral nailing: a cadaver study

Avascular Necrosis of the Femoral Head Following Intramedullary Nailing of a Femoral Shaft Fracture in a Skeletally Mature Adult: A Case Report

Avascular necrosis (AVN) of the femoral head is a well-documented complication that occurs following femoral neck fractures in both adults and pediatrics. Incidence of AVN following intramedullary nailing (IMN) for femoral shaft fractures is relatively rare. We are reporting an exceptional case of a 28-year-old skeletally mature adult, with no risk factors, who developed stage 3 AVN following trochanteric entry-point IMN for a traumatic femur shaft fracture. Our case contributes to the existing literature by adding to the limited number of reported cases available. In addition, it emphasizes the importance of observation and anticipation for such complications and shows the need for further studies to understand the relationship between this modality of treatment and the development of AVN of the femoral head.

Optimal entry point for antegrade and retrograde femoral intramedullary nails

Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.

Evaluation and management of atypical femoral fractures: an update of current knowledge

Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.

[Research progress in osteonecrosis of femoral head following femoral intertrochanteric fractures in adults]

Objective

To summarize the research progress of osteonecrosis of femoral head (ONFH) following femoral intertrochanteric fractures in adults.

Methods

Relevant literature at home and abroad was extensively reviewed to summarize the pathogenesis, high-risk factors, and treatment of ONFH after femoral intertrochanteric fracture in adults.

Results

ONFH after femoral intertrochanteric fracture mostly occurs within 2 years after operation, with a lower incidence. At present, it is believed that comminuted and large displacement fractures caused by high-energy injuries, fracture line close to the base of neck, excessive external rotation deformity, improper intramedullary nail entry points, and rough intraoperative manipulating may injury the deep branch of the medial circumflex femoral artery, causing ONFH. Hip replacement is the main treatment for necrosis, which can achieve good results.

Conclusion

Addressing the above risks, excessive external rotation, overstretching, and rough manipulating should be avoided. Anatomical reduction should be performed during the operation, the nail entry point should be accurate and avoid repeated drilling and thermally bone necrosis.

Treatment of Ipsilateral Femoral Neck and Shaft Fractures With Cannulated Screws and Antegrade Reconstruction Nail

Ipsilateral femoral neck and shaft fractures are challenging injuries, and there are different fixation options but no consensus on a superior construct. Our preferred method is cannulated screw fixation of the femoral neck and antegrade reconstruction nailing of the shaft. Compressive fixation of the femoral neck fracture with cancellous lag screws followed by reconstruction nail placement provides compressive fixation and fixed angle support of the neck fracture while allowing for more optimal treatment of femoral shaft fractures at or above the isthmus. The purpose of this submission is to describe the surgical decision-making, surgical technique, and all surgically related complications of this technique.

Detection of vascularity of femoral head using sub-millimeter resolution steady-state magnetic resonance angiography-initial experience

OBJECTIVE

The purpose of this study was to use the steady-state (SS) magnetic resonance angiography (MRA) with a sub-millimeter resolution to detect the arteries supplying to the femoral head (FH).

MATERIALS AND METHOD

SS MRA scanning of hips was performed bilaterally in 15 healthy volunteers. A blood pool contrast agent was used. The scanning protocol included a 0.8-mm³ isotropic T1-fast field echo sequence with spectral fat suppression technique. Two highly qualified radiologists independently evaluated the medial circumflex femoral artery (MCFA), the lateral circumflex femoral artery (LCFA), and the three retinacular arteries including superior retinacular artery (SRA), inferior retinacular artery (IRA), and anterior retinacular artery (ARA). The intraosseous branches of the three retinacular arteries were also evaluated. An orthopaedic surgeon was consulted in case of disagreement. Observation by the two radiologists and support from the orthopaedic surgeon served as the end result. Agreement between the two observer radiologists was evaluated.

RESULTS

Interobserver agreement between the two radiologists was found to be substantial to perfect. Of the 30 hips, the LCFA and MCFA were detected in all hips; the SRA and IRA were detected in most hips (100%, 90%), and the ARA was detected in 13 hips (43%). The intraosseous branches of SRA and IRA were detected in 30 and 22 hips (100%, 73%), respectively, while the intraosseous branches of ARA were detected in 11 hips (37%).

CONCLUSION

The main arteries supplying the FH can be detected by the SS MRA, making it a novel method to detect the vascularity of FH.

Greater trochanteric versus piriformis fossa entry nails for femur shaft fractures: Resolving the controversy

BACKGROUND

Intramedullary nailing is the treatment of choice for shaft of femur fractures in adults. Antegrade nails involve entry through either piriformis fossa (PE) or greater trochanteric (GT) tip. The superiority of one entry point over the other is a matter of debate, and the present review was done to determine the same.

RESEARCH QUESTION

Is GT entry for antegrade femur nailing superior to the PE for shaft femur fractures in adults?

OBJECTIVE

The present systematic review was conducted to determine the superiority of one entry point over the other by comparing the outcome parameters like operative time, exposure to fluoroscopy, mal-unions, non unions, abductor weakness, varus malalignment and Harris Hip scores (HHS).

METHODOLOGY

Three databases of PubMed, EMBASE and SCOPUS were searched for relevant articles that directly compared GT with PE for nailing in shaft femur fractures in adults.

RESULTS

We analysed a total of 9 studies published between the years 2011-2017. There were 5 retrospective and 4 prospective studies, out of which 3 were randomised. The total number of patients was 256 in GT group and 460 in PE group.

OUTCOMES

There was significant superiority of GT entry over PE on meta analysis; lesser operation time: standard mean difference (SMD): -21.01; lesser exposure to fluoroscopy : SMD: 36.36; lesser incidence of abductor weakness: Odd's ratio (OR): 14.35; better functional outcome (HHS): SMD -2.48.

CONCLUSION

GT entry nails are superior to PE nails for treating shaft of femur fractures in adults. They have a shorter learning curve and better functional outcomes, however the rates of union are comparable in both.

Femoral Head Vascularity: Implications Following Trauma and Surgery About the Hip

Traumatic injury and surgical intervention about the hip joint place the arterial supply to the femoral head (FH) at risk. Compromised perfusion may lead to FH ischemia, cell death, and osteonecrosis. Progression to FH collapse may lead to pain, functional impairment, and decreased quality of life, especially in younger patients. This review describes the arterial supply to the FH, analyzes the impact of femoral neck fractures on FH vascularity, and explores the vascular implications of various surgical interventions about the hip, offering specific techniques to minimize iatrogenic damage to the vessels supplying the FH. [Orthopedics. 2019; 42(5):250-257.].

