Analysis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures

Early outcome measurement of the effectiveness of conventional physical therapy versus continuous passive motion in knee function following retrograde femoral nailing-a prospective randomized controlled trial

PURPOSE

This study evaluated the efficacy of continuous passive motion (CPM) versus conventional physical therapy (CPT) in the early postoperative period following retrograde femoral nailing (RFILN). Based on the principles of operation of CPM, we hypothesized that it would improve knee function and decrease pain after open reduction and internal fixation with a retrograde femoral interlocking nail.

PATIENTS AND METHODS

Eighty-eight patients over the age of 18 years who met the inclusion criteria got randomized into one of two groups. The experimental group had CPM, while the control group had CPT. Postoperative knee functions assessed were the degree of knee stiffness, the total arc of motion, and knee pain. Knee stiffness, defined as the range of motion ≤ 90° assessed one week, two weeks, and six weeks postoperatively, while knee pain was measured using the visual analog scale (VAS) on days one, two, three, four, five, six and seven postoperatively.

RESULTS

The CPM group had a significantly lower incidence of knee stiffness at one week, two weeks, and six weeks postoperatively than the CPT group (all p < 0.0001). The VAS scores of the CPM group on days one, two, three, four, five, six and seven were significantly lower than those of the CPT group (p < 0.006 for day one and p < 0.001 for the remaining days). Similarly, the total arc of motion gained postoperatively was significantly greater in the CPM group than in the CPT (all p < 0.001).

CONCLUSION

The continuous passive motion effectively reduced the number of patients with knee stiffness and knee pain. It increased the total arc of motion in the early postoperative period compared to CPT. Therefore, we recommend CPM for patients undergoing retrograde femoral nailing use in the early postoperative period.

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

Background

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

Methods

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

Results

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

Conclusion

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

Initial definitive treatment of open femoral shaft fractures with retrograde nailing - is it safe? A retrospective analysis comparing antegrade to retrograde nailing

INTRODUCTION

Treatment of severe open femoral fractures with retrograde intramedullary nailing, raises concerns of septic arthritis of the knee due to its intra-articular entrance point. There is little evidence concerning the safety of retrograde femoral nailing (RFN) usage in these cases, and what evidence there is does not necessarily include severe open fractures. Furthermore, the outcome of ballistic injuries treated in this manner and a comparison with antegrade femoral nailing (AFN), is yet to be established. The aim of this study was to examine the outcome of primary retrograde femoral nailing in high-grade open fractures and compare our results with similar fractures treated with AFN.

PATIENTS AND METHODS

A retrospective analysis of treated high-grade open femoral fractures, was performed at an academic level one trauma centre between 2006 and 2016. Included were all open femur shaft fractures treated with either RFN or AFN as primary fixation. We analysed both patient groups and compared outcomes including the infection rate, non-union rate and secondary interventions. Presence of knee pain and long-term function, was evaluated using the Short-Form 12 (SF-12) questionnaire.

RESULTS

Forty-nine patients with open femoral shaft fractures whose primary treatment was intramedullary nailing (IMN), were included in the cohort. Thirty patients were treated with RFN and 19 with AFN. No septic arthritis of the knee was detected in either group. One patient in the RFN group and two in the AFN had a deep surgical wound infection. Excluding reoperations for locking screw removal due to local irritation, the reoperation rate was 22% with two patients treated for non-union in the RFN group and two in the AFN. When comparing outcome measures, including SF-12 scores and the reported knee pain rates of AFN and RFN groups, no significant differences were observed.

CONCLUSION

Our study showed that retrograde femoral nailing as initial definitive treatment in high-grade open femoral shaft fractures, resulted neither in septic arthritis of the knee nor in an unacceptable infection rate. General outcomes regarding complications and reoperations, was similar to antegrade femoral nailing performed in our centre for similar injuries.

A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular

Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

Dilemma of Supra- or Infrapatellar Tibial Nailing: Anterior Knee Pain vs. Intra-Articular Damage

AIM

Intramedullary nailing (IMN) is widely accepted as the treatment of choice for tibial fractures, and a suprapatellar method has been described to prevent common problems associated with the typical infrapatellar IMN technique, such as anterior knee pain. However, in the suprapatellar technique, injury to intra-articular structures is a concern. The aim of this study was to compare the clinical and radiological results of suprapatellar and infrapatellar IMN in terms of union, complications, and function.

