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Nino S, Courington R, Brooks P, Langford J, Haidukewych G. Retrograde Nailing for Extremely Proximal Fractures of the Femoral Shaft. J Orthop Trauma 2023; 37:346-350. [PMID: 36821474 DOI: 10.1097/bot.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To report the results of retrograde intramedullary nailing (RIMN) for the treatment of extremely proximal femur fractures. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS 63 patients with femoral shaft fractures involving the anatomic region within 10 centimeters of the inferior border of the lesser trochanter, which were treated with retrograde intramedullary nailing. INTERVENTION Retrograde intramedullary femoral nail. MAIN OUTCOME MEASUREMENTS Time to union, nonunion, malunion, and unplanned reoperation. RESULTS Between 2009 and 2020, 63 fractures were followed up to fracture union, reoperation, or a minimum of 1 year clinically. The mean follow-up was 32 months, and 48 (76%) of the patients were followed up beyond 1 year clinically. The mean patient age was 34 years (range 18-84 years), and the mean BMI was 27 (range 14-45) kg/m 2 . Forty (64%) patients were polytraumatized. Clinical and radiographic union was achieved in 59 (94%) fractures after index operation at a mean time to union of 22 weeks (range 9-51 weeks). Delayed union requiring nail dynamization occurred in 1 (2%) instance. Malreduction was noted in 1 (2%) patient with a 12-degree flexion deformity that resulted in nonunion. In total, there were 3 (5%) nonunions requiring revision surgery, 1 treated with retrograde exchange nailing and 2 revised to cephalomedullary nails; all were united after revision. CONCLUSIONS Retrograde intramedullary nailing can be an effective treatment strategy for extremely proximal femur fractures when necessary. Our series demonstrated a high rate of union and a low rate of malalignment and complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Song W, Wang Y, Chen W, Zhang Z, Liu X, Ou G, Cheng B, Lin H. The comparison of the Effect of double reverse traction repositor (DRTR) and traction table assisted Anterograde Intramedullary nail in treatment of femoral shaft fractures. BMC Musculoskelet Disord 2023; 24:303. [PMID: 37072713 PMCID: PMC10111643 DOI: 10.1186/s12891-023-06421-x] [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: 02/03/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023] Open
Abstract
OBJECTIVE The objective of this study was to compare the clinical efficacy of DRTR (Double Reverse Traction Repositor, DRTR)and traction table in the treatment of femoral shaft fractures with the aid of AN-IMN (Antegrade intramedullary nailing). PATIENTS AND METHODS In this study, patients with femoral shaft fractures admitted to the Department of Orthopedics at Zhaoqing First People's Hospital from May 2018 to October 2022 were recruited. All patients were treated with anterograde intramedullary nailing, with 23 patients in the DRTR-assisted group and 21 patients in the traction table-assisted group. The demographic characteristics, fracture classification, intraoperative data, postoperative data, and prognostic indicators of the two groups were recorded and analyzed retrospectively. All procedures were performed by the same team of experienced physicians. RESULTS All the patients in the two groups were followed up for more than 12 months. Both traction methods could provide stable traction for the operator during AN-IMN, and there was no significant difference in demographic characteristics and fracture classification. The intraoperative fluoroscopy times and opening reduction rate of the DRTR group were lower than those of the traction table group (P < 0.05), and the postoperative Harris Hip Score, as well as the Lyshol Lysholm knee function Score of the DRTR group, were significantly higher than the traction table group members (P < 0.05). Postoperative complications such as perineal soft tissue injury and lateral femoral cutaneous nerve injury occurred in the traction table group, but not in the DRTR group. CONCLUSION DRTR can safely and effectively provide continuous and stable traction in the femoral shaft fractures surgery, and outperforms the traction table in the number of intraoperative fluoroscopy, opening reduction rate, reduction of complications, and postoperative joint function score.
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Affiliation(s)
- Wei Song
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China.
- Department of Orthopaedics, The First people's Hospital of Zhaoqing, Zhaoqing, China.
| | - Yueying Wang
- Clinical Laboratory of the First People's Hospital of Zhaoqing, Zhaoqing, China
| | - Weihao Chen
- Department of Orthopaedics, The First people's Hospital of Zhaoqing, Zhaoqing, China
| | - Zhenqian Zhang
- Department of Orthopaedics, The First people's Hospital of Zhaoqing, Zhaoqing, China
| | - Xuzhou Liu
- Department of Orthopaedics, The First people's Hospital of Zhaoqing, Zhaoqing, China
| | - Guoji Ou
- Department of Orthopaedics, The First people's Hospital of Zhaoqing, Zhaoqing, China
| | - Benqiang Cheng
- Department of Orthopaedics, The First people's Hospital of Zhaoqing, Zhaoqing, China
| | - Hongsheng Lin
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China.
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Practical approach to the native distal femur fractures in the elderly: A rapid review over the recent trends. Injury 2022; 53:2389-2394. [PMID: 35644641 DOI: 10.1016/j.injury.2022.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 02/02/2023]
Abstract
Significant work has been done in recent years on treatment strategies for distal femur fractures. Inclusive reviews on periprosthetic fractures of distal femur have been carried out recently, but there is a lack of such reviews on the subject of native distal femur fractures in the recent literature. In this narrative review, we are set out to address the latest updates on geriatric non-periprosthetic distal femur fractures, and perform a rapid review over different treatment options, arriving at a summarized proposed treatment algorithm.
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Vrahas MS. A Personal Remembrance: Berton Roy Moed MD (1950-2020). Clin Orthop Relat Res 2021; 479:2336-2337. [PMID: 37574752 PMCID: PMC8445555 DOI: 10.1097/corr.0000000000001906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/29/2021] [Indexed: 08/15/2023]
Affiliation(s)
- Mark S Vrahas
- Professor and Chairman, Department of Orthopaedics, Cedars Sinai, Los Angeles, CA, USA
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Albareda-Albareda J, Gabarre-Raso S, Rosell-Pradas J, Puértolas-Broto S, Ibarz-Montaner E, Redondo-Trasobares B, Gómez-Vallejo J, Blanco-Rubio N, Sánchez-Gimeno M, Herrera-Rodríguez A, Gracia-Villa L. Biomechanical behavior of retrograde intramedullary nails in distal femoral fractures. Injury 2021; 52 Suppl 4:S76-S86. [PMID: 33642084 DOI: 10.1016/j.injury.2021.01.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/25/2021] [Indexed: 02/02/2023]
Abstract
Fractures of the distal femur affect three different groups of individuals: younger people suffering high-energy trauma, elderly people with fragile bones and people with periprosthetic fractures around previous total knee arthroplasty. Main indications of intramedullary nailing are for supracondylar fractures type A or type C of the AO classification. The main objective of the present work is to analyze, by means of FE simulation, the influence of retrograde nail length, considering different blocking configurations and fracture gaps, on the biomechanical behavior of supracondylar fractures of A type. A three dimensional (3D) finite element model of the femur from 55-year-old male donor was developed, and then a stability analysis was performed for the fixation provided by the retrograde nail at a distal fracture with different fracture gaps: 0.5 mm, 3 mm y 20 mm, respectively. Besides, for each gap, three nail lengths were studied with a general extent (320 mm, 280 mm and 240 mm), considering two transversal screws (M/L) at the distal part and different screw combinations above the fracture. The study was focused on the immediately post-operative stage, without any biological healing process. In view of the obtained results, it has been demonstrated new possibilities of blocking configuration in addition to the usual ones, which allows establishing recommendations for nail design and clinical practice, avoiding excessive stress concentrations both in screws, with the problem of rupture and loss of blocking, and in the contact of nail tip with cortical bone, with the problem of a new stress fracture.