Impacted Steel Sleeves for a minimally invasive approach in intramedullary nailing

A custom-made instrument set of Steel Sleeves was developed to assist the insertion of reamers and intramedullary devices for fixation of long bone fractures or lengthening procedures with intramedullary nails. By use of the Steel Sleeves, migration of the entry point is prevented and protection of the bone and soft tissue at the entry point is guaranteed. In addition, the principle of a closed working channel for trans-articular approaches can be provided. In this article, a description of properties and clinical application of custom-made steel sleeve instrument set is provided.

Enhanced recovery after surgery (ERAS) in elective intertrochanteric fracture patients result in reduced length of hospital stay (LOS) without compromising functional outcome

Background

Enhanced recovery after surgery (ERAS) has rapidly gained popularity among hip or knee arthroplasty area which can decrease hospital length of stay (LOS). However, limited data exist regarding its safety and efficacy among intertrochanteric fracture patients. The purpose of this study was to determine if LOS associated with intertrochanteric fracture patients can be improved following an existing orthopedic ERAS procedure.

Methods

We reviewed the outcomes of all patients who had been treated with the PFNA intramedullary fixation at our institution. Open fractures, metastatic pathological fractures, patients unable to walk independently before fracture and patients with Alzheimer's disease were excluded. A quasi-experimental study was adopted between patients treated in an ERAS after intramedullary fixation with those rehabilitated on a traditional pathway. Clinical and demographic data were collected among the two pathway cohorts including LOS, Harris hip scores (HHS), visual analog scale (VAS), and activity of daily living scale (ADL).

Results

A total of 100 intertrochanteric fracture patients (ERAS pathway 50 cases, traditional care pathway 50 cases) were selected between January 2016 and December 2017 met the inclusion criteria. ERAS procedure was associated with shorter LOS, lower postoperative VAS scores, reduced opioid consumption, earlier mobilization, significant improvement in the mean HHS scores at 3 months postoperatively, lower risk of complications, lower rates of readmission, and reoperation and higher likelihood of being discharged home. The mean LOS decreased from 8.21 ± 0.83 days to 5.82 ± 0.64 days after implementation of the evidence-based orthopedic ERAS pathway (p < 0.05).

Conclusions

This series of intertrochanteric fracture patients treated with the orthopedic ERAS procedure demonstrated that the procedure is capable of reducing LOS and preserving hip function without compromising functional outcome. This improvement was possible without a concomitant increase in postoperative complications and readmission rates.

Level of Evidence

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

Reverse distal femoral locking plate for subtrochanter femur fracture

In these case series, we used titanium locking compression plate-distal femur (LCP-DF) plate (Synthes) 9–11 hole using less invasive stabilization system or open reduction technique. This case series aims to determine the functional scores on reverse distal femoral locking plate for subtrochanteric femur fracture. A 34-year-old male with closed subtrochanteric fracture of the right femur (Seinsheimer 2B) with Harris hip scores (HHS) of 17, 96, and 97 obtained consecutively in 0, 6, and 12 months, respectively. A 24-year-old male with closed comminuted subtrochanteric fracture of the right femur (Seinsheimer V) with HHS of 13, 93, and 97 at 0, 6, and 12 months respectively. A 39-year-old male with non-union, left subtrochanteric femur fracture (Seinsheimer 2C) yielded HHS of 38, 73, and 77 at 0, 6, and 12 months, respectively. A 35-year-old female with close subtrochanteric fracture of the right femur (Seinsheimer IIB) yielded HHS of 23, 40, and 73 at 0, 6, and 12 months, respectively. Mean initial HHS and scores at 6 and 12 months reached 22, 75, and 86, respectively.

The impact of antegrade intramedullary nailing start site using the SIGN nail in proximal femoral fractures: A prospective cohort study

INTRODUCTION

In many low and middle-income countries (LMICs) SIGN nail is commonly used for antegrade femoral intramedullary (IM) nailing, using a start site either at the tip of the greater trochanter or piriformis fossa. While a correct start site is considered an essential technical step; few studies have evaluated the impact of using an erroneous start site. This is particularly relevant in settings with limited access to fluoroscopy to aid in creating a nail entry point. The purpose of this study was to evaluate the impact of antegrade SIGN IM nailing start site on radiographic alignment and health-related quality of life.

METHODS

In this prospective cohort study, adult patients with proximal femur fractures (OTA 32, subtrochanteric zone) treated with antegrade IM SIGN nail at Muhimbili Orthopaedic Institute (MOI), Dar es Salaam, Tanzania were enrolled. Start site was determined on the immediate postoperative X-ray and was graded on a continuous scale based on distance of the IM nail center from the greater trochanteric tip. The primary outcome measurement was coronal alignment on the post-operative x-ray. The secondary outcomes were reoperation rates, RUST scores and EQ5D scores at one year follow-up.

RESULTS

Seventy-nine patients were enrolled. 50 of them (63.3%) had complete data at 1year and were included in the final data analysis. Of the fifty patients, nine (18%) had IM nails placed laterally, 26 (52%) medially and 15 (30%) directly over the tip of the greater trochanter. Compared to a start site at the tip or medial to the greater trochanter, a lateral start site was 9 times more likely to result in a varus malalignment (95% CI: 1.42-57.70, p=0.021).

CONCLUSIONS

Lateral start site was associated with varus malalignment. Although lateral start site was not significantly associated with reoperation, varus deformity was associated with higher reoperation rates. Surgeons should consider avoiding a start site lateral to the tip of the greater trochanter or allow the nail to rotate to avoid malalignment when using the SIGN nail for proximal femur fractures.

Robotic technique improves entry point alignment for intramedullary nailing of femur fractures compared to the conventional technique: a cadaveric study

We aimed to test whether a robotic technique would offer more accurate access to the proximal femoral medullary cavity for insertion of an intramedullary nail compared to the conventional manual technique. The medullary cavity of ten femur specimens was accessed in a conventional fashion using fluoroscopic control. In ten additional femur specimens, ISO-C 3D scans were obtained and a computer program calculated the ideal location of the cavity opening based on the trajectory of the medullary canal. In both techniques, the surgeon opened the cavity using a drill and inserted a radiopaque tube that matched the diameter of the cavity. The mean difference in angle between the proximal opening and the medullary canal in the shaft of the femur was calculated for both groups. Robotic cavity opening was more accurate than the manual technique, with a mean difference in trajectory between the proximal opening and the shaft canal of 2.0° (95% CI 0.6°-3.5°) compared to a mean difference of 4.3° (95% CI 2.11°-6.48°) using the manual technique (P = 0.0218). The robotic technique was more accurate than the manual procedure for identifying the optimal location for opening the medullary canal for insertion of an intramedullary nail. Additional advantages may include a reduction in total radiation exposure, as only one ISO-C 3D scan is needed, as opposed to multiple radiographs when using the manual technique.

