Limb Malalignment and Functional Outcome After Antegrade Versus Retrograde Intramedullary Nailing in Distal Femoral Fractures

Impact of operative position on rotational alignment after intramedullary nailing of trochanteric fractures: a comparative analysis of lateral decubitus versus supine position

BACKGROUND

Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures.

METHODS

The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant, and excessive. The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared.

RESULTS

The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12 were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time.

CONCLUSION

Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time.

Accuracy of the Lesser Trochanter Profile as a Marker of Femoral Rotation: Computed Tomography-Based Study of 1,722 Femora

BACKGROUND

The lesser trochanter (LT) profile is an often-used marker for proximal femoral rotation, particularly during the operative fixation of femoral fractures. Previous studies have come to conflicting conclusions about its reliability for this purpose.

METHODS

The SOMA (Stryker Orthopaedic Modeling and Analytics) database (Stryker) was used to identify 1,722 computed tomographic (CT) scans of whole femora. Each femur was taken through an 80° rotational arc in 2.5° increments, and the LT profile was constructed for each position. These 56,826 LT profile measurements were then correlated with the femoral rotation.

RESULTS

Across the arc of motion studied, the LT correlated weakly with proximal femoral rotation (R 2 = 0.32). There was a 35° arc, between 10° and 45° relative external rotation of the proximal femur, within which the LT profile only changed by 1 mm. The mean overall femoral anteversion was 21.2°, and women tended to have more femoral anteversion (23.9°) than men (19.2°). On average, men had a 1.6-mm more prominent LT than women. Side-to-side differences in femoral anteversion as well as LT position and size were not significant or were clinically unimportant.

CONCLUSIONS

A large-scale, CT-based study shows that the LT profile is a less reliable marker of proximal femoral rotation than previously thought. This is true particularly if there is relative external rotation of the proximal femur, where the proximal femur can undergo up to 35° of rotation before 1 mm of change in the LT profile occurs. Care must be taken to check other markers of rotation such as by clinical examination during fixation of femoral fractures and not rely solely on the LT profile.

CLINICAL RELEVANCE

In the largest study of its kind, this CT-based study of 56,826 LT profile measurements found that when the proximal femur is externally rotated, the LT profile becomes an unreliable marker of rotation, which can lead to excessive internal rotation of the distal fracture fragment. The LT profile should be used with caution, and confirmation of rotation by other means is recommended.

Individual Bilateral Difference of Femur, Tibia, and Leg Rotation: A Clinical Study of 141 Healthy Japanese Individuals Using Computed Tomography

Background The malrotation of a femur and tibial fracture after surgery has been described in many articles. However, these studies have not considered individual bilateral differences (IBDs). The IBD of femur and tibial rotation has been identified via computed tomography (CT) in recent American studies. The IBD in rotation should be considered during femur and tibial surgery. However, IBDs in femur and tibial rotation remain unknown in the Japanese population. This study aimed to evaluate the rotation of the femur, knee, tibia, and leg, sex differences, and IBD in rotation among Japanese individuals with healthy bones by using CT analysis. Materials and methods In total,141 patients who underwent CT angiography or venography were included (70 men, 71 women; mean age, 44.7 years). The bilateral axial femur, knee, tibia, and leg rotation alignment were independently measured. The distribution, sex, and IBD were analyzed. The IBD in rotation had two statistical factors: absolute bilateral difference (ABD) and relative bilateral difference (RBD). Results The mean ABD of femur rotation was 6.5°, and the distribution of ABD of femur rotation ≤15° was 95%. The mean ABD of tibia rotation was 5.1°, and the distribution of ABD of tibia rotation ≤10° was 89%. The RBD of femur rotation was not significantly different between the right and left sides. The RBD of tibia rotation showed a higher mean external rotation of 3.3° on the right side (<0.001). The Pearson correlation coefficients of the femur, knee, tibia, and leg rotation between the right and left sides were high (r= 0.702-0.81; all, p<0.001). All elements of rotation showed significant differences between men and women, whereas the ABD and RBD of all elements showed no significant difference. Conclusion The distributions of ABD in femur and tibia rotation supported the previous definition of an acceptable rotation difference between the normal and fractured femur and tibia of ≤15°and ≤10°, respectively. The possibility of higher external rotation on the right side needs to be taken into account during tibial surgery.

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

Measurement of Lag-Screw Anteversion With an iPhone During Trochanteric Fracture Surgery

Introduction  A useful way to easily evaluate femoral rotation during surgery for trochanteric fractures is not known. Hence, this pilot study aimed to develop an intraoperative indicator to evaluate anteversion in femoral trochanteric fractures. Material and methods Prospectively, from June 2021 to January 2022, all patients with femoral trochanteric fractures (Orthopaedic Trauma Association classification: 31A1-3) treated using a cephalo-medullary nail with a lag-screw neck-shaft angle of 125° were included in this study. During surgery, lag-screw anteversion (LS-AV) was measured using the goniometer application in an iPhone with the fractured femur table-top-plane level with the traction table floor. Accuracy was analyzed by comparing axial-projected lag-screw anteversion (AxP-LS-AV) and three-dimensional computed tomography lag-screw anteversion (3DCT-LS-AV) measurements after surgery. Results Fifty patients (14 males and 36 females) were included in the study. The mean age was 87 (range; 69-98) years; the Orthopaedic Trauma Association classifications were A1 (28 patients), A2 (18 patients), and A3 (4 patients). The mean LS-AV was 10.7° ± 6.9°, the mean AxP-LS-AV was 12.8° ± 8.3°, and the mean 3DCT-LS-AV was 13.1° ± 8.6°. The median difference between AxP-LS-AV and 3DCT-LS-AV was 3.0° (range: 0°-12°), and 40 (80%) patients had differences of ≤5° (Bland-Altman plot: inside of limit of agreement = 86%, paired t-test p = 0.7, Pearson correlation coefficient r = 0.817, p <0.001). Conclusion Femur malrotation is defined as a deformity of >15° relative to the normal contralateral limb. Intraoperative LS-AV iPhone measurement on table-top-plane standard had sufficient accuracy as an indicator of anteversion in femoral trochanteric fractures.