METHODS

A retrospective evaluation of 61 patients who had undergone suprapatellar (n = 29, Group A) or infrapatellar (n = 31, Group B) tibial IMN was conducted. For the suprapatellar group, magnetic resonance imaging scans were acquired on the sixth month follow-up. Complications, radiological findings, functional outcomes, surgery duration, and differences in a range of motion (ROM) were compared.

RESULTS

Surgery duration was significantly shorter in Group A (81 mins vs. 107 mins, p < 0.001), and visual analog scale (VAS) values were significantly higher in Group B (0.17 vs. 1.62, p < 0.001). In Group A, the patients' Lysholm scores were significantly higher (95.6 vs. 92, p=0.006). In terms of anterior knee pain, none was experienced in Group A (0%), while 11 patients (26.1%) reported about it in Group B. There were no statistically significant differences between the two groups in SF-36 score (p=0.925), the radiographic union scale in tibial (RUST) fractures score (p=0.454), union time (p=0.110), or ROM (p=0.691). In Group A, two cases of patellofemoral cartilage degeneration were observed.

CONCLUSION

If performed with sufficient expertise, the suprapatellar IMN technique is a safe, reliable technique with a low frequency of anterior knee pain for treating tibial fractures. There is no clear evidence that it causes damage to intra-articular structures. The possibility of patellofemoral cartilage degeneration due to this technique should be further evaluated by prospective studies including pre- and postoperative radiologic assessments.

ANTEGRADE X RETROGRADE NAILING IN FEMORAL FRACTURES: A STUDY ON CONSOLIDATION AND INFECTION

Objective:

Osteosynthesis with intramedullary nailing is considered the method of choice to treat diaphyseal femur fractures in adults. The objective of this retrospective study was to evaluate the bone healing time and incidence of infection in patients with diaphyseal femur fractures treated surgically with retrograde and antegrade intramedullary nailing.

Methods:

The medical records of 123 patients from two university hospitals dated 2011-2013 were evaluated, with 126 diaphyseal femur fractures having been found. The most frequent treatment was antegrade intramedullary nailing (51%), of which 38% involved reaming (n=25).

Results:

We found evidence of 92% healed fractures at 12 months postoperatively. Complications included chronic osteomyelitis in one patient and femoral neck fracture in another patient, both after reamed antegrade nailing. Pyoarthritis of the knee associated with osteomyelitis affected two patients after reamed retrograde nailing and one patient after unreamed retrograde nailing.

Conclusion:

We did not observe a significant difference in bone healing rates with the use of reamed or unreamed antegrade or retrograde nailing. Complications included the presence of infection with an incidence similar to that reported in the literature, and of particular significance, unrelated to the type of approach. Level of evidence III, Retrospective comparative study.

Suprapatellar Tibial Nailing

The suprapatellar nailing technique is an important adjunct in the armamentarium of an orthopedic surgeon. Although a variety of new instrumentations are required for insertion of the suprapatellar nail, most companies now carry these instruments. Easier positioning, maintenance of reduction, ease of intraoperative fluoroscopy, more anatomic starting trajectory, decreased malreduction rates, and possible decrease in anterior knee pain are all benefits of suprapatellar nailing, thus making mastery of this technique essential for an orthopedic surgeon.

Is staged management with immediate conversion of external fixation to retrograde intramedullary nailing for combat-related Gustilo Type III supracondylar femur fractures safe and reliable method?

INTRODUCTION

Femur fractures due to bomb explosions and gunshots in battlefield require osseous stabilization as quickly as possible to expedite emergent conditions. İmmediate external fixation is the initial procedure as usual with planned early conversion to definitive treatment. The purpose of the current study is to determine the results of the early retrograde intramedullary nailing in combat-related injuries.

MATERIAL AND METHODS

Eighteen patients with comminuted supracondylar femur fractures, initially treated with external fixation followed by planned conversion to retrograde intramedullary nailing in a one-stage procedure, were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis.

RESULTS

According to the system of Gustilo Anderson and Orthopedic Trauma Association, all fractures were open type III and 33-A3, respectively. The mean follow-up, operation time and union time were 1.8 years (range, 6 months to 2,6 years), 75 min (range, 60-100), and 3 months (range, 1.5-4), respectively. There was one complication of acute osteomyelitis which was successfully treated with antibiotic-load beams and aggressive bone debridement. No septic arthritis was observed.

CONCLUSIONS

We concluded that immediate retrograde intramedullary nailing in combat-related supracondylar femur fractures regardless of contamination even in Gustilo type III is a safe and reliable treatment method.