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.

An Anatomic Study of the Greater Trochanter Starting Point for Intramedullary Nailing in the Skeletally Immature

BACKGROUND

Trochanteric entry femoral nails have been increasing in popularity in the pediatric population for stabilization in fractures and osteotomies. The proper position for entry point in the coronal plane has been well studied; however, the sagittal plane in the pediatric population has not yet been well characterized.

METHODS

Eighty-eight cadaveric femora aged 8 to 20 years were studied in an apparent neck-shaft angle (ANSA) position, with distal condyles flat on the surface, and a true neck-shaft angle (TNSA) position, with internal rotation to neutralize femoral anteversion. Anterior and lateral offset were measured on lateral and anteroposterior photographs, respectively, as the perpendicular distance from the greater trochanter apex to the center of the intramedullary canal. The effect of rotational position (ANSA vs. TNSA) of the proximal femur was compared using the intraclass correlation coefficient for anterior and lateral offset. Correlations between age, demographics, anteversion, and greater trochanter morphology with anterior and lateral offset were evaluated with multiple regression analysis.

RESULTS

The mean age was 15.8±3.8 years. The mean anterior displacement of the trochanteric apex was 4.8±3.0 and 4.6±3.2 mm in the ANSA and TNSA positions, respectively. The mean lateral displacement was 10.6±4.2 and 9.7±4.0 mm in the ANSA and TNSA positions, respectively. The intraclass coefficient for anterior offset in the ANSA versus TNSA position was 0.704 and 0.900 for lateral offset. Change was minimal for anterior offset in the ANSA and TNSA positions versus age (standardized beta values 0.240, 0.241, respectively). There was a significant correlation with increasing lateral offset in the ANSA and TNSA positions with increasing age (standardized beta values 0.500, 0.385 respectively).

CONCLUSIONS

In the pediatric population, the tip of the greater trochanter is consistently anterior by approximately 5 mm. The mean lateral displacement was approximately 10 mm and increased with increasing age.

CLINICAL RELEVANCE

Nail entry at the pediatric greater trochanter apex would likely result in anterior placement. We recommend inserting the guidewire 5 mm posterior to the apex of the trochanter and confirming coronal and sagittal position with fluoroscopy.

Where is the true location of the femoral piriform fossa?

OBJECTIVE

To analyze knowledge of the anatomic location of the piriform fossa using a questionnaire with anatomic figures.

MATERIALS AND METHODS

Participants taking AO Trauma Brasil courses were requested to complete a questionnaire containing a photograph of the superior surface and a photograph of the lateral surface of the femur and answer a question asking which of four numbered points corresponded to the piriform fossa.

RESULTS

Just 4.5% of respondents correctly chose point 2 (the piriform fossa) in both images, while 75.4% of respondents chose point 4 (the trochanteric fossa) as the correct anatomic structure. The subset of 4th-year residents' answers was significantly different from those of the other subsets, with 7.5% of correct answers.

CONCLUSIONS

The low rate of correct answers indicates a tendency for the respondents to be influenced by illustrations in text books or examples in scientific publications that indicate the site of the piriform fossa incorrectly. Interest in the specialty of traumatology is possibly the reason why the subset of 4th-year residents had a better- than-average rate of correct answers.

Comparing Entry Points for Antegrade Nailing of Femoral Shaft Fractures

The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. The purpose of this systematic review was to determine whether there is a difference in operative parameters, healing, and functional outcome when comparing the greater trochanter (GT) and piriformis fossa (PF) entry points. A systematic search of multiple databases and 3 major orthopedic meetings (American Academy of Orthopaedic Surgeons, Canadian Orthopaedic Association, and Orthopaedic Trauma Association) was conducted. Four studies (570 patients) met the inclusion criteria. Mean patient age was 34.5 years, and 60.4% were male. The GT entry point was associated with significantly shorter operative (mean difference [MD], -20.05 minutes [95% confidence interval (CI), -23.09 to -17.02]; P<.00001) and fluoroscopy times (MD, -24.55 seconds [95% CI, -43.23 to -5.86]; P=.01). There was no significant difference in nonunion (risk ratio [RR], 0.74 [95% CI, 0.35 to 1.58]; P=.44) and delayed union rates (RR, 0.94 [95% CI, 0.41 to 2.14]; P=.88) between the 2 entry points. Heterogeneity in outcome measures reported prevented pooled analysis of functional outcomes. This review supports the use of the GT entry point during antegrade nailing of femoral shaft fractures over the PF entry point, with regard to shorter operative and fluoroscopy times. Healing and complication rates were not related to the entry point. Further study is required to determine the effect of each entry point on the surrounding soft tissue structures and ultimately its impact on postoperative function.

Incidence of Avascular Necrosis of the Femoral Head After Intramedullary Nailing of Femoral Shaft Fractures: A Multicenter Retrospective Analysis of 542 Cases

The goal of this study was to determine the incidence of avascular necrosis of the femoral head (AVNFH) after intramedullary nailing of femoral shaft fractures and to identify risk factors for developing AVNFH.We retrospectively reviewed all patients with femoral shaft fractures treated with antegrade intramedullary nailing at 10 institutions. Among the 703 patients enrolled, 161 patients were excluded leaving 542 patients in the study. Average age was 42.1 years with average follow-up of 26.3 months. Patient characteristics and fracture patterns as well as entry point of femoral nails were identified and the incidence of AVNFH was investigated. Patients were divided into 2 groups according to open versus closed physis, open versus closed fractures, and age (<20 versus ≥20 years).Overall incidence of AVNFH was 0.2% (1 of 542): the patient was 15-year-old boy. Of 25 patients with open physis, the incidence of AVNFH was 4%, whereas none of 517 patients with closed physis developed AVNFH (P < 0.001). The incidence of AVNFH in patients aged < 20 versus ≥20 years was 1.1% (1 of 93) and 0.0% (0 of 449), respectively (P = 0.172), which meant that the incidence of AVNFH was 0% in adult with femur shaft fracture. Of 61 patients with open fractures, the incidence of AVNFH was 0%. The number of cases with entry point at the trochanteric fossa or tip of the greater trochanter (GT) was 324 and 218, respectively, and the incidence of AVNFH was 0.3% and 0.0%, respectively (P = 0.412).In patients aged ≥20 years with isolated femoral shaft fracture, there was no case of AVNFH following antegrade intramedullary nailing regardless of the entry point. Therefore, our findings suggest that the risk of AVNFH following antegrade femoral nailing is extremely low in adult patients.

