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Kumar P, Neradi D, Kansal R, Aggarwal S, Kumar V, Dhillon MS. Greater trochanteric versus piriformis fossa entry nails for femur shaft fractures: Resolving the controversy. Injury 2019; 50:1715-1724. [PMID: 31358301 DOI: 10.1016/j.injury.2019.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Prasoon Kumar
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
| | - Deepak Neradi
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
| | - Rohit Kansal
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
| | - Sameer Aggarwal
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
| | - Vishal Kumar
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
| | - Mandeep Singh Dhillon
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
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Labronici PJ, Dos Santos Filho FC, Pires RES, Wajnsztejn A, Hungria JOS, Gameiro VS, da Silva LHP. Where is the true location of the femoral piriform fossa? Injury 2016; 47:2749-2754. [PMID: 28340942 DOI: 10.1016/j.injury.2016.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/23/2016] [Accepted: 10/17/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Pedro José Labronici
- Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil; Faculdade de Medicina de Petrópolis (FMP), Petrópolis, RJ, Brazil.
| | | | | | - André Wajnsztejn
- Trauma and Walk-in Clinic Team, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - José Octavio Soares Hungria
- Trauma Team, Department of Orthopedics and Trauma, Irmandade de Misericórdia da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | | | - Luiz Henrique Penteado da Silva
- Department of Trauma, Member of Pelvic and Hip Surgery Team, Instituto de Ortopedia e Traumatologia (IOT), Hospital do Trauma, Hospital Escola São Vicente Paula, Passo Fundo, RS, Brazil
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Sheth U, Gohal C, Chahal J, Nauth A, Dwyer T. Comparing Entry Points for Antegrade Nailing of Femoral Shaft Fractures. Orthopedics 2016; 39:e43-50. [PMID: 26709564 DOI: 10.3928/01477447-20151218-09] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 05/18/2015] [Indexed: 02/03/2023]
Abstract
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.
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The effect of antegrade femoral nailing on femoral head perfusion: a comparison of piriformis fossa and trochanteric entry points. Arch Orthop Trauma Surg 2015; 135:473-80. [PMID: 25708026 DOI: 10.1007/s00402-015-2169-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Indexed: 10/24/2022]
Abstract
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.
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Sikka R, Fetzer G, Hunkele T, Sugarman E, Boyd J. Femur fractures in professional athletes: a case series. J Athl Train 2015; 50:442-8. [PMID: 25680071 DOI: 10.4085/1062-6050-49.5.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Joglekar SB, Lindvall EM, Martirosian A. Contemporary management of subtrochanteric fractures. Orthop Clin North Am 2015; 46:21-35. [PMID: 25435032 DOI: 10.1016/j.ocl.2014.09.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cephalomedullary interlocking nails that allow for trochanteric entry and minimally invasive fixation have revolutionized the contemporary management of subtrochanteric fractures with improved union rates and decreased incidence of fixation failure. The most successful alternative to intramedullary fixation remains the angled blade plate. Despite biomechanical superiority of contemporary intramedullary implants to previous intramedullary devices, the importance of achieving and maintaining satisfactory fracture reduction prior to and during hardware insertion cannot be overemphasized. In comminuted and more challenging fractures, additional techniques, such as limited open reduction with clamps and/or cables, can allow for canal restoration and more anatomic reductions prior to and/or during nail insertion.
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Affiliation(s)
- Siddharth B Joglekar
- VAMC Fresno, 2615 East Clinton Avenue, Fresno, CA 93730, USA; UCSF Fresno, 2823 Fresno Street, Fresno, CA 93721, USA.
| | - Eric M Lindvall
- UCSF Fresno, 2823 Fresno Street, Fresno, CA 93721, USA; Department of Orthopedic Surgery, CRMC Fresno, 2823 Fresno Street, Fresno, CA 93721, USA
| | - Armen Martirosian
- UCSF Fresno, 2823 Fresno Street, Fresno, CA 93721, USA; Department of Orthopedic Surgery, CRMC Fresno, 2823 Fresno Street, Fresno, CA 93721, USA
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Ansari Moein CMS, Gerrits PD, ten Duis HJ. Trochanteric fossa or piriform fossa of the femur: time for standardised terminology? Injury 2013; 44:722-5. [PMID: 23026115 DOI: 10.1016/j.injury.2012.08.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 08/29/2012] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- C M S Ansari Moein
- Department of Surgery and Traumatology, University Medical Centre Groningen, The Netherlands.
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Abstract
OBJECTIVES This study was performed to determine (1) the incidence of humeral shaft fractures within the Medicare noncancer population, (2) the trends in utilization of humeral shaft fixation techniques by plate-and-screw devices and intramedullary nails, (3) differences in procedure times, and (4) the outcomes of individuals as measured by rate of secondary operations and 1-year mortality. DESIGN/SETTING Retrospective comparative cohort analysis. A cancer-free Medicare part B claims sample derived from a 5% sample from the years 1993 to 2007 was analyzed. PATIENTS/INTERVENTION Our cohorts were generated by diagnostic and procedural codes for humeral shaft fractures. MAIN OUTCOME MEASUREMENT The incidence of humeral shaft fracture and trend in operative fixation were evaluated for all years of data. Surgical times were assessed by anesthesia Current Procedural Terminology codes. Outcomes and complications were assessed by Current Procedural Terminology codes. The proportion of individuals experiencing complications and 1-year mortality were compared by proportion hazards. RESULTS We identified 1385 claims for humeral shaft fractures over 15 years, with an adjusted rate of between 12.0 and 23.4 fractures per 100,000 beneficiaries. We identified 511 individuals who received surgical treatment for humeral shaft fractures, 451 of whom had complete 1-year follow-up data. Nail fixation was more prevalent than plate fixation most years and had shorter anesthesia time by 27.1 minutes (P < 0.0001). There were no significant differences in the complication rates between the 2 groups as measured by incidence of secondary operations and 1-year mortality. CONCLUSIONS Intramedullary nails are used for the majority of operative humeral shaft fractures among Medicare beneficiaries. Nailing has a shorter mean operative time. The 2 surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality. LEVEL OF EVIDENCE : Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Foster Chen
- National Institutes of Health, 10 Center Dr., Building 10, Mail Code 1468, Bethesda, MD 20892-1150
| | - Zhong Wang
- National Institutes of Health, 10 Center Dr., Building 10, Mail Code 1468, Bethesda, MD 20892-1150
| | - Timothy Bhattacharyya
- National Institutes of Health, 10 Center Dr., Building 10, Mail Code 1468, Bethesda, MD 20892-1150
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