Incidence of deep infection, union and malunion for open diaphyseal femoral shaft fractures treated with IM nailing: A systematic review

BACKGROUND

and purpose: We have undertaken a systematic review to evaluate the clinical results of intramedullary nailing (IMN) for open diaphyseal femoral fractures on the rates of union, delayed union, malunion, superficial and deep infection and bone grafting.

METHODS

We searched the electronic databases of EMBASE, MEDLINE, from their inception until December 1st, 2017 with no language restrictions. The reference lists of all included articles and relevant reviews were also examined for potentially eligible studies. Hand search using electronic database of recent major orthopaedic journals was also carried. Two reviewers working independently extracted study characteristics and data to estimate the diagnostic odds ratio and 95% confidence interval for each result.

RESULTS

Seventeen studies were eligible. Pooled estimate of effect size for union rate was 97% (95% CI: 94-99%). Deep infection rate was 6% (95% CI: 3-9.3%) and more prominent in Gustilo type III injuries; superficial infection was 5.6% (95% CI: 3-9.3%). Delayed union rate 3% (95% CI: 1-5.6%) while, malunion rate was 8.4% (95% CI: 5.7-11.6%). The need for bone grafting ranged from 0 to 9%.

CONCLUSIONS

IMN remains the treatment of choice for open femoral diaphyseal fractures with very good union rates. Gustilo grade III injuries demonstrate a distinct higher deep infection rate and strict adherence to established surgical debridement and fixation protocols is advocated. The need for bone grafting can be as high as 9% and patients should be made aware of the possibility of requiring this additional procedure.

Risk of Knee Sepsis After Treatment of Open Tibia Fractures: A Multicenter Comparison of Suprapatellar and Infrapatellar Approaches

OBJECTIVES

The suprapatellar approach for medullary nailing of the tibia is increasing. This requires intra-articular passage of instruments, which theoretically places the knee at risk of postoperative sepsis in the setting of open fracture. We hypothesized that the risk of knee sepsis is similar after suprapatellar or infrapatellar nailing of open tibia fractures.

DESIGN

Retrospective, multicenter.

SETTING

Three urban level 1 trauma centers.

PATIENTS

All patients treated with medullary nailing for open diaphyseal tibia fractures (OTA 42) from 2009 to 2015. Patients younger than 18 years of age and with less than 12 weeks of follow-up were excluded. We identified 289 fractures in 282 patients.

INTERVENTION

Suprapatellar (SP) or infrapatellar (IP) medullary nailing of open tibia fractures.

MAIN OUTCOME MEASUREMENT

Occurrence of ipsilateral knee sepsis, defined as presence of a positive culture from knee aspiration or arthrotomy. Deep infection requiring operative debridement, superficial infection requiring antibiotic therapy alone, and all-cause reoperation were also recorded.

RESULTS

IP nailing was used for 142 fractures. There were 20 infections (14.1%), of which 14 (9.8%) were deep. Fourteen tibias (9.8%) required reoperation for noninfectious reasons for 28 total reoperations (19.7%). SP nailing was used in 147 fractures. There were 24 infections (16.2%), of which 16 (10.8%) were deep. Fourteen additional tibias (9.5%) required reoperation for noninfectious reasons for a total of 30 reoperations (20.4%). There were no differences in the rates of infection, deep infection, or reoperation between groups. There were 2 cases of knee sepsis after SP nailing (1.4%) but zero cases after IP nailing (P = 0.5).

CONCLUSIONS

There was no significant difference in the rate of knee sepsis with SP or IP approaches. The risk of knee sepsis after SP nailing of open fractures is low, but present.

LEVEL OF EVIDENCE

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

No Incidence of Postoperative Knee Sepsis With Suprapatellar Nailing of Open Tibia Fractures

OBJECTIVE

To evaluate the incidence of knee sepsis after suprapatellar (SP) nailing of open tibia fractures.

DESIGN

Retrospective; Setting: ACS level 1 trauma center.

PATIENTS/PARTICIPANTS

We reviewed 139 open tibia fractures that underwent SP nailing as definitive treatment over a 5-year period (January 1, 2011 to January 1, 2016). Most patients (90%, n = 126) underwent intramedullary nailing at the time of their initial surgery. We defined knee sepsis as intra-articular infection requiring operative debridement, either open or arthroscopically, within 1 month's time.

INTERVENTION

Open tibia fractures treated with an SP tibial nail.