Osteonecrosis of the femoral head: diagnosis and classification systems

Osteonecrosis of femoral head is a rare but disabling condition that usually results in progressive femoral head collapse and secondary arthritis necessitating total hip arthroplasty if not treated appropriately in early stages. However, early diagnosis is challenging as the onset of disease is insidious and the symptoms and signs are usually minimal and nonspecific until it becomes advanced. Of several diagnostic modalities, magnetic resonance imaging (MRI) is considered the imaging method of choice with the highest sensitivity and specificity, while detection of potential risk factors is very important as well. Many investigators have developed several different classification systems; however, there still is controversy regarding the optimal classification system. Diagnostic methods and the evolution of different classification systems will be reviewed in this paper.

The effect of antegrade femoral nailing on femoral head perfusion: a comparison of piriformis fossa and trochanteric entry points

INTRODUCTION

Piriformis fossa entry antegrade femoral nailing is a common method for stabilizing diaphyseal femur fractures. However, clinically significant complications such as chronic hip pain, hip abductor weakness, heterotopic ossification and femoral head osteonecrosis have been reported. A recent cadaveric study found that piriformis entry nailing damaged either the deep branch of the medial femoral circumflex artery (MFCA) or its distal superior retinacular artery branches in 100% of specimens and therefore recommended against its use. However, no study has quantitatively assessed the effect of different femoral entry points on femoral head perfusion.

MATERIALS AND METHODS

Twelve fresh-frozen cadaveric lower extremity specimens were randomly allocated to either piriformis fossa or trochanteric entry nailing using a 13-mm reamer. The contralateral hip served as an internal matched control. All specimens subsequently underwent gadolinium-enhanced fat-suppressed gradient-echo sequence MRI to assess femoral head perfusion. Gross dissection was also performed to assess MFCA integrity and distance to the opening reamer path.

RESULTS

MRI quantification analysis revealed near full femoral head perfusion with no significant difference between the piriformis and trochanteric starting points (95 vs. 97%, p = 0.94). There was no observed damage to the deep MFCA in either group. The mean distance from the reamer path to the deep MFCA was 3.2 mm in the piriformis group compared to 18.5 mm in the trochanteric group (p = 0.001). Additionally, there was a significantly greater number of mean terminal superior retinacular vessels damaged by the opening reamer in the piriformis cohort (1 vs. 0; p = 0.007).

CONCLUSIONS

No statistically significant difference in femoral head perfusion was found between the two groups. Therefore, we cannot recommend against the use of piriformis entry femoral nails. However, we caution against multiple errant starting point attempts and recommend meticulous soft tissue protection during the procedure.

Nailing proximal femur fractures: how to choose starting point and proximal screw configuration

Fractures of the proximal femur can be a challenging treatment dilemma for the orthopaedic surgeon. Complex mechanical forces and anatomic variables in this region combine to make treatment of these injuries difficult and can often result in serious complications. The decision to treat this fracture with an intramedullary device requires the surgeon evaluate many variables in the context of the specific fracture pattern. These include the choice of implant, starting portal location, and positioning of the patient. Assessment of the fracture pattern and its 3 dimensional orientation is usually accomplished with the aid of advanced imaging. The patient's physiological status, body habitus and bone quality must also be incorporated into the treatment algorithm. We review these issues and how they factor into the decision making process in order to develop a successful operative plan for these injuries. We will review the starting portal selection, reduction and insertion techniques and examine options for proximal locking screw configurations.

Predicting the optimal entry point for femoral antegrade nailing using a new measurement approach

PURPOSE

To establish a new reliable approach for measuring proximal femoral anatomical parameters and determining the optimal entry point of the antegrade intramedullary (IM) nailing.

METHODS

A new method for measuring the proximal femoral anatomy and locating the optimal entry point for the antegrade nailing was developed using Mimics and 3-Matic softwares (Materialise, Haasrode, Belgium). After verifying the reliability of the measurement method using 15 pairs of the femoral models by the intraclass correlation coefficient, the anatomical parameters of 200 Chinese femurs were measured, and statistical analyses were performed to compare the proximal femoral anatomical parameters between different genders or lateralities and determine the most relevant factors of the optimal entry point.

RESULTS

Reliability study showed that both intraobserver reliability and interobserver reliability of the current measurement approach were excellent. After independent samples [Formula: see text]-test, the proximal femoral anatomical parameters were shown significant difference between genders. Stepwise regression statistical analyses showed that the most relevant factors of the distances between the optimal entry point and the femoral head centre, the femoral neck axis and the tip of the greater trochanter were the 3D femoral neck-shaft angle (Pearson's [Formula: see text]; the model's [Formula: see text]), the femoral radius (Pearson's [Formula: see text]; the model's [Formula: see text]) and the femoral length (Pearson's r = 0.316; the model's [Formula: see text]), respectively.

CONCLUSIONS

The current study provided a new and reliable measurement approach to evaluating the anatomical morphology of the proximal femur and revealed the most influential factors on the locations of the simulated optimal entry point for the proximal femoral antegrade IM nailing. Furthermore, this study was useful for establishing methodological basis for future researches and developments of the custom-made IM nailing and affiliated surgical instruments.

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.

Four pins assisted reduction of complex segmental femoral fractures: a technique for closed reduction

Complex segmental femoral fractures are usually not amenable to closed reduction. The purpose of this study was to evaluate a series of patients who had undergone four pins assisted reduction and intramedullary nail fixation to determine the therapeutic effect of this closed reduction technique. Between December 2010 and January 2013, 15 consecutive patients with segmental femoral fractures were treated with four pins assisted reduction at our hospital. The patient was placed in a supine position on a radiolucent fracture table and a gentle traction was attempted on the limb. Usually, the proximal fracture segment exhibited the typical deformity of flexion, external rotation, and abduction, the middle segment exhibited adduction and distal fracture segment exhibited flexion. Four Schanz pins were placed percutaneously to fix one cortex and did not penetrate into the medullary cavity, and the "T" sharp handles were fixed on the Schanz pins. The fragments were then reduced by reversing the deforming forces for segmental fractures by two assistants. And then, the reduction could be easily achieved and intramedullary nail fixation was performed. Radiographs were evaluated for the quality of the reduction and fracture union. Closed reduction was achieved in all patients using the four pins technology. All 15 fractures united uneventfully. No patient had a rotational malunion or limb length discrepancy at the time of the last follow-up. Thirteen of the fifteen (86.7%) patients had anatomic reduction and two of them (13.3%) had minor varus alignment of 3° and 5°. Knee stiffness was observed in 2 patients and no implant failure was observed. Surgical treatment of complex segmental femoral fractures with four pins assisted reduction and intramedullary nail fixation techniques can result in excellent reductions and a high union rate.