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Affiliation(s)
- J Albareda-Albareda
- Department of Surgery, University of Zaragoza. Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Spain
| | | | - J Rosell-Pradas
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - S Puértolas-Broto
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - E Ibarz-Montaner
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - B Redondo-Trasobares
- Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Spain.
| | - J Gómez-Vallejo
- Department of Surgery, University of Zaragoza. Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Spain
| | - N Blanco-Rubio
- Department of Surgery, University of Zaragoza. Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Spain
| | - M Sánchez-Gimeno
- Department of Surgery, University of Zaragoza. Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Spain
| | - A Herrera-Rodríguez
- Department of Surgery, University of Zaragoza. Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - L Gracia-Villa
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
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Takahashi Y, Hatashita S, Shinden Y, Ito M, Kaneuchi Y, Hakozaki M, Konno S. Periprosthetic Fracture Resembling Atypical Femoral Fracture After Fixation With Retrograde Intramedullary Nail in Elderly Women: A Report of Two Cases. In Vivo 2021; 35:1837-1842. [PMID: 33910870 DOI: 10.21873/invivo.12445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The number of individuals diagnosed with and requiring medical treatment for osteoporosis continues to increase due to global population aging and the high awareness of osteoporosis. Bone-modifying agents (BMAs) including bisphosphonate and denosumab are widely used for osteoporosis, and atypical femoral fracture (AFF) is also gaining attention as a severe potential side effect of long-term BMA treatment. The definition of AFF excludes periprosthetic femoral fracture; here, we describe two cases of a periprosthetic femoral fracture that resembled AFF. CASE REPORT The fractures occurred at the proximal tip of the retrograde femoral nail after an internal fixation for a distal femoral shaft fracture in elderly Japanese women. Each woman had been treated with bisphosphonate therapy for >2 years and had continued the bisphosphonate after undergoing surgery for a distal femoral shaft fracture. Each patient had noticed thigh pain before falling down, and plain radiographs showed a short oblique or transverse fracture with medial spike and localized periosteal reaction of the lateral cortex in each case. The fractures were re-fixed with an antegrade intramedullary nail, and bone union was achieved at >1 year after the second operation. Although these two cases were classified as periprosthetic fractures, they fulfilled the characteristics of AFF. CONCLUSION Physicians should conduct a thorough interview of patients with a history of BMA treatment in order to correctly diagnose periprosthetic fractures that resemble AFFs, and they should be aware that symptomatic fractures can be prevented by prophylactic fixation. The discontinuance of BMA therapy and the introduction of another drug such as teriparatide may lead to faster healing of surgically treated AFFs.
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Affiliation(s)
- Yojiro Takahashi
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Satoshi Hatashita
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yumetaka Shinden
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masayuki Ito
- Aizu Traumatology and Reconstructive Surgery Center, Aizu Chuo Hospital, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yoichi Kaneuchi
- Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Michiyuki Hakozaki
- Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan; .,Higashi-Shirakawa Orthopaedic Academy, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shinichi Konno
- Department of Orthopaedic Surgery Fukushima Medical University School of Medicine, Fukushima, Japan
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Angelini A, Mavrogenis AF, Crimì A, Georgoulis J, Sioutis S, Bekos A, Igoumenou VG, Cerchiaro MC, Berizzi A, Ruggieri P. Double fractures of the femur: a review of 16 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1345-1354. [PMID: 33496867 DOI: 10.1007/s00590-021-02873-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Double ipsilateral femoral fractures account for 1-9% of femoral fractures. There is no clear advantage between single or double implant osteosynthesis. We present a series of patients with double ipsilateral femoral fractures, to address the challenges in treatment, namely the implants for osteosynthesis and complications of treatment. MATERIALS AND METHODS We retrospectively studied 16 patients (7 men, 9 women; mean age, 51 years) treated from January 2015 to December 2018. Motor vehicle accidents were the leading cause of injury. Types of fractures were pertrochanteric and shaft (6), pertrochanteric and distal (2), double shaft (3), neck and shaft (2), neck and distal (1), shaft and distal (1), and triple fracture including a pertrochanteric, shaft and distal (1). In five patients, two different implants were used (plate and screws, cannulated hip screws, femoral nail), whereas in 11 patients a long femoral nail was used. RESULTS Fourteen patients experienced union at a mean of 3 months (2-6 months). Two patients experienced nonunion: both had plate and screws osteosynthesis. One patient died 15 days after admission from polytrauma and another patient experienced central venous catheter thrombosis and pneumonia. Surgical complications (2 patients) included a thigh skin necrosis, and external fixator pin tract infection/infected non-union. Weight-bearing was delayed in all patients; full weight-bearing was allowed in 11 patients at 4 months postoperatively, and in four patients at 5 months. CONCLUSION Due to the rarity and the difficulty of standardization of double ipsilateral femoral fractures, there is variable information on the optimal osteosynthesis of the fractures and the outcome of the patients. It seems that closed reduction and long hip nailing is the treatment of choice, with few complications.
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Affiliation(s)
- Andrea Angelini
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, Padova, Italy
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | - Alberto Crimì
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, Padova, Italy
| | - Jim Georgoulis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Spyros Sioutis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Achilles Bekos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasilios G Igoumenou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Chiara Cerchiaro
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, Padova, Italy
| | - Antonio Berizzi
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, Padova, Italy
| | - Pietro Ruggieri
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, Padova, Italy
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Kim JW, Oh CW, Oh JK, Park KH, Kim HJ, Kim TS, Seo I, Park EK. Treatment of infra-isthmal femoral fracture with an intramedullary nail: Is retrograde nailing a better option than antegrade nailing? Arch Orthop Trauma Surg 2018; 138:1241-1247. [PMID: 29799078 DOI: 10.1007/s00402-018-2961-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Antegrade intramedullary (IM) nailing is ideal for femoral shaft fractures, but fixing the fracture distal to the isthmal level may be difficult because of medullary canal widening and the proximity of fracture location from the distal femoral joint line. This study aimed to compare treatment results between antegrade and retrograde nailing for infra-isthmal femoral shaft fracture, and to identify influencing factors of nonunion and malalignment. MATERIALS AND METHODS Sixty patients with infra-isthmal femoral shaft fractures treated with IM nailing and followed-up for > 1 year were enrolled in this retrospective study, 38 in the antegrade nailing group, and 22 in the retrograde nailing group. The two groups had no significant differences in age, sex, and fracture location (p = 0.297, Mann-Whitney test). Radiological evaluation was performed, and functional result was assessed using the Knee Society scoring system. Complications were analyzed in accordance with fracture location, fracture type, and operative method. RESULTS According to the AO/OTA classification, 35, 16, and 9 cases were type A (A1: 1, A2: 11, A3: 23), B (B1: 2, B2: 7, B3: 7), and C fractures (C2: 4, C3: 5), respectively. The mean follow-up duration was 29.5 months. In the antegrade and retrograde nailing groups, the primary bony union rates were 73.7% in 20.7 weeks (range 12-41) and 86.4% in 17.4 weeks (range 12-30), respectively. The two groups showed no significant differences in union rate (p = 0.251, Pearson's Chi-square test) and union time (p = 0.897, Mann-Whitney test). No cases of malalignment of > 10° in any plane were found in both groups. The mean Knee Society scores were 92 (range 84-100) and 91 (range 83-95) in the antegrade and retrograde nailing groups, respectively, showing no significant difference (p = 0.297, Pearson's Chi-square test). Although fracture location was not significantly related to union rate (p = 0.584, Mann-Whitney test), patients with an effective working length of the distal segment of < 0.75 were prone to nonunion (p = 0.003, Pearson's Chi-square test). CONCLUSIONS Although no significant difference was found in IM nail type, the IM nail with a shorter working length distal to the fracture showed a strong relationship with nonunion.
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Affiliation(s)
- Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, South Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, South Korea.
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Seoul, South Korea
| | - Kyeong-Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, South Korea
| | - Hee-June Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, South Korea
| | - Tae-Seong Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, South Korea
| | - Il Seo
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, South Korea
| | - Eung-Kyoo Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 41944, South Korea
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Zhang R, Yin Y, Li S, Jin L, Hou Z, Zhang Y. Traction table versus double reverse traction repositor in the treatment of femoral shaft fractures. Sci Rep 2018; 8:5952. [PMID: 29654282 PMCID: PMC5899094 DOI: 10.1038/s41598-018-24317-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 03/27/2018] [Indexed: 01/24/2023] Open
Abstract
A novel reduction technique of intramedullary nailing (IMN) for femoral shaft fractures was introduced, and in this study, its therapeutic effect was compared with patients treated with the traditional traction table. From November 2012 to August 2015, the patients with femoral shaft fractures fixed with anterograde IMN were reviewed. Seventy-four patients treated with the traction table and forty-eight patients treated with the double reverse traction repositor (DRTR) met the inclusion criteria of this study. The surgical time, blood loss, open reduction rate and complications were reviewed in this study. The fracture healing was assessed by the radiographs conducted at each follow-up. The functional outcome (hip and knee flexion, Harris Hip Score, and Lysholm knee score) was evaluated at the final follow-up. Average surgical time, blood loss, hip and knee flexion, and Harris Hip Score showed no difference (P > 0.05) between the two groups. However, the DRTR was superior to the traction table in fracture healing, Lysholm knee score, open reduction and complications rate (P < 0.05). Thus, we concluded that minimally invasive treatment of femoral shaft fractures could be obtained with the DRTR.
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Affiliation(s)
- Ruipeng Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Yingchao Yin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Shilun Li
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Lin Jin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China.
