Retrograde versus antegrade nailing of femoral shaft fractures

OBJECTIVES: To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05). INTERVENTION: Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques. MAIN OUTCOME MEASURES: Union, delayed union, nonunion, malunion, and complication rates. RESULTS: After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05). CONCLUSIONS: Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.     

逆行和顺行交锁髓内钉治疗股骨干骨折的比较研究

目的比较逆行和顺行交锁髓内钉治疗股骨干骨折的愈合率和并发症。方法前瞻性地研究应用闭合扩髓交锁髓内钉技术治疗新鲜股骨干骨折72例，其中逆行钉治疗34例，顺行钉治疗38例。所有72例患者均进行了1次以上的随访，随访时间平均19个月（6～31个月）。结果逆行钉组中32例骨折愈合，延迟愈合3例，畸形愈合4例；顺行钉组35例骨折愈合，延迟愈合5例，畸形愈合3例。排除术前即有膝关节疼痛的病例，术后患侧膝关节疼痛者逆行钉组24例，顺行钉组9例；排除术前即有髋关节疼痛的病例，术后患侧髋关节疼痛者逆行钉组1例，顺行钉组6例。结论在骨折愈合方面，两种治疗方法无显著性差异。逆行钉治疗术后有较多的膝关节并发症而顺行钉治疗术后有较多的髋关节并发症。     

Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery.     

Antegrade Versus Retrograde Locked Intramedullary Nailing for Femoral Fractures: Which Is Better?

Abstract Background: Locked intramedullary nailing or interlocking nailing (ILN) is a proven mode of treatment for femoral shaft fractures. It can be inserted via the antegrade or retrograde approach. Retrograde approach is technically less demanding especially if the patient is overweight. But there are concerns with regard to the violation of the knee and its effect on subsequent knee function. Methods: We studied consecutive cases of femoral shaft fractures treated with locked intramedullary nailing at the Penang General Hospital, from 1st June 2004 to 1st June 2005. We looked at radiological and clinical union rates, union of fractures, alignment of the operated limb, and the knee function, using the Thoresen scoring system. Results: There were a total of 77 cases of femoral interlocking nails during the study period. Forty-two cases were antegrade nails and 35 cases were retrograde nails. Both groups of patients eventually achieved union of the fracture and retrograde nailing group showed significantly earlier union rate (p = 0.032). There is no significant difference between both groups, in regards to knee pain, swelling, and range of motion as well as postnailing femoral alignment. Conclusions: Both methods of nailing achieved excellent union rates with good alignment of the limb. Contrary to popular belief, we found that retrograde nailing does not give rise to a higher rate of knee complications. Therefore, we strongly recommend this approach of nailing as it is technically less demanding.     

Retrograde nailing for distal third femoral shaft fractures: a prospective study

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.     

Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion.

OBJECTIVE: A new intramedullary nail system for humeral shaft fractures is evaluated to determine whether retrograde nailing is as reliable as antegrade nailing. STUDY DESIGN: Prospective multicenter nonrandomized clinical study. PATIENTS: Eighty-four patients with acute humeral shaft fractures were nailed with the new unreamed humeral nail (UHN) system. Fifty-seven nails were introduced retrogradely, and twenty-seven antegradely. Bone healing and functional outcome were the follow-up parameters. RESULTS: The ratio of perioperative complications was equivalent for both groups, but one shaft fracture and three fractures or fissures at the entry point occurred in the group with retrograde nail insertion. Five fractures, all with retrograde nail insertion, needed secondary surgery to achieve bony healing. There was no difference in functional outcome after healing in either group. CONCLUSION: Retrograde nailing of humeral shaft fractures is technically more demanding than antegrade nailing. Fractures or fissures at the insertion point must be avoided by adequate preparation of the entry hole and careful nail insertion. Bone healing problems seem more surgeon-related than approach-related. As in every other procedure, an optimal fracture configuration and high fracture stability must be achieved.     