Surgical hip dislocation does not result in atrophy or fatty infiltration of periarticular hip muscles

Surgical hip dislocation is the gold standard for treatment of femoroacetabular impingement (FAI). It utilizes an intermuscular and internervous approach to the hip. Concerns have been expressed that this approach causes soft tissue trauma resulting in post-operative muscle weakness of patients undergoing this procedure. We therefore asked whether surgical hip dislocation leads to (i) atrophy (decreased muscle diameter or cross-sectional area [CSA]) and (ii) degeneration (fatty infiltration) of 18 evaluated periarticular hip muscles. We retrospectively evaluated 32 patients (34 hips) following surgical hip dislocation for the treatment of FAI using pre and post-operative magnetic resonance (MR) arthrography of the hip. We evaluated muscle diameter, CSA and degree of fatty infiltration according to Goutallier for 18 periarticular hip muscles on axial and sagittal views. The mean interval between pre and post-operative MR was 1.9 ± 1.5 years (range, 0.4–6.1 years). Pre and post-operative muscle diameter and CSA of all 18 evaluated hip muscles did not differ. There was no post-operative change in the Goutallier classification for any of the evaluated 18 muscles. No muscle had post-operative degeneration higher than Grade 1 according to Goutallier. No atrophy or degeneration of periarticular hip muscles could be found following surgical hip dislocation for treatment of FAI. Any raised concerns about the invasiveness and potential muscle trauma for this type of surgery are unfounded. Level III, retrospective comparative study. See guidelines for authors for a complete description of levels of evidence.

[Femoral nailing using a helical nail shape (LFN(®))]

OBJECTIVE

Antegrade femoral nailing through a greater trochanteric entry portal avoids damage to the proximal external rotators and to the ramus profundus of the medial femoral circumflex artery, furthermore eases insertion in adipose subjects. However a helical nail shape is necessary for this pathway because bending in two perpendicular planes has to be passed by the nail.

INDICATIONS

All femoral shaft fractures suitable for antegrade nailing (type 32-A/B/C). Additional femoral neck fractures (type 31-B) by using proximal Recon-interlocking screws.

CONTRAINDICATIONS

The common contraindications for femoral nailing. In certain subtrochanteric fractures (Type 32-A/B) the proximal femoral nail may be favorable.

SURGICAL TECHNIQUE

General or spinal anesthesia. Supine position with flexion/abduction of the contralateral leg in order to facilitate fluoroscopy of the proximal femur in a true lateral view. Closed reduction of length and axis. Measurement of length and diameter of the nail using a radiolucent ruler. Dorsolateral approach to the greater trochanter. Insertion of the guide wire 10 mm lateral to the trochanteric tip (anteroposterior view) and in the middle third of the trochanter (lateral view). Reaming of the insertion point using a flexible reamer. If reaming of the entire medullary canal is desired, this should be done using a long intramedullary guide wire in combination with a long flexible reamer. Insertion of the nail starts in an anterior position and ends in a lateral position of the insertion instrument, so a 90° external rotation of the nail occurs during insertion. Proximal interlocking is performed using the guide of the insertion instrument. Check interfragmentary rotation. Distal interlocking using a radiolucent drill device.

POSTOPERATIVE MANAGEMENT

Depends on the fracture shape: stable interfragmentary support may allow early full weight bearing. Otherwise, reduced weight bearing is recommended for at least 6 weeks.

RESULTS

In a prospective mulicentric study, 227 helical femoral nails were used for antegrade femoral nailing. Follow-up after 12 month was available in 74 %. Surgeons' rating for ease of identifying entry site was excellent or good in 89 %. Functional and radiological results after 12 months do not prove significant benefits over conventional antegrade femoral nails.

Avascular necrosis of femoral head: a rare complication of a common fracture in an octogenarian

Avascular necrosis (AVN) of the femoral head is a relatively uncommon complication following an extracapsular hip fracture. Although it can occur following fixation of unstable 3-part or 4-part intertrochanteric fractures with significant posteromedial and posterolateral comminution, it remains a rare complication. We present a case of AVN of the femoral head following fixation of a stable 2-part intertrochanteric fracture in spite of good healing at the hip fracture site. This is a rare but eminently treatable cause of persisting hip pain after hip fracture surgery, and primary or secondary care physicians should be aware of this possibility.

Open reduction and intramedullary stabilisation of subtrochanteric femur fractures: A retrospective study of 56 cases

Subtrochanteric femur fractures commonly present with predictable displacement because of the deforming muscle forces acting upon the proximal femur. For this reason, successful closed reduction and femoral nailing can be a technically demanding procedure. Open reduction prior to nail placement has been advocated to improve and maintain anatomic fracture alignment. The purpose of this study was to evaluate the results of patients with closed subtrochanteric femur fractures treated with open reduction and a reamed antegrade statically locked intramedullary nail. An initial query of our database identified 154 patients who had sustained a subtrochanteric femur fracture over the defined study period. Ninety-six patients had adequate radiographic and clinical follow-up. Fifty-six (58%) patients were treated with open reduction and nail placement. There were no wound complications or infections and all patients went on to successful osseous union. There was no loss of reduction and a final coronal and sagittal plane deformity of <5 degrees in 55 of 56 (98%) patients. Open reduction of closed subtrochanteric femur fractures followed by intramedullary nailing leads to high union rates with rare complications.

Trochanteric fossa or piriform fossa of the femur: time for standardised terminology?

Piriform fossa, trochanteric fossa and greater trochanteric tip have each been described as entry points for antegrade femoral nailing. However, the terminology used for these entry points is confusing. The accuracy of the entry point nomenclature in published text and illustrations was recorded in this review study. The trochanteric fossa, a deep depression at the base of the femoral neck is indicated as 'piriform fossa' in the vast majority of the publications. Other publications indicate the insertion site of the tendon of the piriformis muscle on the greater trochanteric tip as 'piriform fossa'. As a result of recurrent terminology error and consistent reproductions of it, the recommended entry point in literature is confusing and seems to need standardisation. The piriform fossa does not appear to exist in the femoral region. The trochanteric fossa is the standard entry point which most surgeons recommend for facilitating a standard straight intramedullary nail, as is in line with the medullary canal. The greater trochanteric tip is the lateral entry point for intramedullary nails with a proximal lateral bend.