Intraoperative Comparative Femoral Rotation Imaging: Do not Overlook Parallax

OBJECTIVE

To investigate the degree of error due to parallax during intraoperative rotational imaging involving the distal femur.

METHODS

Twelve, fresh-frozen, lower-extremity cadaveric specimens were studied. The limbs were positioned supine and rotated until the posterior femoral condyles were superimposed using a C-arm. The C-arm was then repositioned to place the femoral condyles at the anterior and posterior margins of the image intensifier. The rotation necessary to resuperimpose the femoral condyles due to parallax was recorded. A second C-arm was then used from the contralateral side to simulate the rotational imaging technique to determine the magnitude and directionality of combined parallax.

RESULTS

All 12 specimens demonstrated parallax, resulting in rotational discrepancies. Compared with central field of view alignment, the mean rotational discrepancy was 5.6 and 5.5 degrees for anterior and posterior positions, respectively. Contralateral imaging resulted in an additive effect with rotational differences of 9.0 and 12.6 degrees for bilateral anterior and posterior positions, respectively.

CONCLUSIONS

Parallax causes rotational discrepancies with fluoroscopic imaging of the distal femur when the posterior femoral condyles are off-center in the imaging field of view. If femoral condyles are not centered when obtaining intraoperative rotational imaging of the uninjured and injured femurs, parallax can result in potentially clinically significant rotational deformity even if the femurs seem perfectly matched at the conclusion of surgery. We recommend perfectly centering of the posterior femoral condyles in the imaging field of view when obtaining lateral images of the distal femur to prevent this potentially overlooked contribution to malrotation.

Displaced distal femur metaphyseal fractures: clinical and radiographic outcome in children aged 6-16 years treated by elastic stable intramedullary nailing

Fractures of the distal femur metaphysis (DFM) are rare. The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced DFM fractures in children treated by elastic stable intramedullary nailing (ESIN). We retrospectively reviewed 24 DFM fractures, including five pathological fractures secondary to non-ossifying fibroma (mean age, 10.9 years; range, 6-16) who underwent surgical treatment by ESIN. The patients were followed radiographically and clinically on a regular basis. Sixteen boys and eight girls were included in the study. Radiographically, all fractures healed, but five healed with complications. Most of the DFM fractures were transverse (n = 18, 75%), and all patients but two (91.7%) underwent closed reduction and stabilization of the fracture. All the patients were pain-free at their last follow-up. All regained full normal activities, although five patients developed a postoperative complication (20.8%). At the last follow-up visit, all fractures achieved union including the two cases of nonunion; moreover, none of the patients showed any signs of growth arrest or disturbances in radiological and clinical assessment. On the ESIN outcome measure scale, 12/24 patients (50%) had excellent results, 11/24 (45.8%) had good-satisfactory results and 1/24 (4.2%) had poor results. Fracture of the DFM can be challenging due to the relatively short length of the distal fragment, the proximity of the growth plate and the tendency of the distal fragment to displace. Following the surgical principles and understanding the anatomical constraints of the distal femur help to obtain satisfactory clinical and radiological results.

"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).

Rotational malalignment in femoral nailing: prevention, diagnosis and surgical correction

Background and aim of the work:

to review and discuss the literature about rotational malalignment during and after femoral nailing.

Methods:

analysis of the literature on prevention and evaluation of rotation during femoral nailing, clinical and subjective consequences of malrotation and techniques used to correct the deformity, both in the acute and chronic phase.

Results:

malrotation is very common after femoral nailing. The exact definition of a malrotated femur is controversial, but it is widely agreed that a rotational malalignment <10° is considered normal while >30° is a deformity which requires correction. The complaints of the patients with a malrotated femur can be various and can involve the hip, the knee or below the knee. The ability to compensate for the deformity while standing and walking may decrease the symptoms. Surgical correction is feasible with many techniques and devices: the procedure involving derotation, changing the locking screws and maintaining the nail is safe, reproducible and relatively easy.

Conclusions:

prevention of malrotation during femoral nailing is the cornerstone of successful operation outcomes. If rotational malalignment is suspected, prompt diagnosis and adequate surgical treatment are mandatory to overcome this common complication. (www.actabiomedica.it)

Assessing Femoral Rotation: A Survey Comparison of Techniques

OBJECTIVES

To compare 3 common techniques for assessing femoral malrotation through a response analysis.

METHODS

Ten intact human cadaveric pelvis-to-knee specimens were used to create a fracture model. A mobile C-arm x-ray system was used to capture images of an intact control femur and a contralateral test femur on each specimen. A midshaft femoral osteotomy was created on the test femur and it was then internally and externally rotated in 5-degree intervals up to 20 degrees. Images were obtained and stored at each increment of malrotation. Eight surveys of 20-paired images each were generated and presented for surgeon review. Accuracy of predicting femoral malrotation using the true lateral technique (TLT), neck horizontal angle (NHA) method, and lesser trochanter profile (LTP) was measured.