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10
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DePhillipo NN, Lebus GF, Cinque ME, Kennedy NI, Chahla J, LaPrade RF. Iatrogenic Trochlear Chondral Defects After Anterolateral Placement of Retrograde Femoral Nails. Arthroscopy 2017; 33:1727-1730. [PMID: 28754245 DOI: 10.1016/j.arthro.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/01/2017] [Accepted: 06/01/2017] [Indexed: 02/02/2023]
Abstract
Femoral shaft fractures are common injuries with an incidence of 37.1 per 100,000 person-years in the United States. Retrograde femoral nailing is an increasingly used treatment strategy to manage these injuries, particularly in fractures below stemmed hip prostheses, in supracondylar or distal femur fractures, in fractures in pregnant or obese patients, and when concomitant ipsilateral acetabular/pelvic ring fractures are present. Retrograde fixation has been shown to be a viable option with union rates comparable to antegrade intramedullary nailing. Despite having excellent results in the treatment of femoral fractures, retrograde femoral nails have been associated with iatrogenic patellofemoral chondral damage that may occur because of malpositioning of the intramedullary nail at the entry point. The objective of this case report is to describe 2 patients who suffered iatrogenic trochlear chondral defects after retrograde femoral nailing and subsequently underwent osteoarticular allograft transplantation surgery.
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Affiliation(s)
- Nicholas N DePhillipo
- Steadman Clinic, Vail, Colorado, U.S.A.; Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - George F Lebus
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Mark E Cinque
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Robert F LaPrade
- Steadman Clinic, Vail, Colorado, U.S.A.; Steadman Philippon Research Institute, Vail, Colorado, U.S.A..
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11
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Hamaker M, O'Hara NN, Eglseder WA, Sciadini MF, Nascone JW, O'Toole RV. Radiographic predictors of symptomatic screw removal after retrograde femoral nail insertion. Injury 2017; 48:758-762. [PMID: 28153480 DOI: 10.1016/j.injury.2017.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/27/2016] [Accepted: 01/05/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Removal of symptomatic implants is a common procedure performed by orthopaedic trauma surgeons. No guidance is available regarding which factors contribute to the likelihood of an implant becoming symptomatic. Our objective was to determine whether radiographic parameters associated with distal interlocks in retrograde femoral nails are associated with the rate of symptomatic screw removal. PATIENTS AND METHODS We conducted a retrospective review at a Level I trauma center. Study patients (n=442) had femoral fractures treated with retrograde intramedullary nails from 2007 to 2014 and at least 1year of follow-up. The main outcome measurement was symptomatic distal screw removal as predicted by radiographic parameters. RESULTS Symptomatic screw removal occurred in 12% of the patients. Increased distance between the most distal screw and the articular surface of the femur significantly reduced likelihood of symptomatic screw removal. A cutoff of 40mm from the articular block was predictive of removal (≥40mm, 0% removal; <40mm, 18% removal, p<0.0001). In patients with distal screws placed within 40mm of the articular surface of the femur, a ratio of screw length to distance between medial and lateral femoral cortices that was ≥1 was a strong predictor of symptomatic screw removal (area under Receiver Operating Characteristic curve, 0.75; p<0.0001). CONCLUSIONS More distal screws and screws that radiographically extend to or beyond the medial cortex are more likely to cause pain and require removal in femoral fractures treated with retrograde intramedullary nails. We identified a specific distance from the joint (<40mm) and a ratio of screw length to bone width (≥1) that significantly increased the likelihood of symptomatic screw removal. Clinicians can use these data to inform patients of the likely risk of implant removal and perhaps to better guide placement and length of screws when the clinical scenario allows some flexibility in location and length of screws.
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Affiliation(s)
- Max Hamaker
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan N O'Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - W Andrew Eglseder
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marcus F Sciadini
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jason W Nascone
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
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Hussain N, Hussain FN, Sermer C, Kamdar H, Schemitsch EH, Sternheim A, Kuzyk P. Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and meta-analysis. Can J Surg 2017; 60:19-29. [PMID: 28234586 DOI: 10.1503/cjs.000616] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Nasir Hussain
- From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar)
| | - Farrah Naz Hussain
- From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar)
| | - Corey Sermer
- From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar)
| | - Hera Kamdar
- From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar)
| | - Emil H Schemitsch
- From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar)
| | - Amir Sternheim
- From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar)
| | - Paul Kuzyk
- From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar)
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13
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Fallen end cap of retrograde femoral nail inside the knee joint. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zheng ZL, Yu X, Chen W, Liu YJ, Yu KL, Wu T, Zhang YZ. Femoral Condyles Tangential Views: An Effective Method to Detect the Screw Penetration of Femoral Condyles After Retrograde Nailing. Chin Med J (Engl) 2015; 128:3352-6. [PMID: 26668151 PMCID: PMC4797512 DOI: 10.4103/0366-6999.171441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Postoperative knee soft tissue irritation is a common complication after retrograde nail fixation of femoral fractures. Distal locking screw prominence is one of the causes for soft tissue irritation. This study aimed to determine whether the use of the femoral condyles tangential views improve the diagnostic accuracy compared with anteroposterior (A-P) view in detecting distal locking screw penetrations during retrograde femoral nailing. Methods: The angle between the sagittal plane and lateral aspect of the condyle and the angle between the sagittal plane and medial aspect of condyle were measured on computed tomography (CT) images. After the angles were measured and recorded, cadaveric femurs were used in a simulated surgical procedure. The retrograde femoral nail was inserted into the femur and placed distal locking screws, which were left 2, 4, and 6 mm proud of the medial and lateral condyles for each femur. A-P view, lateral condyle tangential view and medial condyle tangential view were obtained. All fluoroscopic images were recorded and sent to three observers blinded to the experimental procedure to determine whether screws penetrated the condyle cortex or not. Results: According to the results of CT scan, the lateral condyle view was 20.88 ± 0.98° and the medial condyle view was 40.46 ± 3.14°. In the A-P view, we detected 0% at 2 mm penetration, 16.7% (lateral condyle screw) and 25.0% (medial condyle screw) at 4 mm, and 41.7% (lateral condyle screw) and 58.3% (medial condyle screw) at 6 mm. In the lateral tangential view, we detected 91.7% at 2 mm penetration of the lateral condyle and 100% at 4 mm and 6 mm. In the medial tangential view, we detected 66.7% at 2 mm penetration of the medial condyle and 100% at 4 mm and 6 mm. The femoral condyle tangential views provided significant improvement in detecting screw penetrations at all lengths (2, 4, and 6 mm) compared with the A-P view (P < 0.05). Conclusions: The femoral condyles tangential views increased the accuracy of detecting screw penetrations on the medial and lateral condyles. Routine clinical use of the femoral condyles tangential views has the potential to increase accuracy in detecting distal locking screw penetration during retrograde femoral nailing.
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Affiliation(s)
| | | | | | | | | | | | - Ying-Ze Zhang
- Department of Orthopedic, The Thrid Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
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15
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La nostra esperienza nel trattamento delle fratture del terzo distale di femore con chiodo endomidollare retrogrado. LO SCALPELLO-OTODI EDUCATIONAL 2015. [DOI: 10.1007/s11639-015-0123-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Shah S, Desai P, Mounasamy V. Retrograde nailing of femoral fractures: a retrospective study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1093-7. [PMID: 26126587 DOI: 10.1007/s00590-015-1658-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 06/02/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Retrograde femoral nailing is a common method to repair femoral shaft fractures in polytrauma patients. Studies have reported varying incidences of complications associated with retrograde femoral nailing such as knee pain, nonunion, and arthrofibrosis. The objective of this retrospective study was to describe healing and complication rates of 31 patients who underwent retrograde femoral nailing at our academic medical center. METHODS Clinical notes and radiographs were reviewed retrospectively. Data points such as demographics, fracture location on femur, time to union after surgery, presence or absence of comminution, associated injuries, and complications were assessed. RESULTS Average time to union was 4.69 months with no statistically significant relationship found between time to union and age, sex, comminution, or location of fracture. Knee pain was present in 23 % of patients, and distal screw removal was necessary in 19.4 % of patients. DISCUSSION Retrograde femoral nailing is an effective method of femoral shaft fracture fixation in polytrauma patients. The healing rate of femoral shaft fractures fixed with a retrograde nail is the same regardless of location of fracture, age, sex, or comminution. Prevention of tip of nail lying into the knee and early physical therapy are important to prevent arthrofibrosis knee.