The surgical anatomy of the piriformis tendon, with particular reference to total hip replacement

The piriformis muscle is an important landmark in the surgical anatomy of the hip, particularly the posterior approach for total hip replacement (THR). Standard orthopaedic teaching dictates that the tendon must be cut in to allow adequate access to the superior part of the acetabulum and the femoral medullary canal. However, in our experience a routine THR can be performed through a posterior approach without sacrificing this tendon.

We dissected the proximal femora of 15 cadavers in order to clarify the morphological anatomy of the piriformis tendon. We confirmed that the tendon attaches on the crest of the greater trochanter, in a position superior to the trochanteric fossa, away from the entry point for broaching the intramedullary canal during THR. The tendon attachment site encompassed the summit and medial aspect of the greater trochanter as well as a variable attachment to the fibrous capsule of the hip joint. In addition we dissected seven cadavers resecting all posterior attachments except the piriformis muscle and tendon in order to study their relations to the hip joint, as the joint was flexed. At flexion of 90° the piriformis muscle lay directly posterior to the hip joint.

The piriform fossa is a term used by orthopaedic surgeons to refer the trochanteric fossa and normally has no relation to the attachment site of the piriformis tendon. In hip flexion the piriformis lies directly behind the hip joint and might reasonably be considered to contribute to the stability of the joint.

We conclude that the anatomy of the piriformis muscle is often inaccurately described in the current surgical literature and terms are used and interchanged inappropriately.

Cite this article: Bone Joint J 2013;95-B:764–9.

Risk of injury to the superior gluteal nerve when using a proximal incision for insertion of a piriformis-entry reamed femoral intramedullary nail: a cadaveric study

BACKGROUND

This cadaveric study evaluated the risk of injury to the superior gluteal nerve when a proximal incision site is used for insertion of an antegrade, reamed femoral intramedullary nail into the piriformis fossa. Based on prior anatomical studies, our hypothesis is that the use of a proximal incision site for intramedullary nail insertion will consistently injure the superior gluteal nerve.

METHODS

A reamed femoral intramedullary nail was inserted through a piriformis fossa entry site in six pairs of fresh-frozen cadaver femora. The specimens were randomized to two groups: reaming of the femoral canal with or without a protective sleeve. Damage to the superior gluteal nerve was evaluated by means of layered dissection of specimens. Damage to any part(s) of the superior gluteal nerve was recorded, and the distances between the path of the instrumentation and nail and the branches of the superior gluteal nerve were measured.

RESULTS

A "spray" nerve pattern of the superior gluteal nerve was present in all twelve specimens. The average distance and standard deviation between the most superior branch of the superior gluteal nerve and the instrumentation and nail path was 17.75 ± 8.58 mm. The average distance between the most inferior branch of the superior gluteal nerve and the instrumentation and nail path was 22.39 ± 10.52 mm. There were no significant differences between the two groups. There were no injuries to any part of the superior gluteal nerve regardless of whether or not a protective sleeve was used.

CONCLUSIONS

This anatomic study demonstrated that the superior gluteal nerve is not at risk for injury when a proximal incision site is used to place a reamed intramedullary nail into the piriformis fossa.

[Experiences with a helical femoral nail (LFN®). A multicenter study]

INTRODUCTION

Antegrade intramedullary nailing is the method of choice in most femoral shaft fractures. The trochanteric entry portal of classic femoral nails is in close proximity to the piriformis tendon, the gluteus minimus tendon, the obturator tendons, and the medial femoral circumflex artery. Nail insertion lateral to the tip of the greater trochanter may be more favorable but needs the use of a helical implant.

MATERIAL AND METHODS

Measurement of the reamer pathway through an entry point lateral to the superior trochanteric border was performed with a three-dimensional motion tracking sensor in human cadaveric femurs. These results provided a scientific rationale for the design of a helical femoral nail (LFN®). In a prospective multicenter study a total of 227 femoral shaft fractures were treated by nailing with the LFN. Patients were followed at 3 months (n=193) and 12 months (n=167).

RESULTS

The ease of defining the entry point and inserting the nail was rated as"very good and good" by 90% of the surgeons. Intraoperative technical complications included incomplete reduction (14%), additional iatrogenic fractures (6%), and difficulties in interlocking (3.5%). At the 1-year follow-up, delayed unions were seen in 10%, secondary loss of reduction in 3%, and deep infection in 1.8% of the patients. Angular malalignment of more than 5° was seen in 5%, mostly in valgus. A normal walking capacity was seen in 68% and normal active hip flexion in 45%.

CONCLUSION

The results obtained in this study during 1 year do not provide evidence for an advantage of the LFN over conventional antegrade femoral nails.

Correlation of trochanter-shaft angle in selection of entry site in antegrade intramedullary femoral nail

Background. Selection of entry point for nail insertion is controversial and lack firm anatomical basis. The study is done to analyze the proximal anthropometry of femur and measure the Trochanter-Shaft Angle to find its relation and significance in selection of entry point for antegrade uniplanar femoral nail. Materials and Methods. Study involves the measurement of trochanter-shaft angle and other anthropometric measurements on 50 dry femora and on digital radiogram. Results. Trochanter-Shaft angle ranges between 5-17 degrees in anthropometric study and 4-14 degrees in radiological study. Over all in 27 cases (54%), exit points of reamur fall in the middle quadrant in sagittal and coronal plane, which corresponds to the T-S angle of 6-12 degrees. Discussion and Conclusion. Proximal femoral Anthropometry and Trochanter-shaft angle is variable; hence it is difficult to fix any anatomical point as a universal entry point for antegrade femoral nail insertion. Trochanter shaft angle (TSA) can be well accessed radiologically and serve as a guide for selection of proper entry point.for safe nail insertion. Clinical Relevance. Individual variations in the proximal femur anatomy for safe nail insertion can be correlated with Trochanter shaft angle to serve safe entry site.