RESULTS

Eighty-five surgeons completed a survey with 80 surgeons (94%) acknowledging the use of a described fluoroscopic method for assisting with rotational alignment. Surgeons correctly accepted a fracture rotated less than 20 degrees and rejected a fracture rotated 20 degrees or more 63% of the time. The ability to correctly identify 20 degrees of malrotation varied per technique used to assess rotation. With the LTP and NHA method, 67% of surgeons responded correctly. Surgeons performed significantly worse when using the TLT with only 53% providing correct responses (P < 0.0001).

CONCLUSIONS

Surgeons using described fluoroscopic methods to identify acceptable rotation in femoral shaft fractures are correct 63% of the time. The LTP and NHA techniques are equally reliable and more effective than the TLT at detecting clinically significant femoral malrotation.

Effect of inherent tibial asymmetry on leg length discrepancy measurements after intramedullary nailing of comminuted femoral shaft fractures

Introduction: Locked intramedullary nailing (IMN) is the standard treatment for femoral shaft fractures in adults with high rates of union and relatively low rates of complications. Leg length discrepancy (LLD) after IMN of femoral shaft fractures is common, and is reported in 20–43% of cases. A known surgical challenge when trying to obtain equal leg lengths is comminuted fracture, which results in a loss of bony landmarks that guide reduction. The purpose of this study was to assess the effect of inherent tibial asymmetry on LLD measurements after IMN.

Methods: Postoperative CT scanograms were performed on 79 consecutive patients after locked IMN for comminuted femoral shaft fracture. Leg lengths were determined by measurements taken from the scout view of a CT scanogram. Calculations of discrepancy were made for both femurs, tibias, and total leg length. Assessment was also made on the frequency wherein the tibial discrepancy compounded the femoral discrepancy. In situations where a limb segment was exactly symmetric to the contralateral side, the total leg was not regarded as a having compounded asymmetry.

Results: Notable discrepancies were found in tibial length that significantly departed from the null of symmetry (p < 0.0001). Forty-two patients (53.2%) were found to have a tibial asymmetry of 3 mm or more, and 20 patients (25.3%) were found to exhibit a difference of 6.3 mm or more. Median femoral discrepancy was 5.3 mm and median tibial discrepancy was 3.0 mm. Seven patients were found to be asymmetric in total leg length as a consequence of underlying tibial asymmetry. Conversely, 11 patients benefited from their tibial asymmetry, which compensated for femoral asymmetry after IMN.

Conclusion: Tibial symmetry cannot be assumed. If not accounted for, inherent tibial asymmetry may influence LLD after IMN of femur fractures.

Use of Inherent Anteversion of an Intramedullary Nail to Avoid Malrotation in Comminuted Femur Fractures: A Prospective Case- Control Study

OBJECTIVES

To (1) evaluate using the inherent anteversion of a second or third generation femoral nail to set the version of the femur during locked intramedullary nailing of comminuted femoral shaft fractures (Espinosa Technique [ET]) and compare it with our traditional method (traditional group [TG]) and (2) assess the variation of anteversion because of the inherent play in the nail itself.

DESIGN

A prospective IRB-approved study.

SETTING

Academic US Level 1 Trauma Center.

PATIENTS

Fifty-two consecutive patients with comminuted femur fractures all completed the study.

INTERVENTION

The first 27 patients had the anteversion determined using the patellar shadow and lesser trochanter (TG), and the next 25 patients were treated by ET.

MAIN OUTCOME MEASURE

Computed tomography scanogram for femoral anteversion and length in the normal versus operated femur.

RESULTS

A >15 degree difference from native to operated legs was found in 8/27 TG (29%, 95% CI 15.3%-54.2%), with a mean difference of 11.6 ± 10.2 degrees (95% CI 8.8-16.17) verses 1/25 in the ET group (2.5%, 95% CI 0%-15.3%), with a mean difference of 4.8 ± 6.2 degrees (95% CI 1.38-8.9) (P = 0.0068). There was a 5 degree variability in our ability to center the proximal locking screw in the femoral head and 5 degrees variation in distal locking.

CONCLUSIONS

The inherent anteversion of a second generation nail can be used to minimize malrotation of the femur after comminuted fractures during locked intramedullary nailing in patients with normal anteversion and is superior to our present fluoroscopic technique.

LEVEL OF EVIDENCE

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

Femoral malalignment after gamma nail insertion in the lateral decubitus position

Introduction: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position.

Methods: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides.

Results: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019).

Discussion: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus −valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.

Is the Lesser Trochanter Profile a Reliable Means of Restoring Anatomic Rotation After Femur Fracture Fixation?

BACKGROUND

Restoring normal femoral rotation is an important consideration when managing femur fractures. Femoral malrotation after fixation is common and several preventive techniques have been described. Use of the lesser trochanter profile is a simple method to prevent malrotation, because the profile changes with femoral rotation, but the accuracy of this method is unclear.

QUESTIONS/PURPOSES

The purposes of this study were (1) to report the rotational profiles of uninjured femora in an adult population; and (2) to determine if the lesser trochanter profile was associated with variability in femoral rotation.

METHODS

One hundred fifty-five consecutive patients (72% female and 28% male) with a mean age of 32 years (range, 12-56 years) with a CT scanogram were retrospectively evaluated. Patients were included if CT scanograms had adequate cuts of the proximal and distal femur. Patients were excluded if they had prior hip/femur surgery or anatomic abnormalities of the proximal femur. CT scanogram measurements of femoral rotation were compared with the lesser trochanter profile (distance from the tip of the lesser trochanter to the medial cortex of the femur) measured on weightbearing AP radiographs. These measurements were made by a single fellowship-trained orthopaedic surgeon and repeated for intraobserver reliability testing. Presence of rotational differences based on sex and laterality was assessed and correlation of the difference in lesser trochanter profile to the difference in femoral rotation was determined using a coefficient of determination (r).