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MESH Headings
- Adolescent
- Adult
- Aged
- Bone Nails
- Bone Screws
- Female
- Femoral Fractures/diagnostic imaging
- Femoral Fractures/physiopathology
- Femoral Fractures/surgery
- Follow-Up Studies
- Fracture Fixation, Intramedullary/instrumentation
- Fracture Fixation, Intramedullary/methods
- Fracture Healing/physiology
- Fractures, Comminuted/diagnostic imaging
- Fractures, Comminuted/physiopathology
- Fractures, Comminuted/surgery
- Fractures, Open/diagnostic imaging
- Fractures, Open/physiopathology
- Fractures, Open/surgery
- Humans
- Knee Joint
- Male
- Multiple Trauma/surgery
- Pain, Postoperative/diagnostic imaging
- Pain, Postoperative/etiology
- Pain, Postoperative/physiopathology
- Radiography
- Retrospective Studies
- Young Adult
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Bliemel C, Buecking B, Mueller T, Wack C, Koutras C, Beck T, Ruchholtz S, Zettl R. Distal femoral fractures in the elderly: biomechanical analysis of a polyaxial angle-stable locking plate versus a retrograde intramedullary nail in a human cadaveric bone model. Arch Orthop Trauma Surg 2015; 135:49-58. [PMID: 25388863 DOI: 10.1007/s00402-014-2111-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Compromised bone quality and the need for early mobilization still lead to high rates of implant failure in geriatric patients with distal femoral fractures. With the newest generation of polyaxial locking plates and the proven retrograde femoral nails today two minimally invasive surgical procedures have been established. Indications for both procedures overlap. This study attempts to define the strength and failure mode of both surgical procedures. MATERIALS AND METHODS A standardized fracture model was established to simulate an unstable AO/OTA 33-A3 fracture. Eight pairs of human cadaver femora (mean age 79 years, range 63-100 years) with compromised bone quality were used. Osteosyntheses with eight retrograde femoral nails and eight locking plates were randomly performed. A materials testing machine (Instron 5566) was used to perform cyclic stress tests according to a standardized loading protocol, up to a maximum load of 5,000 N. RESULTS All specimens survived loading of at least 2,500 N. Three nail and one plate construct survived a maximum load of 5,000 N. The mean compressive force leading to failure was 4,400 N (CI 4,122-4,678 N) for nail osteosynthesis and 4,429 N (CI 3,653-5,204 N) for plate osteosynthesis (p = 0.943). Proximal cutting out of the osteosynthesis was the most common reason for interruption in the nail and plate osteosyntheses. Significant differences between the retrograde femoral nail and plate osteosyntheses were seen under testing conditions for plastic deformation and stiffness of the constructs (p = 0.002 and p = 0.001, respectively). CONCLUSION Based on our results, no statements regarding the superiority of either of the devices can be made. Even though the load to failure values for both osteosyntheses were much higher than the loads experienced during normal walking; however, because only axial loading was applied, it remains unclear whether both osteosyntheses meet the estimated requirements for postoperative full weight-bearing for an average heavy patient with a distal femoral fracture.
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Affiliation(s)
- Christopher Bliemel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35043, Marburg, Germany,
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18
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Sadic S, Custovic S, Smajic N, Fazlic M, Vujadinovic A, Hrustic A, Jasarevic M. Complications and functional recovery in treatment of femoral shaft fractures with unreamed intramedullary nailing. Med Arch 2014; 68:30-3. [PMID: 24783908 PMCID: PMC4272482 DOI: 10.5455/medarh.2014.68.30-33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Fracture of the femoral shaft is a common fracture encountered in orthopedic practice. In the 1939, Küntscher introduced the concept of intramedullary nailing for stabilization of long bone fractures. Intramedullary nailing has revolutionized the treatment of fractures. MATERIAL AND METHODS The study included 37 male patients and 13 female patients, averaged 39 +/- 20.5 years (range, 16 to 76 years). RESULTS AND DISCUSSION There were 31 left femurs and 21 right femurs fractured. 46 fractures were the result of blunt trauma. Low energy trauma was the cause of fractures in six patients, of which five in elderly females. 49 fractures were closed. Healing time given in weeks was 19.36 +/- 6.1. The overall healing rate was 93.6%. There were three (6.25%) major complications nonunion. There were one (2%) delayed union, one (2%) rotational malunion and no infection. The shortening of 1 cm were in two patients. Antercurvatum of 10 degrees was found in one patient. There was no statistically significant reduction of a motion in the hip and knee (p < 0.05). There was statistically significant in the thigh (knee extensors) muscle weakness (p < 0.001). CONCLUSION : Intramedullary nailing is the treatment of choice for femoral shaft fractures.
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Affiliation(s)
- Sahmir Sadic
- University Clinical Center, Orthopaedic and Traumatology Clinic, Trnovac bb 75 000 Tuzla, Bosnia and Herzegovina
- Corresponding author: Sahmir Sadic MD. PhD. mail: , phone: 0038761333346
| | - Svemir Custovic
- University Clinical Center, Orthopaedic and Traumatology Clinic, Trnovac bb 75 000 Tuzla, Bosnia and Herzegovina
| | - Nedim Smajic
- University Clinical Center, Orthopaedic and Traumatology Clinic, Trnovac bb 75 000 Tuzla, Bosnia and Herzegovina
| | - Mirsad Fazlic
- University Clinical Center, Orthopaedic and Traumatology Clinic, Trnovac bb 75 000 Tuzla, Bosnia and Herzegovina
| | - Aleksandar Vujadinovic
- University Clinical Center, Orthopaedic and Traumatology Clinic, Trnovac bb 75 000 Tuzla, Bosnia and Herzegovina
| | - Asmir Hrustic
- University Clinical Center, Orthopaedic and Traumatology Clinic, Trnovac bb 75 000 Tuzla, Bosnia and Herzegovina
| | - Mahir Jasarevic
- University Clinical Center, Orthopaedic and Traumatology Clinic, Trnovac bb 75 000 Tuzla, Bosnia and Herzegovina
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Dougherty PJ, Gherebeh P, Zekaj M, Sethi S, Oliphant B, Vaidya R. Retrograde versus antegrade intramedullary nailing of gunshot diaphyseal femur fractures. Clin Orthop Relat Res 2013; 471:3974-80. [PMID: 23690149 PMCID: PMC3825896 DOI: 10.1007/s11999-013-3058-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Paul J Dougherty
- Detroit Receiving Hospital, 4201 St Antoine Street, Detroit, MI, 48201, USA,
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20
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el Moumni M, Voogd EH, ten Duis HJ, Wendt KW. Long-term functional outcome following intramedullary nailing of femoral shaft fractures. Injury 2012; 43:1154-8. [PMID: 22483542 DOI: 10.1016/j.injury.2012.03.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 12/06/2011] [Accepted: 03/06/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND The management of femoral shaft fractures using intramedullary nailing is a popular method. The purpose of this study was to evaluate the long-term functional outcome after antegrade or retrograde intramedullary nailing of traumatic femoral shaft fractures. We further determined predictors of these functional outcome scores. METHODS In a retrospective study, patients with a femoral shaft fracture but no other injuries to the lower limbs or pelvis were included. A total of 59 patients met the inclusion criteria. Functional outcome scores (Short Musculoskeletal Functional Assessment (SMFA), Western Ontario and McMaster University Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and the Lysholm knee function scoring scale) were measured at a mean of 7.8 years (± 3.5 years) postoperatively. The Visual Analogue Scale (VAS) was used to determine pain complaints of the lower limb. RESULTS The range of motion (ROM) of the hip and knee joints was comparable between the injured and uninjured leg, regardless of the nailing technique. Correlation between ROM and the final outcome scores was found to be fair to moderate. Even years after surgery, 17% of the patients still reported moderate to severe pain. A substantial correlation was observed between VAS and the patient-reported outcome scores. The most significant predictor of functional outcome was pain in the lower limb. CONCLUSIONS Our findings suggest that the ROM of hip and knee returns to normal over time, regardless of the nailing method used. However, pain in the lower limb is an important predictor and source of disability after femoral shaft fractures, even though most patients achieved good functional outcome scores.
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Affiliation(s)
- Mostafa el Moumni
- Department of Traumatology, University Medical Center Groningen, Groningen, The Netherlands.