Retrograde femoral nailing: a focus on the knee

A consecutive series of 23 patients with reamed retrograde femoral nails was reviewed. Nails were placed through the intercondylar notch with a minimal incision. Nineteen patients with retrograde femoral nails were available at an average follow-up of 19.3 months. The union rate was 100% with no infections or malunions. No second surgeries were required for union. Knee range of motion averaged 109 degrees and was greater in those patients with shaft fractures (117 degrees) than in those with supracondylar-intercondylar fractures (91.3 degrees) (P=.02). Pain (0-3 scale) averaged 0.36. Hospital for Special Surgery knee scores averaged 80.4 (90% good or excellent results). Minor knee pain (55%) and secondary surgeries (35%) were common. The only fair or poor results were in patients with preexisting osteoarthritis. A literature review of 14 papers and abstracts was conducted. Exposure, often extensive initially, is more recently percutaneous. The infection rate is acceptable (0-14%), with knee sepsis uncommon. Lower union rates were observed for supracondylar femur fractures (80%-84%) than for femoral shaft fractures (85%-100%) after a single surgery. Second surgeries are common (14%-60%). Varus/valgus malunion, common (12%-29%) with the initial extrarticular entry site, occurs less with the intercondylar entry site. The antegrade femoral nail allows for better control of proximal shaft fractures, while the retrograde femoral nail is more reliable in controlling distal shaft fractures. Rotational malunion still remains a problem. Mild knee pain is common (13%-60%). The treatment of supracondylar femur nonunions with retrograde femoral nailing is disappointing.     

肱骨干骨折顺行与逆行髓内针固定的病例 对照研究

目的：比较肱骨干骨折顺行与逆行髓内针固定的疗效。方法：入选1999年3月至2006年10月间有完整随访资料的肱骨干骨折105例,分为顺行髓内针组（A组）82例,逆行髓内针组（B组）23例。对两组的手术时间、术中出血量、并发症发生率、骨折愈合时间、骨折愈合率、Constant—Murley肩关节功能评分和Mayo肘关节功能评分等指标进行比较。结果：随访时间平均（31．2±20．9）个月。两组的手术时间、骨折愈合时间、愈合率及并发症发生率比较差异无统计学意义（P〉0．05）。B组术中出血量大于A组（P=0．002）。A组有4例（4．9％）不愈合,8例（9．8％）发生肩痛伴肩关节活动度减小,B组3例（13．0％）术中发生医源性骨折。A组肩关节功能评分低于B组（P=0．04）,肘关节功能评分两组比较差异无统计学意义（P〉0．05）。结论：顺行与逆行髓内针固定均是治疗肱骨干骨折的有效方法,但逆行髓内针固定医源性骨折发生率较高,应正确选择和制备髓内针入点。顺行髓内针固定有较高的肩痛和肩关节活动度减小的并发症发生率,注意将髓内针尾埋于肩袖下方,细致保护和修复肩袖,术后进行合理的康复练习,有利于减少肩痛和改善肩关节功能。     

Treatment of humeral shaft delayed unions and nonunions with humeral locked nails

OBJECTIVE: To report experience with use of humeral locked nails in treating humeral delayed unions and nonunions. The following techniques yielded encouragingly good results: static locking, short-to-long segment nailing, bone grafting, fracture compression, and minimal surgical trauma. DESIGN AND METHODS: A total of 41 consecutive patients with 13 delayed unions and 28 nonunions were treated with humeral locked nails. Delay from trauma to surgery averaged 4.2 months for delayed union and 15.5 months for nonunion. The average age of patients was 50.2 years; average follow-up time was 23.2 months. There were 7 proximal-third fractures, 21 middle-third fractures, and 13 distal-third fractures. The antegrade approach was used for 13 fractures and retrograde for 28. Open nailing was performed in 39 fractures and closed nailing in 2. If the fracture motion was still present after nail insertion, axial compression of the fracture site was specially applied. Bone grafting was performed in the fractures with open nailing. Thirty-four fractures were nailed with 8-mm nails, and 7 fractures were nailed with 7-mm nails. RESULTS: With a single operation, all but two patients achieved osseous union in, on average, 5.6 months. One of these two patients eventually gained union after another surgery with fracture compression along the original nail and concurrent bone grafting. The second patient, undergoing hemodialysis for chronic renal failure, had persistent nonunion. At follow-up, for patients with antegrade nailing, all but four patients had less than 20 degrees limitation of shoulder abduction. For patients with retrograde nailing, all but two had less than 10 degrees limitation of elbow motion. Only the patient with persistent nonunion had continual pain and significant impairment of arm function. CONCLUSIONS: Humeral locked nailing seems to be effective for humeral delayed unions or nonunions. It may be an acceptable alternative for fractures unsuited for plate fixation, such as those with comminution, osteoporosis, or a severely adhered radial nerve.     