CROSS-SECTIONAL STUDY ON DIFFERENT ENTRY POINTS FOR ANTEROGRADE FEMORAL INTRAMEDULLARY OSTEOSYNTHESIS

Objective: To analyze the degree of knowledge among professionals who treat fractures using the recommended technique, with regard to correlating the nail with the entry point that is considered appropriate. Methods: A questionnaire that presented five types of nail and simulated a transverse diaphyseal fracture of the femur was developed. Results: Responses regarding the entry points corresponding to choosing the type of nail were obtained from 370 orthopedists who were participating in the 41^st Brazilian Congress of Orthopedics and Traumatology. It was observed that only 20% correctly identified the entry point and that there was no difference between the professionals within the specialty of Traumatology and the others. Conclusion: It was concluded that the majority of the physicians attending the congress were unaware of the entry points.

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.

Vascular safe zones in hip arthroscopy

BACKGROUND

Hip arthroscopy is an evolving surgical technique being performed in greater numbers because of advances in skill, improved technology, and increased demand. Identifying vascular safe zones using anatomic and intracapsular landmarks provides a valuable intraoperative guide to reduce the risk of damage to the femoral head blood supply during femoral neck osteoplasty and psoas tendon release.

PURPOSE

This series is presented to identify vascular safe zones for use in hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors analyzed 76 consecutive contrast-enhanced magnetic resonance scans obtained from patients with diagnosed femoral acetabular impingement. High-resolution 3-dimensional images were reconstructed to visualize the vasculature. The medial femoral circumflex artery (MFCA) course was traced from the anterior thigh to the femoral head. Specific attention was paid to its proximity to the psoas tendon at the site of release and the retinacular vessel course in relation to the femoral neck using a clock-face orientation.

RESULTS

The MFCA was found inserting on the posterior superior femoral neck from the 10:30 to 12-o'clock position on the femoral neck shaft, just posterior to the lateral synovial fold, and progressed on the femoral neck via an average of 4 retinacular vessels (range, 2-6). Ninety-seven percent of vessels were posterior to the 12-o'clock position. The MFCA passes posteriorly a mean distance of 50% ± 8% between the lesser trochanter and inferior femoral head/acetabular junction, located a mean 15 ± 0.37 mm medial to the medial cortex of the femoral neck. The MFCA was within the middle third zone in 100% of the measurements.

CONCLUSION

The authors defined the following 2 safe zones: the femoral neck osteoplasty safe zone is on the anterior half of the femoral neck; the psoas tendon release safe zone is astride the middle third of the medial hip capsule (bordered by the lesser trochanter and inferior femoral head/acetabular junction).

Functional outcome after antegrade femoral nailing: a comparison of trochanteric fossa versus tip of greater trochanter entry point

OBJECTIVES

This study was performed to explore the relationship between entry point-related soft tissue damage in antegrade femoral nailing and the functional outcome in patients with a proximal third femoral shaft fracture.

DESIGN

Retrospective clinical trial.

SETTING

Level I university trauma center.

PATIENTS

Seventeen patients with a high femoral shaft fracture treated with an antegrade femoral nail joined the study.

INTERVENTION

Nine patients with an Unreamed Femoral Nail (UFN; Synthes, Bettlach, Switzerland) inserted at the trochanteric fossa and eight patients with a long Proximal Femoral Nail (PFN; Synthes) inserted at the tip of the greater trochanter.

MAIN OUTCOME MEASUREMENTS

Pain, gait, nerve, and muscle function along with endurance.

RESULTS

Five patients with a UFN had a positive Trendelenburg sign and a reinnervated superior gluteal nerve after initial injury of the nerve at operation. None of these findings occurred in the long PFN group (P = 0.01). Isokinetic measurements showed diminished abduction as well as external rotator function in the UFN group rather than in the long PFN group. Leg endurance was significantly lower in patients with a UFN.

CONCLUSIONS

Compared with the trochanteric fossa, femoral nailing through the greater trochanter tip may decrease the risk of damage to the superior gluteal nerve and intraoperative damage to the muscular apparatus of the hip region, resulting in some improved muscle function. Therefore, a lateral entry point may be a rational alternative for conventional nailing through the trochanteric fossa.

Is there a standard trochanteric entry site for nailing of subtrochanteric femur fractures?

OBJECTIVES

To evaluate the variability of the ideal trochanteric starting point as a possible cause for malreduction of subtrochanteric fractures and to analyze the accuracy of contralateral templating to predict correct entry site.

METHODS

Standardized anteroposterior pelvis radiographs of 50 patients were evaluated by two independent reviewers. Patients with advanced osteoarthritis, severe hip deformity, and radiographs with asymmetric hip rotation were excluded. Ideal nail entry site was established using a template for a trochanteric nail with a 6° proximal bend. The distance from the greater trochanteric tip to the ideal nail entry site was measured. Additionally, offset of the greater trochanter tip from the femoral longitudinal axis was measured. Interobserver reliability and accuracy of contralateral templating were evaluated.

RESULTS

The ideal entry point ranged from 16 mm medial to 8 mm lateral to the trochanteric tip (mean, 3 mm medial; standard deviation, 5 mm). In 70% of patients, the ideal entry point was medial to and in 23% lateral to the tip of the greater trochanter. Ideal entry points were located within 2 mm of the trochanteric tip in 29% and within 4 mm in 44% of patients. The location of the ideal entry point relative to the trochanteric tip had a weak correlation with patient height and neck shaft angle (r: -0.23 and r: -0.35, respectively). Interobserver reliability and agreement between left and right side measurements were strong (intraclass correlation coefficient: >0.94 and >0.88, P < 0.001, respectively). The mean measurement differences between sides was 0 mm (95% confidence interval: -1 to 1). Greater trochanter offset averaged 15 mm (range, 5-26 mm; standard deviation: 5) on the right and 15 mm (range, 5-25 mm; standard deviation: 5.1) on the left (P = 0.95).

CONCLUSION

A high degree of variability exists for the ideal trochanteric entry site. The trochanteric tip represents the ideal starting point in only the minority of cases. Preoperative contralateral templating provides an accurate means for establishing a patient-specific entry point to minimize fracture malreduction.

Intramedullary femoral nailing through the trochanteric fossa versus greater trochanter tip: a randomized controlled study with in-depth functional outcome results

PURPOSE

In a level 1 university trauma center, an explorative randomized controlled study was performed to compare soft tissue damage and functional outcome after antegrade femoral nailing through a trochanteric fossa (also known as piriform fossa) entry point to a greater trochanter entry point in patients with a femoral shaft fracture.