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Clement H, Heidari N, Kosuge D, Grechenig W, Tesch NP, Weinberg AM. Anatomical structures at risk with the proud retrograde femoral nail. Arch Orthop Trauma Surg 2011; 131:1539-44. [PMID: 21706305 DOI: 10.1007/s00402-011-1347-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Indexed: 01/29/2023]
Abstract
BACKGROUND Post-operative knee pain is common following retrograde nailing, with its etiology often multifactorial although a well-established cause is nail protrusion from the intercondylar notch. The aim of this study was to assess the structures at risk if the nail is left proud of the femoral articular surface. METHODS A retrograde femoral nail (Synthes Distal Femoral Nail) was inserted into the distal femur of 15 cadaveric lower limbs using the standard technique. The nail was left 10 mm proud of the articular surface and locked in this position. The knee was then put through a full range of movement while recording the intra-articular structures that came into contact with the distal end of the nail as well as the position of the knee when this occurred. This was repeated with the nail 5 mm proud. RESULTS With the nail 10 mm proud, it impinged on the anterior horn of the medial meniscus in 14 cases and the anterior horn of the medial meniscus as well as the tibial insertion of the ACL in one case at 15° of flexion. At 70° of flexion the nail came into contact with the distal margin of the patellar articular surface in the midline in all 15 cases. With the nail 5 mm proud, it impinged on the anterior horn of the medial meniscus in seven cases and the tibial insertion of the ACL as well as the anterior horn of the medial meniscus in eight cases as the knee was brought into full extension. In flexion the distal margin of the patellar articular surface in the midline came into contact with the nail at 70° of flexion in all 15 cases. CONCLUSION Correct positioning of a retrograde femoral nail is of paramount importance to avoid further iatrogenic injury to intra-articular structures.
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Affiliation(s)
- Hans Clement
- Department of Traumatology, Medical University of Graz, Auenbruggerplatz 7a, 8036, Graz, Austria
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23
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Hierholzer C, von Rüden C, Pötzel T, Woltmann A, Bühren V. Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis. Indian J Orthop 2011; 45:243-50. [PMID: 21559104 PMCID: PMC3087226 DOI: 10.4103/0019-5413.80043] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND TWO MAJOR THERAPEUTIC PRINCIPLES CAN BE EMPLOYED FOR THE TREATMENT OF DISTAL FEMORAL FRACTURES: retrograde intramedullary (IM) nailing (RN) or less invasive stabilization on system (LISS). Both operative stabilizing systems follow the principle of biological osteosynthesis. IM nailing protects the soft-tissue envelope due to its minimally invasive approach and closed reduction techniques better than distal femoral locked plating. The purpose of this study was to evaluate and compare outcome of distal femur fracture stabilization using RN or LISS techniques. MATERIALS AND METHODS In a retrospective study from 2003 to 2008, we analyzed 115 patients with distal femur fracture who had been treated by retrograde IM nailing (59 patients) or LISS plating (56 patients). In the two cohort groups, mean age was 54 years (17-89 years). Mechanism of injury was high energy impact in 57% (53% RN, 67% LISS) and low-energy injury in 43% (47% RN, 33% LISS), respectively. Fractures were classified according to AO classification: there were 52 type A fractures (RN 31, LISS 21) and 63 type C fractures (RN 28, LISS 35); 32% (RN) and 56% (LISS) were open and 68% (RN) and 44% (LISS) were closed fractures, respectively. Functional and radiological outcome was assessed. RESULTS Clinical and radiographic evaluation demonstrated osseous healing within 6 months following RN and following LISS plating in over 90% of patients. However, no statistically significant differences were found for the parameters time to osseous healing, rate of nonunion, and postoperative complications. The following complications were treated: hematoma formation (one patient RN and three patients LISS), superficial infection (one patient RN and three patients LISS), deep infection (2 patients LISS). Additional secondary bone grafting for successful healing 3 months after the primary operation was required in four patients in the RN (7% of patients) and six in the LISS group (10% of patients). Accumulative result of functional outcome using the Knee and Osteoarthritis Outcome (KOOS) score demonstrated in type A fractures a score of 263 (RN) and 260 (LISS), and in type C fractures 257 (RN) and 218 (LISS). Differences between groups for type A were statistically insignificant, statistical analysis for type C fractures between the two groups are not possible, since in type C2 and C3 fractures only LISS plating was performed. CONCLUSION Both retrograde IM nailing and angular stable plating are adequate treatment options for distal femur fractures. Locked plating can be used for all distal femur fractures including complex type C fractures, periprosthetic fractures, as well as osteoporotic fractures. IM nailing provides favorable stability and can be successfully implanted in bilateral or multisegmental fractures of the lower extremity as well as in extra-articular fractures. However, both systems require precise preoperative planning and advanced surgical experience to reduce the risk of revision surgery. Clinical outcome largely depends on surgical technique rather than on the choice of implant.
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Affiliation(s)
- Christian Hierholzer
- Department of Trauma Surgery, Trauma Center Murnau, Murnau, Germany,Address for correspondence: Prof. Dr. Christian Hierholzer, Department of Trauma Surgery, Trauma Center Murnau, Prof.-Küntscher- Str 8, 82418 Murnau, Germany. E-mail:
| | | | - Tobias Pötzel
- Department of Trauma Surgery, Trauma Center Murnau, Murnau, Germany
| | | | - Volker Bühren
- Department of Trauma Surgery, Trauma Center Murnau, Murnau, Germany
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Streubel PN, Gardner MJ, Ricci WM. Management of femur shaft fractures in obese patients. Orthop Clin North Am 2011; 42:21-35, v. [PMID: 21095432 DOI: 10.1016/j.ocl.2010.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Given the ongoing epidemic of obesity, femoral fracture management in the population affected by this condition is likely to become more frequent. Fracture treatment in obese patients poses a special challenge given greater difficulty in establishing an accurate diagnosis and confirming associated injuries. Adequate intraoperative positioning and obtaining accurate reduction and stable fixation may require special considerations. Obese patients have a high predisposition for complications such as compartment syndrome, nerve injuries, and pressure ulcers, and are at increased risk for medical complications given the high prevalence of comorbidities. A thorough understanding of the risks associated with obesity and the diagnostic and therapeutic challenges involved with femoral shaft fractures in this setting is paramount to achieve adequate results.
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Affiliation(s)
- Philipp N Streubel
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
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Abstract
OBJECTIVES Retrograde nailing of open femoral fractures has presumed increased risk of knee sepsis. Our hypothesis was that the incidence of secondary knee infection after retrograde nailing of open femoral fractures is low. DESIGN Retrospective, multicenter. SETTING Four Level I trauma centers. PATIENTS AND METHODS A retrospective review of prospective trauma registries and fracture databases identified all open femoral fractures treated with retrograde intramedullary nailing from January 1, 2003, through February 15, 2007. Patients with ballistic injuries and those with less than 1 month follow up were excluded. Ninety-three open femoral fractures were identified in 90 patients. We defined a septic knee as a knee with infection that required reoperation with arthrotomy or arthroscopy. Infections at an open fracture site were defined as those treated with local irrigation and débridement and intravenously and/or orally administered antibiotics. INTERVENTION Open femoral shaft fractures treated with a retrograde approach. MAIN OUTCOME MEASUREMENTS Occurrence of an ipsilateral postoperative septic knee. RESULTS One acute septic knee was identified (1.1%; 95% confidence interval, 0.0%-3.2%) noted at time of repeat irrigation and débridement of a massive degloving wound that left no skin coverage over the knee. We also observed one late knee sepsis 2.5 years after the index procedure occurring after quadricepsplasty. The nail had been removed 1.5 years before surgery, so we did not include that case in our knee sepsis rate. Two additional infections at the open wound site did not involve the knee. CONCLUSIONS Previous publications have argued that retrograde nailing of open femoral fractures provides a potential conduit for knee infection. Our data show that risk of a septic knee as a direct result of retrograde nailing of an open femoral fracture is relatively low (1.1%; 95% confidence interval, 0.0%-3.2%). To our knowledge, this is the first case series to document the relative safety associated with retrograde nailing of open femoral fractures.
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Wild M, Gehrmann S, Jungbluth P, Hakimi M, Thelen S, Betsch M, Windolf J, Wenda K. Treatment strategies for intramedullary nailing of femoral shaft fractures. Orthopedics 2010; 33:726. [PMID: 20954660 DOI: 10.3928/01477447-20100826-15] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).
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Affiliation(s)
- Michael Wild
- Department of Trauma and Hand Surgery, Heinrich Heine University Hospital Düsseldorf, Germany
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Biomechanical strain analysis of the proximal femur following retrograde intramedullary nailing. CURRENT ORTHOPAEDIC PRACTICE 2010; 21:385-389. [PMID: 21151706 DOI: 10.1097/bco.0b013e3181d73bae] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND: The purpose of this study was to examine the influence of proximal retrograde intramedullary nail position on proximal femoral strain, since stress risers occurring at the end of an implant can increase fracture risk. METHODS: Proximal femoral strains during axial and torsional loading were measured in composite Sawbone femurs after placement of retrograde intramedullary nails that ended at three different locations (2 cm proximal, 4 cm distal, and at the level of the lesser trochanter). RESULTS: No statistically significant difference was found between the axial or torsional strain observed in the intact femur and that seen after placement of a retrograde femoral nail ending at any of the three positions. Gages proximal to the nail tip demonstrated higher strains than the strains for the intact femur when compared with gages distal to the nail tip. CONCLUSION: The ending location of a retrograde nail in the proximal femur does not appear to significantly alter strain in the proximal femur under the axial and torsional loading methods used in the study.