RESULTS

The mean femoral rotation was 10.9° (SD ± 8.8°) of anteversion. Mean right femoral rotation was 11.0° (SD ± 8.9°) and mean left femoral rotation was 10.7° (SD ± 8.7°) with a mean difference of 0.3° (95% confidence interval [CI], -1.7° to 2.3°; p = 0.76). Males had a mean rotation of 9.4°(SD ± 7.7°) and females had a mean rotation of 11.5° (SD ± 9.1°) with a mean difference of 2.1° (95% CI, -0.1° to 4.3°; p = 0.06). Mean lesser trochanter profile was 6.6 mm (SD ± 4.0 mm). Mean right lesser trochanter profile was 6.6 mm (SD ± 3.9 mm) and mean left lesser trochanter profile was 6.5 mm (SD ± 4.0 mm) with a mean difference of 0.1 mm (-0.8 mm to 1.0 mm, p = 0.86). The lesser trochanter profile varied between the sexes; males had a mean of 8.3 mm (SD ± 3.4), and females had a mean of 5.9 mm (SD ± 4.0). The mean difference between sexes was 2.5 mm (1.5-3.4 mm; p < 0.001). The magnitude of the lesser trochanter profile measurement and degree of femoral rotation were positively correlated such that increasing measures of the lesser trochanter profile were associated with increasing amounts of femoral anteversion. The lesser trochanter profile was associated with femoral version in a linear regression model (r = 0.64; p < 0.001). Thus, 64% of the difference in femoral rotation can be explained by the difference in the lesser trochanter profile. Intraobserver reliability for both the femoral version and lesser trochanter profile was noted to be excellent with intraclass correlation coefficients of 0.94 and 0.95, respectively.

CONCLUSIONS

This study helps define the normal femoral rotation profile among adults without femoral injury or bone deformity and demonstrated no rotational differences between sexes. The lesser trochanter profile was found to be positively associated with femoral rotation. Increasing and decreasing lesser trochanter profile measurements are associated with increasing and decreasing amounts of femoral rotation, respectively.

CLINICAL RELEVANCE

The lesser trochanter profile can determine the position of the femur in both anteversion and retroversion, supporting its use as a method to restore preinjury femoral rotation after fracture fixation. Although some variability in the rotation between sides may exist, matching the lesser trochanter profile between injured and uninjured femora can help reestablish native rotation.

The antegrade angle-stable locking intramedullary nail for type-C distal femoral fractures: a thirty four case experience

INTRODUCTION

This is a retrospective study that provides initial experience and verifies the effectiveness of the newly-designed antegrade interlocking angle-stable intramedullary nail (IAIN) combined with half-threaded cancellous screws in the management of type-C (AO/OTA classification) distal femoral fractures.

METHODS

During a period of 30 months, 34 patients (mean age 43.1 years) with type-C (AO/OTA classification) fractures of the distal femur were treated with IAIN and half-threaded cancellous screws were reviewed. Peri-operative and post-operative parameters were analyzed.

RESULTS

All of the fractures healed in a mean time of 12.6 weeks with no incidences of malunion, nonunion or infection. No secondary failure of fixation occurred. Partial weight bearing was initiated in an average of 7.4 weeks post-operatively, with full weight bearing initiated in 13.8 weeks. All of the patients, except for one, gained full extension. The mean flexion of the knee joint was 110.1°, while the mean Hospital for Special Surgery (HSS) knee score was 85.2.

CONCLUSION

The IAIN and half-threaded cancellous screws provided a reliable fixation that facilitated uncomplicated outcomes and uneventful early mobilization in treating type-C fractures of the distal femur.

Is Contralateral Templating Reliable for Establishing Rotational Alignment During Intramedullary Stabilization of Femoral Shaft Fractures? A Study of Individual Bilateral Differences in Femoral Version

OBJECTIVES

To determine native individual bilateral differences (IBDs) in femoral version in a diverse population.

METHODS

Computed tomography scans with complete imaging of uninjured bilateral femora were used to determine femoral version and IBDs in version. Age, sex, and ethnicity of each subject were also collected. Femoral version and IBDs in version were correlated with demographic variables using univariate and multivariate regression models.

RESULTS

One hundred sixty-four subjects were included in the study. The average femoral version was 9.4 degrees (±9.4 degrees). The mean IBD in femoral version was 5.4 degrees (±4.4 degrees, P < 0.001). A total of 17.7% of subjects had a difference in version ≥10 degrees, and 4.3% had a difference in version ≥15 degrees. A femur with anteversion ≥20 degrees or retroversion was associated with a greater mean difference in version from the contralateral side compared with those with midrange anteversion.

CONCLUSIONS

Bilateral differences in femoral version are common and can result in a difference from native anatomy that may be clinically significant if only the contralateral limb is used to establish rotational alignment during intramedullary stabilization of diaphyseal femur fractures. This is also an important consideration when considering malrotation of femur fractures because most studies define malrotation as a greater than 10-15-degree difference compared with the contralateral side.

LEVEL OF EVIDENCE

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

Computer-assisted surgery: The use of stored intraoperative images for accurate restoration of femoral length and rotational alignment after fracture

Most femoral fractures are now managed with minimally invasive internal fixation. In the absence of formal exposure of the fracture lines, these procedures make heavy use of C-arm fluoroscopy to allow both fracture reduction and placement of implants, at the expense of measurable radiation exposure to both patient and surgeon. Although this technology has been commercially available for over a decade, it has not yet been widely accepted by the Orthopaedic community.