Treatment of femoral shaft fracture using unreamed interlocked nails

OBJECTIVE: To evaluate healing rates of femoral shaft fractures treated with interlocked nails inserted without reaming. STUDY DESIGN: Review of prospectively collected data. SETTING: Level I trauma center. METHODS: From the trauma registry, 159 patients with 164 femoral shaft fractures were identified who had been treated from March 1993 through December 1995 with femoral nails inserted without reaming in either an antergrade or retrograde manner. Fractures were classified according to the AO/OTA method. Patients were followed for a minimum of one year with clinical and radiographic examinations. RESULTS: One hundred twenty-one patients with 125 fractures were available for review. Average follow-up was 18.3 months (range 12 to 59 months). One hundred sixteen of the 125 fractures (93 percent) healed after the index procedure. Type A fractures healed at an average of 3.8 months (range 2 to 8 months), Type B fractures at 4.8 months (range 2 to 16 months), and Type C fractures at 6.2 months (range 3 to 12 months). There were no increases in complication rates or differences in ranges of knee and hip motion as compared with other published series. Overall, there was no difference in the length of time to union between antegrade or retrograde nailings, and the healing rates for the two methods showed only a small statistical difference. CONCLUSIONS: The use of femoral nails inserted in an unreamed manner in this series produced healing rates comparable with historic standards using reamed insertion. Smaller diameter nails inserted without reaming did not compromise fracture management and produced no increase in complication rates. The causes for delayed union or nonunion appear to be multifactorial, and secondary procedures should be considered if fractures have demonstrated little or no healing by three months.     

Trochanteric nail insertion for the treatment of femoral shaft fractures

OBJECTIVES: This study was designed to evaluate whether the use of a new femoral nail, specifically designed to be inserted through the greater trochanter, could eliminate the complications previously seen with insertion of straight nails through this entry portal for the treatment of femoral shaft fractures. DESIGN: Prospective, clinical trial. SETTING: Three level I trauma centers. PATIENTS: Sixty-one consecutive patients with femoral shaft fractures (50 closed and 11 open fractures) treated with antegrade nailing with insertion through the greater trochanter. INTERVENTION: All patients were treated in the supine position with a TAN nail (Trigen System, Smith & Nephew, Memphis, TN) inserted through the greater trochanter. MAIN OUTCOME MEASURE: Union, alignment, complications, and hip function. RESULTS: Forty-six of 57 (81%) surviving patients were available for follow-up at a minimum of 12 (range, 12-25) months. Union occurred in all but 1 fracture after the index procedure. No patient sustained iatrogenic fracture comminution, and there were no angular malunions. Pain was reported as slight in 6 patients and moderate in 2. Visual and videotaped gate analysis, performed on 24 patients, revealed symmetrical walking in 21. CONCLUSIONS: This study demonstrates that antegrade nailing of femoral shaft fractures with a specially designed nail inserted through a trochanteric starting point provides predictably high union rates and low rates of complications. Ease of entry and utility in patients with a large body habitus are advantages over conventional piriformis fossa entry techniques. Nailing through the greater trochanter with the patient supine is presently our treatment of choice for patients with femoral shaft fractures.     