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Abstract
Intramedullary nailing is the preferred method for treating fractures of the femoral shaft. The piriformis fossa and greater trochanter are viable starting points for antegrade nailing. Alternatively, retrograde nailing may be performed. Each option has relative advantages, disadvantages, and indications. Patient positioning can affect the relative ease of intramedullary nailing and the incidence of malalignment. The timing of femoral intramedullary nailing as well as the use of reaming must be tailored to each patient to avoid systemic complications. Associated comorbidities, the body habitus, and associated injuries should be considered when determining the starting point, optimal patient positioning for nailing, whether to use reduction aids as well as which to use, and any modifications of standard technique. Intramedullary nailing of diaphyseal femur fractures provides a stable fixation construct that can be applied using indirect reduction techniques. This method yields high union rates and low complication rates when vigilance is maintained during preoperative planning, the surgical procedure, and the postoperative period.
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The stress response to bilateral femoral fractures: a comparison of primary intramedullary nailing and external fixation. J Orthop Trauma 2009; 23:90-7; discussion 98-9. [PMID: 19169099 DOI: 10.1097/bot.0b013e31819194c6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Concern has recently been expressed with regard to the physiologic effects of primary intramedullary femoral nailing in seriously injured patients. "Damage control orthopaedics" techniques have been proposed, which comprise principally the use of primary external fixation. The aim of this study was to compare the physiologic effects of external femoral fixation with those of intramedullary stabilization over the first 24 hours after femoral fracture using an established large animal (ovine) trauma model. METHODS Under terminal anesthesia, bilateral high-energy femoral fractures and hypovolemic shock were produced using a pneumatic actuator. Twenty-four sheep were randomized into 4 groups and monitored for 24 hours. Group 1--control, group 2--trauma only, group 3--trauma and external fixation, and group 4--trauma and reamed intramedullary nailing. Outcome measures included the following: pulmonary embolic load (transesophageal echocardiography), metabolic base excess, plasma coagulation markers, and polymorphonuclear cell counts obtained from bronchoalveolar lavage samples. RESULTS The total embolic load was significantly higher (P < 0.001) in the intramedullary nailing group. All trauma groups had a significant increase (P < 0.05) in prothrombin times with a fall in antithrombin III and fibrinogen levels. However, the type of fracture stabilization used did not significantly affect any of the other outcome measurements. CONCLUSIONS A higher pulmonary embolic load can be expected during early intramedullary femoral fracture stabilization compared with primary external fixation. However, the degree of stimulation to systemic coagulation and pulmonary inflammation by each type of surgery was comparable.
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Case report: Patella baja after retrograde femoral nail insertion. Clin Orthop Relat Res 2009; 467:566-71. [PMID: 18791771 PMCID: PMC2628525 DOI: 10.1007/s11999-008-0501-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Accepted: 08/22/2008] [Indexed: 01/31/2023]
Abstract
Patella baja is a rare condition that can result from conditions involving trauma around the knee. Risk factors are believed to include scar tissue formation in the retropatellar fat pad, extensor mechanism dysfunction, and immobilization in extension. Early recognition and aggressive treatment are critical components in minimizing long-term disability. We present a case report of a woman with a fracture of the femoral diaphysis who underwent retrograde placement of an intramedullary nail. Subsequent followup revealed development of patella baja with resultant disability. The diagnosis was made late and the treatment was ineffective. Although patella baja has been reported in trauma around the knee, causative factors include retrograde femoral nailing. We believe early recognition and institution of treatment are important.
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Brewster M. Does fixation of femoral fractures using retrograde intramedullary nailing cause long-term knee pain: a systematic review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2008. [DOI: 10.1007/s00590-008-0371-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
OBJECTIVE The purpose of this study was to evaluate the use of retrograde nailing to treat patients with bilateral femur fractures. DESIGN AND SETTING A retrospective review of prospectively obtained trauma databases was completed at 9 Level 1 trauma centers. PATIENTS In all, 3767 patients with femur fractures were identified. Of those, 89 (46 males, 43 females) had bilateral femur fractures treated with reamed, retrograde intramedullary nails within 48 hours after injury. The charts were reviewed for pertinent data. RESULTS The average cohort age was 30 years (16-63 years). The average Injury Severity Score was 21 (9-50). Eighty-five patients (96%) had associated injuries. Thirteen patients (14.6%) developed adult respiratory distress syndrome; 8 had thoracic injuries. There were 4 patients (4%) with fat embolism syndrome, 2 were delayed longer than 24 hours to the operating room. There were 5 deaths (5.6% mortality) in the retrograde nailing group. Thoracic injury was found to be associated with death rate (P < 0.07). CONCLUSIONS Bilateral femur fractures are indicative of severe injuries with mortality rates as high as 40%. There are no specific studies addressing the outcomes of bilateral femur fractures treated with retrograde nailing. In this largest retrospective study to date, the overall death rate of 5.6% was significantly lower than historical controls. The effect of timing and duration of surgery and other injuries is not completely known. In conclusion, retrograde nailing of bilateral femur fractures is an acceptable treatment for bilateral femur fractures.
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Abstract
OBJECTIVES The purpose of this study was to compare the functional outcome of patients with ipsilateral intertrochanteric and femoral shaft fractures treated with a reconstruction nail versus a sliding hip screw and retrograde nail. DESIGN Retrospective cohort study. SETTING Two level 1 trauma centers. PARTICIPANTS Twenty-six patients with ipsilateral intertrochanteric and femoral shaft fractures treated between 1993 and 2003 with a reconstruction nail (n=13) or with a sliding hip screw and retrograde nail (n=13). INTERVENTION Internal fixation with a reconstruction nail or a sliding hip screw and retrograde nail. MAIN OUTCOME MEASUREMENTS Functional outcome was measured using the Short Form-36 (SF-36), Short Musculoskeletal Functional Assessment (SMFA), and Lower Extremity Functional Scale (LEFS). RESULTS The average time to follow-up was 49.6 months. Functional outcome was significantly better in the sliding hip screw with retrograde nail group for the role emotional (P=0.001) and mental component scores (P=0.016) of the SF-36. This group also scored better on the LEFS, although not reaching statistical significance (P=0.099). CONCLUSIONS For most outcome measures, no significant differences in functional outcome scores were observed between the 2 treatment groups. The results of this study suggest the need for a randomized controlled trial with a larger sample size to more definitively compare the 2 fixation constructs.
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Piatek S, Westphal T, Holmenschlager F, Becker R, Winckler S. Retrograde cement removal in periprosthetic fractures following hip arthroplasty. Arch Orthop Trauma Surg 2007; 127:581-5. [PMID: 17143641 DOI: 10.1007/s00402-006-0249-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2006] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Revision of cemented hip arthroplasty after periprosthetic fractures of the femur is a demanding procedure. Many different technical devices have been developed for this purpose. This paper presents a new surgical technique of cement removal avoiding excessive exposure of the fracture site. MATERIALS AND METHODS In six patients with periprosthetic fractures of the femur following hip arthroplasty (Johansson Type II and III) cement removal was performed by means of advancing a retrograde nail through the intercondylar notch of the knee. RESULTS In all cases the cement was removed completely. Intraoperative complications or significant knee problems were not observed. CONCLUSION The intracondylar approach provides a simple, rapid and less invasive technique for cement removal in revision hip arthroplasty.
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Affiliation(s)
- Stefan Piatek
- Department of Trauma Surgery, Otto-von-Guericke-University, Leipziger Strasse 44, 39120 Magdeburg, Germany.