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.

[Antegrade femoral intramedullary nailing in a lateral position]

BACKGROUND

Intramedullary nailing is the gold standard for the treatment of femoral shaft fractures; however, rotational malalignment remains a common complication. The patient can be positioned on the fracture table in a supine position or alternatively in the lateral decubitus position without any traction.

OBJECTIVE

The aim of this article is to describe an effective method to control intraoperative torsion of the femur.

METHOD

The surgical technique described in this article is the standard procedure for femoral shaft fractures and subtrochanteric fractures in this level 1 trauma center. The patient is positioned in a lateral position on a radiolucent table with free draping of the injured leg. Using the C-arm, reduction can be performed with this technique with precise placing of the nails and torsion can be exactly adjusted and controlled with the aid of the femoral neck axis, the distal locking holes and both parallel femoral condyles.

RESULTS

The described technique represents an effective method for the intraoperative control of femoral torsion. With an acceptable and most probably clinically irrelevant bias, this technique is able to avoid significant rotational malalignment. It does not prolong the operative procedure and does not require additional navigation settings. It has also been shown to be helpful in the treatment of subtrochanteric fractures.

CONCLUSION

The surgical technique of anterograde intramedullary nailing using the lateral decubitus position without any traction device and free draping of the injured leg represents a safe and reliable treatment concept and offers logistical advantages compared to the supine position of the patient on a fracture table. Together with other described methods of intraoperative torsional control of femoral fractures, the radiological technique described in this study is an easily applicable and safe method, which needs to be confirmed in clinical studies.

Distal femoral complications following antegrade intramedullary nail placement

While antegrade nailing for proximal and diaphyseal femur fractures is a commonly utilized fixation method with benefits including early mobilization and high rates of fracture union, both intraoperative and postoperative complications may occur. Intraoperative errors include leg length discrepancy, anterior cortical perforation, malreduction of the fracture, and neurovascular injury, and postoperative complications include nonunion, malunion, infection, and hardware failure. This case series reviews complications affecting the distal femur after intramedullary nailing including fracture surrounding a distal femoral interlocking screw (Case #1), nonunion after dynamization with nail penetration into the knee joint (Case #2), and anterior cortical perforation (Case #3). Prevention of intraoperative and postoperative complications surrounding intramedullary nailing requires careful study of the femoral anatomy and nail design specifications (radius of curvature), consideration of the necessity of distal interlocking screws, the need for close radiographic follow-up after nail placement with X-rays of the entire length of the nail, and awareness of possible nail penetration into the knee joint after dynamization.

Application of 3D printed customized external fixator in fracture reduction

INTRODUCTION

Long bone fracture is common in traumatic osteopathic patients. Good reduction is beneficial for bone healing, preventing the complications such as delayed union, nonunion, malunion, but is hard to achieve. Repeated attempts during the surgery would increase the operation time, cause new damage to the fracture site and excessive exposure to radiation. Robotic and navigation techniques can help improve the reduction accuracy, however, the high cost and complexity of operation have limited their clinical application.

MATERIALS AND METHODS

We combined 3D printing with computer-assisted reduction technique to develop a customised external fixator with the function of fracture reduction. The original CT data obtained by scanning the fracture was imported to computer for reconstructing and reducing the 3D image of the fracture, based on which the external fixator (named as Q-Fixator) was designed and then fabricated by 3D printing techniques. The fracture reduction and fixation was achieved by connecting the pins inserted in the bones with the customised Q-Fixator. Experiments were conducted on three fracture models to demonstrate the reduction results.

RESULTS

Good reduction results were obtained on all three fractured bone models, with an average rotation of 1.21°(± 0.24), angulation of 1.84°(± 0.28), and lateral displacement of 2.22 mm(± 0.62).

CONCLUSIONS

A novel customised external fixator for long bone fracture reduction was readily developed using 3D printing technique. The customised external fixator had the advantages of easy manipulation, accurate reduction, minimally invasion and experience-independence. Future application of the customised external fixator can be extended to include the fixation function with stress adjustment and potentially optimise the fracture healing process.

Comparing femoral version after intramedullary nailing performed by trauma-trained and non-trauma trained surgeons: is there a difference?

INTRODUCTION

As with some procedures, trauma fellowship training and greater surgeon experience may result in better outcomes following intramedullary nailing (IMN) of diaphyseal femur fractures. However, surgeons with such training and experience may not always be available to all patients. The purpose of this study is to determine whether trauma training affects the post-operative difference in femoral version (DFV) following IMN.

MATERIALS AND METHODS

Between 2000 and 2009, 417 consecutive patients with diaphyseal femur fractures (AO/OTA 32A-C) were treated via IMN. Inclusion criteria for this study included complete baseline and demographic documentation as well as pre-operative films for fracture classification and post-operative CT scanogram (per institutional protocol) for version and length measurement of both the nailed and uninjured femurs. Exclusion criteria included bilateral injuries, multiple ipsilateral lower extremity fractures, previous injury, and previous deformity. Of the initial 417 subjects, 355 patients met our inclusion criteria. Other data included in our analysis were age, sex, injury mechanism, open vs. closed fracture, daytime vs. nighttime surgery, mechanism of injury, and AO and Winquist classifications. Post-operative femoral version of both lower extremities was measured on CT scanogram by an orthopaedic trauma fellowship trained surgeon. Standard univariate and multivariate analyses were performed to determine statistically significant risk factors for malrotation between the two cohorts.