MATERIALS AND METHODS

Nineteen patients were enrolled and randomly assigned to two nail insertion groups; ten patients were treated with an Unreamed Femoral Nail(®) (UFN, Synthes(®), Solothurn, Switzerland) inserted at the trochanteric fossa and nine patients were treated with an Antegrade Femoral Nail(®) (AFN, Synthes(®), Solothurn, Switzerland) inserted at the tip of the greater trochanter. The main outcome measures were pain, gait, nerve and muscle function, along with endurance. Magnetic resonance imaging (MRI), electromyography (EMG), and Cybex isokinetic testings were performed at, respectively, 2 and 6 weeks and at a minimum of 12 months after surgery.

RESULTS

The MRI and EMG showed, in both groups, signs of iatrogenic abductor musculature lesions (four in the UFN group and four in the AFN group) and superior gluteal nerve injury (five in the UFN group and four in the AFN group). The isokinetic measurements and the patient-reported outcomes showed moderate reduction in abduction strength and endurance, as well as functional impairment with slight to moderate interference with daily life in both groups, with no appreciable differences between the groups.

CONCLUSIONS

Anatomical localization of the entry point seems to be important for per-operative soft tissue damage and subsequent functional impairment. However, the results of this study did not show appreciable differences between femoral nailing through the greater trochanter tip and nailing through the trochanteric fossa.

Splitting of the proximal femur with a new femoral nail

We present a case of a 19-year-old woman with a closed diaphyseal femur fracture and who had fixation of the fracture using a newer lateral entry nail, which resulted in an intraoperative proximal femur fracture. The patient underwent revision the following day and subsequently returned to regular activity without signs of implant failure or loss of reduction at latest follow-up. Caution should be exercised with the use of new implants that require a change in customary technique. In addition, some concern must be raised by the amount of offset from the top of this particular nail to its long axis.

Closed intramedullary nailing of the femur in the lateral decubitus position

Closed intramedullary nailing is the standard of care for femoral shaft fractures and the technique now has broader applications with the proliferation of cephalomedullary instrumentation for the treatment of intertrochanteric and subtrochanteric femur fractures. Nailing in the lateral decubitus position has several advantages, but we are unaware of a detailed, contemporary description of the surgical technique published in the English language literature.A retrospective review of 158 patients treated with intramedullary nailing in the lateral position by a single surgeon over a 3-year period was performed. Clinical and radiographic outcomes were evaluated. In a group of 58 diaphyseal femur fractures, there were three rotational malreductions and one limb length discrepancy that required operative intervention. All but one were recognized and corrected intraoperatively on placing the patient supine. In a group of 100 primarily geriatric intertrochanteric, subtrochanteric, or peritrochatneric fractures managed with a cephalomedullary device, there were two lag screw cutouts, one nonunion, and one hardware failure. All of these required revision surgery. There were no rotational or length malreductions that required correction. There were no injuries to the perineum or contralateral leg, nerve palsies, or traction-related complications. Lateral positioning obviates the need for a fracture table, makes it easier to establish a starting point for an intramedullary device, and facilitates conversion to an open procedure without repositioning should this become necessary. This study demonstrates that the technique is safe and effective with an incidence of complications comparable with fracture table and supine positioning.

[The standard implantation of a total hip prosthesis via two incisions (the Yale Technique)]

OBJECTIVE

Implantation of a total hip endoprosthesis with minimal trauma to the soft tissue. The need for visual aids (e.g., navigation or X-rays) during the procedure is frequently avoided.

INDICATIONS

All kinds of coxarthrosis for every age group, for every variation of bone construction, and even in obese patients.

CONTRAINDICATIONS

Extremely dysplastic hip joints involving the development of a secondary socket and the necessity of reconstruction of the acetabular socket (e.g., in the Harris method).

SURGICAL TECHNIQUE

Using a fixed lateral position, a small entry incision is made between the tensor fasciae latae and the sartorius muscles and the prosthesis socket is put into place. Via a second dorsal incision, after stripping the exterior rotators, the prosthesis stem and ball are implanted and the two parts of the prosthesis are attached.

POSTOPERATIVE MANAGEMENT

Full weight bearing allowed immediately. A luxation prophylaxis, in the form of a self-developed hip bodice (the so-called Yale bandage), is used until the end of the 4th postoperative week. Discharge from hospital is possible after just a few days. Upon discharge, the patient is sent to a rehabilitation facility, either as a resident or as an outpatient, for approximately 3 weeks. Return to the workplace, with only light physical activity, is possible once the wound has healed completely; this could be as soon as 14 days after the operation. Checkups are made after 4 weeks, 6 months, 1 year and then every year; these checkups include a full examination, X-rays and laboratory tests. Full exposure to sport or heavy manual labor is usually approved after the 6-month checkup.

RESULTS

Between October 2004 and April 2006, a total of 221 patients underwent surgery using this new technique (of these 15 patients underwent two-stage bilateral hip joint replacements). Patients were followed up for a minimum of 12 months and a maximum of 30 months. The Harris Hip Score improved from an average of 45.25 preoperatively to 96.4 postoperatively.

Clamp-assisted reduction of high subtrochanteric fractures of the femur

BACKGROUND

Subtrochanteric fractures can be a treatment challenge. The substantial forces that this region experiences and the fact that the proximal fragment is frequently displaced make accurate reduction and internal fixation difficult. The purpose of this study was to evaluate a series of patients who had undergone clamp-assisted reduction and intramedullary nail fixation to determine the impact of this technique on fracture union rates and reduction quality.

METHODS

Between December 2003 and January 2007, fifty-five consecutive patients with a displaced high subtrochanteric femoral fracture were treated with clamp-assisted reduction and intramedullary nail fixation at two level-I trauma centers. Two patients died, and nine were lost to follow-up. The remaining forty-four patients were followed until union or a minimum of six months. There were twenty-seven male and seventeen female patients with a mean age of fifty-five years. All were treated with an antegrade statically locked nail implanted with a reaming technique as well as the assistance of a reduction clamp placed through a small lateral incision. Nine patients were treated with a single supplemental cerclage cable. Radiographs were evaluated for the quality of the reduction and fracture union.

RESULTS

Forty-three of the forty-four fractures united. All reductions were within 5 degrees of the anatomic position in both the frontal and the sagittal plane. Thirty-eight (86%) of the forty-four reductions were anatomic. Six fractures had a minor varus deformity of the proximal fragment (between 2 degrees and 5 degrees ). There were no complications.

DISCUSSION

Surgical treatment of subtrochanteric femoral fractures with clamp-assisted reduction and intramedullary nail fixation techniques with judicious use of a cerclage cable can result in excellent reductions and a high union rate. Careful attention to detail is important to perform these maneuvers with minimal additional soft-tissue disruption.