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35
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Tucker MC, Schwappach JR, Leighton RK, Coupe K, Ricci WM. Results of femoral intramedullary nailing in patients who are obese versus those who are not obese: a prospective multicenter comparison study. J Orthop Trauma 2007; 21:523-9. [PMID: 17805018 DOI: 10.1097/bot.0b013e31813347ac] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Antegrade femoral nailing through a piriformis fossa starting point in patients who are obese has been demonstrated to be problematic. Retrograde femoral nailing therefore has been advocated in this patient population, but little data exist to support such a recommendation. The purpose of this study was to evaluate and compare antegrade and retrograde femoral nailing technique in both patients who are and are not obese. DESIGN Prospective, multicenter, nonrandomized, internal review board (IRB)-approved study. SETTING Four Level 1 trauma centers. PATIENTS Patients (151) with a femoral shaft fracture (OTA 32) treated with intramedullary nailing were studied. Thirty-two with a body mass index (BMI) of >or=30 comprised the obese group (OG), and 119 with a BMI of <30 comprised the nonobese group (NOG). Antegrade nailing was performed in 15 patients from the OG and 84 from the NOG. Retrograde nailing was performed in 17 patients from the OG and 35 from the NOG. INTERVENTION Reamed intramedullary nailing of a femoral shaft fracture. MAIN OUTCOME MEASURES Patient and fracture characteristics, operative time, fluoroscopy time, healing, complications, and functional outcome based on the lower extremity measure (LEM) were evaluated. RESULTS Antegrade technique in the OG was associated with a 52% greater average operative time (94 minutes) compared with antegrade nailing in the NOG (62 minutes; P < 0.003). For retrograde nailing technique, there was no difference in the average operative time between the OG (67 minutes) and NOG (62 minutes; P = 0.51). Antegrade technique in the OG was associated with a 79% greater average radiation exposure time (247 seconds) compared with antegrade nailing in the NOG (135 seconds; P < 0.03). For retrograde nailing technique, average fluoroscopy time was similar between the OG (76 seconds) and the NOG (63 seconds; P = 0.44). Within the OG, antegrade nailing required 40% greater average operative time (94 minutes versus 67 minutes, P < 0.02) and more than 3 times more average fluoroscopy time (242 seconds versus 76 seconds, P < 0.002) than retrograde nailing. Thirty-eight patients from the original cohort were not available for follow-up. Of the 113 patients followed (average 9 months, range: 4 to 25 months), healing complications occurred similarly between the 2 groups, with 1 nonunion and 2 delayed unions in the OG (12%), and 3 nonunions and 9 delayed unions in the NOG (14%). CONCLUSIONS This study provides evidence, in the form of decreased operative and radiation exposure times, to support the use of retrograde nailing technique for the treatment of femoral shaft fractures in patients who are obese. Also, antegrade nailing was found to require significantly more operative and radiation exposure time in the patient who is obese as opposed to the patients who is not obese. Although having similar baseline functional scores, patients who are obese recovered at a slower rate and more incompletely than patients who are not obese.
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Affiliation(s)
- Michael C Tucker
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia 30912, USA.
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36
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Acharya KN, Rao MR. Retrograde nailing for distal third femoral shaft fractures: a prospective study. J Orthop Surg (Hong Kong) 2006; 14:253-8. [PMID: 17200525 DOI: 10.1177/230949900601400305] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the postoperative knee function and results of unreamed retrograde nailing for distal third femoral shaft fractures. METHODS Between January 2002 and 2003 inclusive, a consecutive series of 27 patients (with 28 fractures) who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified Knee Society Knee Score. Correlations between union time and other variables were also studied. RESULTS In these patients 26 (93%) of the 28 fractures achieved union, of which 5 underwent dynamisation; the mean union time for the other 21 fractures was 4.4 months. Angular malalignment was present in 4 patients and shortening in 4 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 26 patients. 19 patients had anterior knee pain and 10 had instability. By the end of one year, excellent or good scores for pain and function were recorded in 77% and 73% respectively, of the 26 patients. CONCLUSION In view of such favourable union rates but significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.
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Affiliation(s)
- K N Acharya
- Department of Orthopaedics, SDM College of Medical Sciences, Dharwad, Karnataka, India.
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Moed BR, Tracy Watson J. [Not Available]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2006; 10:198-209. [PMID: 17003971 DOI: 10.1007/s00064-006-0057-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- B R Moed
- Orthopaedic Trauma Service Department of Orthopaedic Surgery, University Health Center (Suite 7C), 4201 St. Antoine Boulevard, 48202, Detroit, MI, USA
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Oh CW, Oh JK, Park BC, Jeon IH, Kyung HS, Kim SY, Park IH, Sohn OJ, Min WK. Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures. Arch Orthop Trauma Surg 2006; 126:448-53. [PMID: 16810555 DOI: 10.1007/s00402-006-0161-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2005] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures. MATERIALS AND METHODS Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture. RESULTS The average time for union of femoral shaft fractures was 27.3 (14-60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8-12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman-Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty. CONCLUSION Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.
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Affiliation(s)
- Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, 50, Samdok, Chung-gu, Daegu 700-721, South Korea.
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Salem KH, Maier D, Keppler P, Kinzl L, Gebhard F. Limb Malalignment and Functional Outcome After Antegrade Versus Retrograde Intramedullary Nailing in Distal Femoral Fractures. ACTA ACUST UNITED AC 2006; 61:375-81. [PMID: 16917453 DOI: 10.1097/01.ta.0000230282.65606.81] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Torsional malalignment and mechanical axis deviation (MAD) are worrisome complications after nailing of distal femoral fractures. Variable, sometimes contradictory, reports about these problems have been published. METHODS In a retrospective nonrandomized study, 41 patients (mean age, 44.5 years) with distal third femoral fractures that were operatively treated using either antegrade (20 cases) or retrograde (21 cases) intramedullary nailing during a period of 2 years have been reviewed. Goniometric measurement was done using a navigated ultrasound examination whereas functional evaluation and return to sports were assessed using Merle d'Aubigné functional grading system and Tegner and Lysholm activity score. RESULTS There was no difference in femoral length, torsion, or MAD between patients treated using antegrade nails and those treated with a retrograde nail. There was a greater limitation of knee motion with retrograde nailing and of hip motion with antegrade nailing. The functional grading and activity evaluation showed, however, no difference between both groups. CONCLUSIONS The study cohort showed that no treatment method had proved an advantage over the other regarding limb geometry or the functional outcome. The proper operative indication, intraoperative control, and the surgeon's experience seem to be more important in this regard than the nailing technique.
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Affiliation(s)
- Khaled Hamed Salem
- Department of Trauma, Hand, and Reconstructive Surgery, University of Ulm, Ulm, Germany
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Katsoulis E, Court-Brown C, Giannoudis PV. Incidence and aetiology of anterior knee pain after intramedullary nailing of the femur and tibia. ACTA ACUST UNITED AC 2006; 88:576-80. [PMID: 16645100 DOI: 10.1302/0301-620x.88b5.16875] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- E Katsoulis
- Department of Trauma & Orthopaedics, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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41
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Born CT, King PJ, Rehman S, Khoury L, Delong WG. Arthroscopically-assisted removal of retrograde intramedullary femoral nails. J Orthop Trauma 2006; 20:212-5. [PMID: 16648703 DOI: 10.1097/01.bot.0000184139.67577.97] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Retrograde nailing of femoral shaft fractures has become more prevalent as a result of its growing acceptance and familiarity to orthopaedic surgeons. Nail removal is occasionally indicated, which may require a formal arthrotomy. We describe an arthroscopic removal technique that has several advantages. The percutaneous technique imparts less morbidity than a more extensive arthrotomy. More importantly, additional intra-articular pathology can be thoroughly assessed and treated, such as meniscal tears and chondral injury, which may have occurred at the time of injury. These are potential causes of knee pain, which usually cannot be properly diagnosed without arthroscopy. Our findings also support the existence of a stable fibrous cap, which forms over the entry portal of a well-seated retrograde femoral nail as well as no evidence of intra-articular metallosis.
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Affiliation(s)
- Christopher T Born
- Department of Orthopaedic Surgery, Brown University, Providence, RI 02905, USA
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Stahl JP, Alt V, Kraus R, Hoerbelt R, Itoman M, Schnettler R. Derotation of post-traumatic femoral deformities by closed intramedullary sawing. Injury 2006; 37:145-51. [PMID: 16243332 DOI: 10.1016/j.injury.2005.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2005] [Revised: 06/07/2005] [Accepted: 06/21/2005] [Indexed: 02/02/2023]
Abstract
Different techniques and devices have been used for correction osteotomies of bones in patients with malalignments. The most frequently used technique for rotational deformities of the femur and tibia is open osteotomy with an oscillating saw and pre-drilled holes with all well-known drawbacks of open surgery. An intramedullary device with an adapted minimal-invasive surgical technique allows intramedullary osteotomy of the bone preserving the surrounding soft tissue. We performed femoral osteotomies with an intramedullary saw followed by static interlocking nailing in 14 patients with post-traumatic rotational deformity in the femur. Twelve patients had an external rotational deformity of the femur ranging between 26 and 63 degrees , one had an additional leg-shortening of about 4 cm. Two patients had internal rotational deformities. In two patients with delayed fracture healing union was achieved within one year without secondary surgery. Post-operative clinical assessment and CT-scans revealed good derotation results with deformities of less than 4 degrees in all cases. No device-related complications were observed. Therefore, we conclude that "closed" osteotomy with an intramedullary saw is a minimal-invasive, safe and reliable option for derotation procedures in the femur.