RESULTS

Overall, 80.3% (288/355) of all fractures were fixed by trauma-trained surgeons. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. This difference was not statistically significant when accounting for other factors in a multivariate model (p>0.05). The same statistical trend was true when analyzing outcomes of only the more severe Winquist type III and IV fractures. Additionally, surgeon experience was not significantly predictive of post-operative version for either trauma or non-trauma surgeons (p>0.05 for both).

CONCLUSIONS

Post-operative version or percentage of DFV >15° did not significantly differ following IMN of diaphyseal femur fractures between surgeons with and without trauma fellowship training. However, prospective data that removes the inherent bias that the more complex cases are left for the traumatologists are required before a definitive comparison is made.

Femoral malrotation after intramedullary nailing in obese versus non-obese patients

OBJECTIVE

Intramedullary nailing (IMN) of obese patients with femoral fractures can be difficult due to soft tissue considerations and overall body habitus. Complications including malrotation can occur and have significant impact on postoperative function. The purpose of this study was to evaluate femoral rotation after intramedullary nailing of obese and non-obese patients to see if there was a difference in rotation, complications and any risk factors for malrotation.

MATERIALS AND METHODS

Between 2000 and 2009, 417 consecutive patients with femur fractures treated with IM nail at Level I trauma and tertiary referral center. Of these, 335 with postoperative computed tomography (CT) scanogram of the bilateral lower extremities were included in this study. Baseline demographic, perioperative and postoperative femoral version calculations were included in the dataset. Statistical analysis included chi-squared test for categorical data, t-test for continuous data, and univariate and multivariate regression analysis. Significance was set at p<0.05.

RESULTS

Of the 417 patients with femur fractures between 2000 and 2009, 335 met criteria for this study. There were 111 patients with a BMI <25, 129 with BMI 25-29.9, and 95 patients with a BMI >30. When BMI was categorised into 3 groups (<25, 25-29.9, or 30+), none of these groups were predictive of version in univariate or multivariate regressions. Among only obese patients (BMI 30+), BMI of 35+ was not a significant predictor of version when compared to BMI 30-34.9. There were no significant differences in femoral version based on entry point (antegrade vs. retrograde) in any BMI category. There were also no significant difference between groups of patients with a DFV of >15̊ (p=0.212).

CONCLUSIONS

Based on this study, BMI did not have an effect on postoperative difference in femoral version. In fact, in our multivariate regression analysis, BMI of over 30 was actually predictive of significantly lower difference in femoral version. While other studies have documented the intraoperative difficulties encountered with obese patients with femur fractures, the outcome of femoral rotation is not affected by an increasing BMI.

Integration of fluoroscopy-based guidance in orthopaedic trauma surgery - a prospective cohort study

INTRODUCTION

Computer-assisted guidance systems are not used frequently for musculoskeletal injuries unless there are potential advantages. We investigated a novel fluoroscopy-based image guidance system in orthopaedic trauma surgery.

MATERIALS AND METHODS

The study was a prospective, not randomised, single-centre case series at a level I trauma centre. A total of 45 patients with 46 injuries (foot 12, shoulder 10, long bones seven, hand and wrist seven, ankle seven and spine and pelvis four) were included. Different surgical procedures were examined following the basic principles of the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF). Main outcome measurements were the number of trials for implant placement, total surgery time, usability via user questionnaire and system failure rate.

RESULTS

In all cases, the trajectory function was used, inserting a total of 56 guided implants. The system failed when used in pelvic and spinal injuries, resulting in a total failure rate of 6.5% (n=3) of all included cases. The overall usability was rated as good, scoring 84.3%.

CONCLUSION

The novel image-guidance system could be integrated into the surgical workflow and was used successfully in orthopaedic trauma surgery. Expected advantages should be explored in randomised studies.

Impact of specialty and level of training on CT measurement of femoral version: an interobserver agreement analysis

BACKGROUND

To determine the interobserver agreement on femoral version measurements between an orthopedic attending, orthopedic senior and junior residents, and an attending radiologist.

MATERIALS AND METHODS

Postoperative computed tomography (CT) scanograms of 267 patients who underwent femoral intramedullary (IM) nailing with corresponding radiology attending reads for femoral version were collected and de-identified. Femoral version measurements performed by a trauma fellowship-trained attending orthopedic surgeon (ORTHO), a senior orthopedic resident (PGY4), a junior orthopedic resident (PGY1), and a musculoskeletal fellowship-trained attending radiologist (RADS) were compared via Pearson's interclass correlation coefficient to assess interobserver level of agreement.

RESULTS

Version measurements provided by the two attending physicians exhibited the highest level of agreement (r = 0.661, p < 0.01). The orthopedic attending and the senior resident had the next highest level of agreement (r = 0.543, p < 0.01). The first-year orthopedic resident had the weakest agreement across the board: with the orthopedic attending, the radiology attending, and the senior resident.

CONCLUSION

Regardless of specialty, experience and higher levels of training produce stronger agreement when measuring femoral version. Residents in training, especially those who are junior, produce weak agreement when compared to their senior colleagues.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Rotational malalignment after closed intramedullary nailing of femoral shaft fractures and its influence on daily life

BACKGROUND

Any intraoperative rotational malalignment during intramedullary nailing (IMN) of femoral shaft fractures will become permanent. We hypothesized that rotational malalignment of the femur and its compensatory biomechanics may induce problems in the hip, knee, patellofemoral and ankle joints. We purposed to clarify the influence of a femoral rotational malalignment of ≥10° on daily activities.

METHODS

Twenty-four femoral shaft fracture patients treated with closed antegrade IMN were included. At last follow-up, to reveal any rotational malalignment, computerized tomography (CT) scans of both femurs (injured and uninjured sides) were examined. The patient groups with or without CT-detected true rotational malalignment ≥10° were compared with respect to the activity scores.