Reamed intramedullary nailing of the femur: 551 cases

BACKGROUND: The care of the patient with the fractured femur entails a multiple surgical team approach. Healing of the fracture and expediency in the operating room are both important. We sought to determine the results of the treatment of fractures of the femoral shaft with interlocking femoral nails inserted with closed techniques, and to compare the outcomes of fractures nailed by using a fracture table with those stabilized with the leg draped free on a radiolucent table. METHODS: Eight hundred eighty-two consecutive patients with fractures of the femoral shaft treated with a first-generation intramedullary nail at the authors' institution during the years 1986 to 1996 were identified. Five hundred fifty-one fractures in 515 patients met the inclusion criteria. RESULTS: Treatment with an intramedullary nail led to a union rate of 98.9%. There were six infections, all occurring in closed fractures. Thirty-eight percent of the fractures had hardware removed, most commonly because of pain. One nail and 13 locking bolts broke. Four hundred eighteen fractures had adequate radiographs available to assess fracture alignment. No fracture healed with more than 10 degrees of angulation in either plane. Forty-four fractures healed with more than 5 degrees of angulation. A distal third fracture was found to be associated with an increased incidence of malalignment. There were no differences in outcomes between fractures stabilized with or without a fracture table. CONCLUSION: Reamed intramedullary nailing of femoral shaft fractures results in a low rate of nonunion, malunion, infection, and hardware failure. There is no difference in the outcomes of fractures treated with and without the use of a fracture table. This is particularly useful in the patient with multiple injuries for whom transfer to a fracture table may not be time effective.     

Subtrochanteric fractures after retrograde femoral nailing

Secondary fractures around femoral nails placed for the management of hip fractures are well known. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. Only a few reports in the existing literature have described these fractures. Two young men after sustaining a fall presented to us with pain, swelling and deformity in the upper thigh region. On enquiring, examining and radiographing them, peri-implant fractures of subtrochanteric nature through the distal interlocking screws were revealed in both patients who also had histories of previous falls for which retrograde intramedullary nailing was performed for their respective femora. Both patients were managed with similar surgical routines including removal of the existing hardware, open reduction and ace cephallomedullary antegrade nailing. The second case did show evidence of delayed healing and was additionally stabilized with cerclage wires. Both patients had uneventful postoperative outcomes and union was evident at the end of 6 mo postoperatively with a good range of motion at the hip and knee. Our report suggests that though seldom reported, peri-implant fractures around the subtrochanteric region can occur and pose a challenge to the treating orthopaedic surgeon. We suggest these be managed, after initial stabilization and resuscitation, by implant removal, open reduction and interlocking intramedullary antegrade nailing. Good results and progression to union can be expected in these patients by adhering to basic principles of osteosynthesis.     

经皮顺行交锁钉治疗股骨干骨折

目的:评价经皮顺行交锁钉治疗股骨干骨折的临床疗效.方法:对79例82处股骨干骨折采用髋部小切口经皮顺行交锁钉治疗,观察疗效.结果:75例(92%)获得了良好的解剖对位并达到一期愈合,6例(8%)迟缓愈合.另外,由于再次手术1例(1%)发生了深部感染.失血量较少(平均小于100 mL),切口平均长25 mm.1年后随访只有10%髋部疼痛.结论:与传统手术方式相比,经皮技术术中出血少、对周围组织创伤少,是一个安全又有效的方法.     

Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures

OBJECTIVES: The purpose of this study was to compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa with nails specifically designed for each starting point. DESIGN: Prospective cohort study. SETTING: Four level 1 trauma centers. PATIENTS: One-hundred and eight patients treated by 1 of 4 surgeons for a femoral shaft or subtrochanteric fracture with antegrade nailing between January 2001 and April 2003 were included. Four patients who expired early in the postoperative period and 13 with insufficient follow-up were excluded from analysis. INTERVENTION: Patients were treated with either nailing through a greater trochanter starting point with the Trigen TAN nail (GT group) (n = 38) or through a piriformis fossa starting point with the Trigen FAN nail (PF group) (n = 53). OUTCOME MEASURES: Operative time, fluoroscopy time, fracture alignment, fracture healing, complications, and functional outcome based on the lower-extremity measure (LEM). RESULTS: Thirty-seven of the 38 fractures from the GT group and 52 of the 53 fractures from the PF group healed after the index procedure. One patient from the GT group had external rotation malalignment of 12 degrees. There were no other malalignments or iatrogenic fracture comminution. There were 2 infectious complications, 1 from each group. The average operative time was 75 minutes for piriformis insertion using the FAN nail and 62 minutes for trochanteric insertion using the TAN nail (P = 0.08). The average fluoroscopy time was 61% greater for the PF group (153 seconds) than for the GT group (95 seconds) (P < 0.05). These differences were magnified in patients who were obese (body mass index > 30) where the operative time was 30% greater (P < 0.05) and the fluoroscopy time was 73% higher in the PF group (P < 0.02). Patients from both groups had a similar initial decline and subsequent improvement in function over time (P > 0.05). CONCLUSIONS: A femoral nail specially designed for trochanteric insertion resulted in equally high union rates, equally low complication rates, and functional results similar to conventional antegrade femoral nailing through the piriformis fossa. The greater trochanter entry portal coupled with an appropriately designed nail represents a rational alternative for antegrade femoral nailing with the benefit of decreased fluoroscopy time and decreased operative time in patients who are obese.     