MAIN OUTCOME MEASUREMENTS

Demographic data, fracture characteristics, Gustilo and Anderson classification of open fractures, and occurrence of knee sepsis.

RESULTS

In 139 open tibia fractures, there were no cases of knee sepsis in the 30 days after treatment with an SP intramedullary nail. Eighty-seven percent of our cohort had Gustilo and Anderson type II (41%) or type III (46%) open fractures. Most open fractures (83%) underwent primary wound closure during the index procedures. Twenty-five limbs (18%) had evidence of infection at the open fracture site of their open fracture necessitating operative intervention and/or antibiotics: none, however, developed knee sepsis.

CONCLUSIONS

Although the SP approach carries intra-articular risks, we found a low risk of knee sepsis using this technique in the treatment of open tibia fractures. Our data suggest that there is no greater risk of intra-articular infection using an SP portal as compared with an infrapatellar one.

LEVEL OF EVIDENCE

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

Retrograde versus antegrade intramedullary nailing of gunshot diaphyseal femur fractures

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of retrograde femoral intramedullary nail placement through traumatic knee arthrotomies

OBJECTIVES

To analyze the rate of postoperative infection after retrograde femoral nail placement in the setting of traumatic knee arthrotomy (KA).

DESIGN

Retrospective.

SETTING

Level-I trauma center.

PATIENTS

A review of all adult femur fractures (N = 1748) treated with an intramedullary nail over a 10-year period identified 34 retrograde nails with traumatic KA as the study group and 23 antegrade nails with traumatic KA as a control group. The retrograde femoral traumatic KA group was also compared with a 4:1 matched control group of 136 patients with retrograde femoral nails without traumatic KA.

INTERVENTION

Retrograde femoral nail placement with traumatic KA.

MAIN OUTCOME MEASUREMENTS

Occurrence of postoperative infection.

RESULTS

The traumatic KA groups treated with retrograde and antegrade femoral nails were similar across all recorded patient variables. No infections occurred in the retrograde traumatic KA group versus 1 infection (4.3%) in the antegrade traumatic KA group (P = 0.404). Four nonunions (11.8%) occurred in the retrograde traumatic KA group versus 1 nonunion (4.3%) in the antegrade traumatic KA group (P = 0.638). The matched control group of retrograde nails did not significantly differ when compared with the retrograde traumatic KA group for infection or nonunion (P = 1.000 and 0.261).

CONCLUSIONS

This is the first study to investigate retrograde nail placement through traumatic KA with comparison to control groups, with no differences found in infection rates. Furthermore, no infections (knee or fracture) occurred in those patients who were treated using a retrograde femoral nail with traumatic KA. This study documents the relative safety associated with retrograde femoral nailing in the setting of a concurrent traumatic KA with surgical debridement.

[Knee joint infections]

Knee joint infection represents an emergency case at every age. Joint infection occurs frequently after trauma or joint surgery. The infection can be caused by numerous bacteria, viruses, or yeasts; however, Staphylococcus aureus is identified as the cause in 85-95 % of joint infections. Early treatment is important for patient outcome. In addition to synovectomy and therapeutic arthroscopy, antibiotic therapy is essential and should be started after sample recovery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV, case series.

Risk of septic knee following retrograde intramedullary nailing of open and closed femur fractures

Background

One potential complication of retrograde femoral nailing in the treatment of femur fractures is the risk of septic knee. This risk theoretically increases in open fractures as a contaminated fracture site has the potential to seed the instrumentation being passed in and out of the sterile intraarticular starting point. There are few studies examining this potential complication in a relatively commonly practiced technique.

Methods

All patients who received a retrograde femoral nail for femur fracture between September 1996 and November 2006 at a Level 1 trauma center were retrospectively reviewed. This yielded 143 closed fractures, 38 open fractures and 4 closed fractures with an ipsilateral traumatic knee arthrotomy. Patient follow-up records were reviewed for documentation of septic knee via operative notes, wound culture or knee aspirate data, or the administration of antibiotics for suspected septic knee.

Results

No evidence of septic knee was found in the 185 fractures examined in the dataset. Utilizing the Wilson confidence interval, the rate of septic knee based on our population was no greater than 2%, with that of the open fracture group alone being 9%.

Conclusions

Based on these results and review of the literature, the risk of septic knee in retrograde femoral nailing of both open and closed femoral shaft fractures appears low but potentially not insignificant.

Funding

There was no outside source of funding from either industry or other organization for this study.