RESULTS

Ten of the 24 patients (41.7%) had a CT-detected true rotational malalignment of ≥10° compared with the unaffected side. The AOFAS scores were 100.00 for all of the patients. LKS, WOMAC knee, and WOMAC hip scores were significantly decreased in the patients with rotational malalignment compared to those without. Patients without rotational malalignment tolerated climbing stairs significantly better than those with rotational malalignment. Patients who could not tolerate climbing stairs were consistently complaining of anterior knee pain.

CONCLUSIONS

A femoral rotational malalignment of ≥10° is symptomatic for the patients, and the hip, knee, and patellofemoral joints were affected. Because of the possibly altered joint loadings and biomechanics, these could render patients prone to degenerative joint disease. In addition, due to the high rates of rotational malalignment after femoral shaft fracture and consequent malpractice claims, it is important for surgeons to be more aware of rotational alignment during surgery.

Femoral version of the general population: does "normal" vary by gender or ethnicity?

OBJECTIVE

The purpose of this study was to compare various gender and ethnic groups to characterize differences in baseline version and rates of retroversion.

DESIGN

Retrospective.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Between 2000 and 2009, 417 consecutive patients with femur fractures were treated with an intramedullary nail at level I trauma and tertiary referral center. Of these, 328 with computed tomography scanogram of the normal, uninjured contralateral femur were included in this study.

MAIN OUTCOME MEASUREMENTS

Femoral version.

RESULTS

The mean alignment for the all patients was 8.84 ± 9.66° of anteversion. There were no statistically significant differences in mean version between African American, white, and Hispanic patients for males or females. Although there were also no significant differences in rates between ethnicities, retroversion was found to be common in white males (21.4%), African American males (15.1%), and all groups of females (>14.3%). Furthermore, nearly 6% of both African American males and females exhibited >10° retroversion.

CONCLUSIONS

Although there may not be a significant difference in average femoral version between ethnic and gender groups, retroversion is relatively common, and retroversion >10° was observed in nearly 6% of the African American population. This may have important implications in proper alignment restoration and successful clinical outcomes after intramedullary nailing of femur fractures.

Distal femur fractures. Surgical techniques and a review of the literature

Fractures of the distal femur are rare and severe. The estimated frequency is 0.4% with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak for men in their 30s and a peak for elderly women; however, at present it is found predominantly in women and in the elderly with more than 50% of patients who are over 65. The most common mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing. The anatomy of the distal femur explains the three major types of fracture. Because of the anatomy of the distal femur, only surgical treatment is indicated to stabilize the fracture. A non-surgical treatment is a rare option. The aim of this report was to provide an update on the existing surgical solutions for the management of these fractures and describe details of the surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical data published in the literature are reported to compare different surgical options.

Computer navigation in the reduction and fixation of femoral shaft fractures: a randomized control study

OBJECTIVES

We investigated the accuracy of reduction of intramedullary nailed femoral shaft fractures in human cadavers, comparing conventional and computer navigation techniques.

METHODS

Twenty femoral shaft fractures were created in human cadavers, with segmental defects ranging from 9 to 53 mm in length (Winquist 3-4, AO 32C2). All fractures were fixed with antegrade 9 mm diameter femoral nails on a radiolucent operating table. Five fractures ("Fluoro" group) were fixed with conventional techniques and fifteen fractures ("Nav 1" and "Nav 2" groups) with computer navigation, using fluoroscopic images of the normal femur to correct for length and rotation. Postoperative CT scans compared femoral length and rotation with the normal leg.

RESULTS

Mean leg length discrepancy in the computer navigation groups was smaller, namely, 3.6 mm for Nav 1 (95% CI: 1.072 to 6.128) and 4.2 mm for Nav 2 (95% CI: 0.63 to 7.75) vs. 9.8 mm for Fluoro (95% CI: 6.225 to 13.37) (p<0.023). Mean rotational discrepancies were 8.7° for Nav 1 (95% CI: 4.282 to 13.12) and 5.6° for Nav 2 (95% CI: -0.65 to 11.85) vs. 9.0° for Fluoro (95% CI: 2.752 to 15.25) (p=0.650).

CONCLUSIONS

Computer navigation significantly improves the accuracy of femoral shaft fracture fixation with regard to leg length, but not rotational deformity.

The use of a ti-ni shape memory alloy ring bone fixator during the retrograde nailing of supracondylar femoral fractures

Purpose

To identify the effects of using a Ti-Ni shape memory alloy ring shaped bone fixator (SMA-rBF) during the retrograde nailing of supracondylar femoral fractures.

Materials and Methods

The authors reviewed 25 patients with a supracondylar femoral fracture treated by retrograde intramedullary nailing with or without SMA-rBF (group S, 12/25; group N, 13/25). Radiological measurements of angular deformity were performed and functional assessments were made using the Sanders grading system.

Results

All fractures healed after an average of 12.2 weeks (range, 9-15 weeks) in group N and after 11.6 weeks (range, 10-13 weeks) in group S (p=0.351). The mean angle of coronal angular deformity was valgus 0.8° (range, varus 2.3°-valgus 4.5°) in group N and valgus 0.7° (range, varus 1.0°-valgus 2.4°) in group S (p=0.892). The mean angle of sagittal angular deformity was 1.0° in extension (range, flexion 3.2°-extension 3.1°) in group N and 0° (range, flexion 2.1°-extension 1.2°) in group S (p=0.022). However, functional grading evaluations revealed no differences between the two groups.

Conclusions

When reduction of a distal femoral fracture with retrograde nailing was difficult additional mini-open reduction and fixation with a ring shaped SMA did not delay or prevent bony union and resulted in good postoperative alignment.