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Affiliation(s)
- Jens-Peter Stahl
- University Hospital Giessen, Department of Trauma Surgery, Rudolf-Buchheim-Str. 7, Giessen 35385, Germany.
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Papadokostakis G, Papakostidis C, Dimitriou R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury 2005; 36:813-22. [PMID: 15949481 DOI: 10.1016/j.injury.2004.11.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Accepted: 11/25/2004] [Indexed: 02/08/2023]
Abstract
The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6 degrees . The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6 degrees . The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union.
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Affiliation(s)
- G Papadokostakis
- Department of Trauma, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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44
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Pertrochanteric femur fracture at the proximal end of a retrograde intramedullary nail—a case report. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.injury.2004.12.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Pingsmann A, Lederer M, Wüllenweber C, Lichtinger TK. Early patellofemoral osteoarthritis caused by an osteochondral defect after retrograde solid nailing of the femur in sheep. ACTA ACUST UNITED AC 2005; 58:1024-8. [PMID: 15920419 DOI: 10.1097/01.ta.0000171986.10452.f4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Retrograde femoral nailing (RFN) is an increasingly used technique for internal fixation of femoral fractures. Geometrically and empirically, the nail entry zone is close to the center of the femoral groove, causing concern about the development of patellofemoral osteoarthritis. METHODS We studied the effect of opening the distal femur through the femoral groove on the development of osteoarthritis in sheep after retrograde reamed insertion of a solid titanium nail into the femoral canal. Knees were radiographically and macroscopically studied for the presence of osteophytes and signs of cartilage degeneration. Controls underwent the same procedure without opening the femoral groove. RESULTS The study group showed time-dependent macroscopic and radiographic signs of osteoarthritis with predominant involvement of the patellofemoral joint. CONCLUSION RFN can cause patellofemoral osteoarthritis. Care should be exercised to use RFN in isolated supracondylar or shaft fractures of the femur in healthy young adults.
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Affiliation(s)
- Andreas Pingsmann
- Department of Orthopedics, Essen University Medical School, Essen, Germany.
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Oh CW, Oh JK, Min WK, Jeon IH, Kyung HS, Ahn HS, Park BC, Kim PT. Management of ipsilateral femoral and tibial fractures. INTERNATIONAL ORTHOPAEDICS 2005; 29:245-50. [PMID: 15928912 PMCID: PMC3474524 DOI: 10.1007/s00264-005-0661-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2005] [Accepted: 03/09/2005] [Indexed: 10/25/2022]
Abstract
This is a retrospective study of 18 patients who had ipsilateral femoral and tibial fractures. They were treated by the retrograde femoral and antegrade tibial intramedullary nail from a single incision in the knee. The average time for union of femoral shaft fractures was 27.6 (18--40) weeks. One patient required antegrade nailing with a bone graft due to metal failure after using the short nail. Two tibial fractures required bone grafting due to bone loss, with an initial open fracture. The average time for union of tibial fractures was 24.5 (18--30) weeks. Functional results using the Karlstrom-Olerud criteria were excellent in 14, good in three, and acceptable in one. The only acceptable result was in a supra- and inter-condylar femoral fracture, with protrusion of the nail tip into the knee joint, which created moderate limitation of knee motion. Simultaneous retrograde femoral and antegrade tibial nailing with a single incision in the knee can achieve satisfactory results in the management of these types of fracture.
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Affiliation(s)
- Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, 50 Samdok, Chung-gu, Daegu, 700-721, South Korea.
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Friemert B, Keppler P, von Lübken F, Willy C, Claes L, Gerngross H, Wörz D. Ein neues retrogrades Femurmarknagelsystem mit durchleuchtungsfreier proximaler Verriegelung. Unfallchirurg 2005; 108:189-99. [PMID: 15778831 DOI: 10.1007/s00113-004-0863-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Conventional retrograde nailing of the femur causes two important disadvantages: the proximal locking of the nail is difficult because of the anatomic conditions and a chondral defect was left into the knee. MATERIAL AND METHODS After the retrograde implantation the new nail was lead through the greater trochanter. An additional proximal aiming device for proximal interlocking can be fixed. The entrance portal will be sealed by an osteochondral cylinder. 50 cases of femur fractures were selected for the prospective study. We recorded all intraoperative complications and technical difficulties. The cases were followed up for 52 weeks, both clinical and radiology examinations were performed. RESULTS The mean follow up was 15.5+/-5 months. All fractures were healed. Knee movement was 125+/-14 degrees. The Leung Score was 84+/-12.6 points; HSS Score was 90+/-9 points. In two cases wound infections were developed. Mal-union was observed in three cases, in two cases nail brake down. CONCLUSIONS The new retrograde interlocking nail could be used to manage femur fractures successfully. Two aiming devices enable a easy interlocking. Replacement of the osteochondral cylinder into the entry portal reduces cartilage damage.
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Affiliation(s)
- B Friemert
- Chirurgische Klinik, Bundeswehrkrankenhaus Ulm.
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Sears BR, Ostrum RF, Litsky AS. A mechanical study of gap motion in cadaveric femurs using short and long supracondylar nails. J Orthop Trauma 2004; 18:354-60. [PMID: 15213500 DOI: 10.1097/00005131-200407000-00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the relative stability achieved in unstable supracondylar femur fractures treated with long (36 cm) and short (20 cm) retrograde intramedullary nails using 1 or 2 proximal locking bolts. We hypothesized that longer nails would reduce fracture site motion compared with short nails and that 2 proximal locking bolts would improve stability compared with 1 proximal locking bolt. DESIGN Nine pairs of matched human cadaveric femurs were instrumented with 20-cm and 36-cm retrograde intramedullary nails (all 12-mm diameter, Biomet, Warsaw, IN) following reaming to 13 mm. Transverse supracondylar gap (6 mm) osteotomies were created. The femurs were mounted and cyclically tested separately in coronal plane bending and sagittal plane bending on a materials testing system. Fracture site translation was measured using a digital caliper in the respective plane. SETTING Orthopaedic biomaterials laboratory. RESULTS With 2 proximal locking bolts, average sagittal translation was 7.2 mm and 1.8 mm, respectively, for the 20-cm and 36-cm nails. Coronal translation was 6.3 mm and 4.3 mm, respectively. With a single proximal locking bolt, average sagittal translation was 7.6 mm and 2.2 mm, respectively, for the 20-cm and 36-cm nails. Coronal translation was 13.6 mm and 4.4 mm, respectively. A statistically significant difference in fracture site translation was found in each pairing by Student t test (P < 0.005), except coronal translation with 2 proximal locking bolts (P = 0.056). Free-body analysis predicts higher local stresses at the proximal interlocks of the shorter nail. CONCLUSIONS Longer nails provide improved initial fracture stability when compared with short retrograde nails for supracondylar femur fractures due to a more stable mechanical interaction between the femoral diaphysis and the nail. A second proximal locking bolt in the long nail provides no additional stability.
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Abstract
The principles of fracture management in polytrauma patients continue to be of crucial importance. Over the last five decades, various strategies of fracture treatment in the multiply injured patient have evolved. The various new methodologies remain controversial. In the beginning, early surgical fracture treatment of long bone fractures after multiple trauma was not routinely advocated. It was believed that the polytraumatised patient did not have the physiological reserve to withstand prolonged operations. The introduction of standardised, definitive surgical protocols, led to the concept of early total care (ETC) in the 1980s. This concept was subsequently applied universally, in all patient groups, regardless of injury severity and distribution. Later, it became apparent that certain patients did not appear to benefit from ETC. Indeed, extended operative procedures, during the early phase of multiple trauma recovery, were associated with adverse outcome. This applied for patients with significant thoracic, abdominal and head injuries and those with high injury severity scores (ISS). In response, the concept of damage control orthopaedics (DCO) was developed in the 1990s. DCO methodology is characterised by primary, rapid, temporary fracture stabilization. Secondary definitive management follows, once the acute phase of systemic recovery has passed. We explore the processes underlying the systemic biological impact of fracture fixation, the evolution of operative treatment strategies for major fractures in polytrauma and the current trends toward staged management of these patients.
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Affiliation(s)
- Frank Hildebrand
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
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