Retrograde intramedullary nailing of femoral shaft fractures. A prospective study

Purpose of the study. Antegrade intramedullary nailing is seen as a most effective method in the management of femoral fractures. However, complications may arise due to the surgical approach.Can these disadvantages be avoided by using a retrograde approach? Material and methods. In a prospective study 70 femoral fractures in 62 patients were stabilised using a long intramedullary nail by a retrograde approach. Results. We were able to re-examine 50 patients (57 fractures) 13,3 (3–36) months after the operation.Apart from one non-union by infection, all fractures healed in time. Flexion of the knee joint was within a normal ROM in 81% of shaft fractures 12 months or more after the operation, as was the case in 44% of distal fractures. A inhibition of extension was not found in any patient.Two patients had a femoral shortening of up to one centimeter.We observed no rotational malalignement of more than 5°.The clinical results were excellent in 89% of shaft fractures, and in 50% of supra-/diacondylar fractures. In 18 cases a nail removal was already performed, thereby allowing an arthroscopical follow-up inspection of the knee joint.No knee pathology due to nailing was found in either case. Conclusion. Our results show the advantages of retrograde intramedullary nailing in comparison to the antegrade method.     

Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients

BACKGROUND: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. METHODS: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). CONCLUSIONS: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.     

Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study

BACKGROUND: Retrograde nailing of femoral shaft fractures is an effective and increasingly more popular method of fracture fixation. However, concern remains regarding the effect of the intercondylar entry-portal location on knee function. METHODS: The optimal entry-portal location was identified in cadaver femurs. Approximating the clinical intraoperative situation, a threaded guidewire was inserted into each of 26 distal femur specimens and positioned in the center of the femoral shaft as determined by anteroposterior and lateral fluoroscopic imaging. Each guidewire was then overdrilled with a 12-mm cannulated drill bit. All entry-portal locations were recorded relative to the posterior cruciate ligament attachment and the intercondylar groove and mapped relative to the known patellofemoral contact area. RESULTS: The starting holes averaged 6.21 mm anterior to the posterior cruciate ligament attachment and 2.67 mm medial to the intercondylar groove. Overall, 100% of starting portals were located in safe areas relative to the patellofemoral contact area. CONCLUSION: In the vast majority of femurs, the optimal entry portal for retrograde femoral nailing (in line with the long axis of the femur) is located in the expected safe position, anterior to the posterior cruciate ligament insertion and slightly medial to center of the intercondylar groove. However, because of anatomic variability, the ideal starting position occasionally may be located in a patellofemoral contact area. Potential compromise of the patellofemoral contact area by the retrograde nail entry portal can and should be recognized before nailing, allowing the surgeon the option of altering the surgical technique.     

The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature

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.     

股骨干骨折--逆行穿钉与顺行穿钉的探讨

在对股骨骨折进行逆行和顺行置入髓内钉治疗时,两种治疗方法产生很高的愈合率和相近的畸形愈合率。虽然未经过一致的认定,但那些接受顺行穿钉治疗的患者愈合较快。患者在接受逆行穿钉治疗后膝关节疼痛频繁出现,然而髋关节疼痛和异位骨化现象却在接受顺行穿钉治疗的患者中存在。患其它并发症的几率也无显著增长。因此不能决定功能结果。