Navigation in femoral-shaft fractures--from lab tests to clinical routine

INTRODUCTION

This study evaluates the use of a navigation system (BrainLAB, Feldkirchen, Germany) to intra-operatively check for correct length, axis and rotation in intramedullary nailing of femoral-shaft fractures in an experimental setting and in clinical routine.

MATERIALS AND METHODS

We tested the navigation system in two experimental settings before introducing it into clinical routine. In the first experiment, 10 osteotomised model femora were fixed with intramedullary nails by using a navigation system. The goal was a locking fixation in predefined values for length and rotation. In the second experiment, eight examiners assessed values for rotation and length of one femur 10 times to examine the accuracy and reproducibility of that determination. Following this, we navigated 40 femoral nailing procedures in our department. Preoperatively, we assessed values of femur geometry on the contralateral side in a computed tomography (CT) scan and reproduced these values intra-operatively on the fractured side, guided by the navigation system. During the intervention, we recorded the length of the procedure steps and the fluoroscopy time. We verified the intra-operative values achieved with the navigation system in a postoperative CT scan and documented differences in rotation and length. After the assessment, we analysed the data for different findings on femur geometry, fluoroscopy time and procedure duration.

RESULTS

The experimental evaluation showed a range of ±5° for anteversion differences and ±2.3 mm for length differences. We estimated this accuracy as sufficient to use the system in clinical routine. The navigation system was used for 40 fracture fixations. All our criteria for restoring femoral geometry could be achieved by navigation guidance in these procedures. Setting up the system took on average 33±11.5 min. An additional fluoroscopy time of 36±22 s was needed to acquire the reference X-rays and to verify pin placement. The differences between anteversion values assessed in intra-operative planning steps on the navigation system and values assessed with a postoperative CT were on average 5.4±3.5°, whilst femur length differed on average by 4±4 mm.

DISCUSSION

Many authors judge intra-operative control of anteversion in femoral-shaft fracture fixation as problematic. Neither our experimental navigation assessment nor our clinical navigated evaluation showed relevant anteversion differences to a postoperative CT assessment of femur geometry. After initial training, guidance by a navigation system achieves consistent results in a clinical situation.

CONCLUSIONS

The use of a navigation system to align axis, length and rotation led to a secure way of avoiding any relevant malalignment in complex femur-shaft fractures whilst exposing patients to an acceptable amount of additional procedure sequences. Malalignment can be avoided by using a navigation system in the operative treatment of femoral-shaft fractures and may be integrated into clinical routine in specialised centres.

Femoral malrotation following intramedullary nail fixation

Intramedullary nailing of femoral shaft fracture can result in inadvertent malalignment. Malrotation is the most common cause of deformity, but it is underrecognized, in part because of the difficulty in accurately assessing rotation as well as the variation that exists in normal anatomy. The consequences of femoral malrotation are not completely understood. However, initial biomechanical studies suggest that it causes a substantial change in load bearing in the affected extremity. Clinical examination, fluoroscopy, and ultrasonography are useful in measuring femoral rotational alignment intraoperatively and postoperatively. CT is useful in the identification of the degree of malrotation and in surgical planning.

How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe

BACKGROUND

The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA).

METHODS

Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05).

RESULTS

Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values.

CONCLUSIONS

Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.

Comparison of knee function after antegrade and retrograde intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation

OBJECTIVE

To evaluate knee function in patients having femoral diaphyseal fractures treated with antegrade or retrograde intramedullary nail insertion.

DESIGN

Prospective.

SETTING

Level I referral center.

PATIENTS AND METHODS

Seventy patients having 71 OTA 32 fractures were randomly allocated into 2 groups to be treated with either antegrade or retrograde intramedullary nails inserted with reaming.

INTERVENTION

Antegrade nail in 41 fractures and retrograde femoral intramedullary nails in 30 fractures.

MAIN OUTCOME MEASURES

Postoperative knee range of motion, Lysholm Knee Score, and isokinetic knee muscle function testing at least 6 months after documented fracture healing, minimum 1 year postoperatively.

RESULTS

Groups had similar data with regard to demographics and injury patterns. Mean follow-up time was 44 (range: 25-80) months. Mean knee flexion angle was 132 and 134 degrees, and mean Lysholm Score was 84 and 83.1 in antegrade and retrograde groups, respectively (P = 0.893 and P = 0.701). Isokinetic evaluation revealed similar results for peak torque deficiencies at 30 and 180 degrees per second and total work deficiencies at 180 degrees per second (P > 0.05). Age affected the knee functioning as the higher the age of the patient is, the lower the Lysholm Score and knee flexion angle (r = -0.449, P = 0.0321 and r = -0.568, P = 0.001, respectively).

CONCLUSIONS

Knee function seems to have similar clinical results after either antegrade or retrograde nail insertion for femoral diaphyseal fractures when knee range of motion, Lysholm Scores, and isokinetic knee evaluation are considered as outcome measures. With increasing patient age, a decrease in knee functioning should be anticipated in patients with femoral fractures treated with intramedullary nails regardless of technique.

Navigated femoral nailing using noninvasive registration of the contralateral intact femur to restore anteversion. Technique and clinical use

The difficulty in assessing femoral rotation during intramedullary nailing is well-established. Navigation systems allow the surgeon to detect and set the version of the injured leg at the desired angle. We report the first cases of navigated femoral nailing using noninvasive registration of the contralateral uninjured leg to determine the patient's anatomy. This allows the desired femoral rotation, which is that of the healthy femur, to be statically locked to precisely match the contralateral limb.