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.     

Radiological assessment of cervical lateral mass screw angulations in Asian patients

Background:

Various lateral mass screw fixation methods have been described in the literature with various levels of safety in relation to the anterior neurovascular structures. This study was designed to radiologically determine the minimum lateral angulations of the screw to avoid penetration of the vertebral artery canalusing three of the most common techniques: Roy-Camille, An, and Magerl.

Materials and Methods:

Sixty normal cervical CT scans were reviewed. A minimum lateral angulation of a 3.5 mm lateral mass screw which was required to avoid penetration of the vertebral artery canal at each level of vertebra were measured.

Results:

The mean lateral angulations of the lateral mass screws (with 95% confidence interval) to avoid vertebral artery canal penetration, in relation to the starting point at the midpoint (Roy-Camille), 1 mm medial (An), and 2 mm medial (Magerl) to the midpoint of lateral mass were 6.8° (range, 6.3–7.4°), 10.3° (range, 9.8–10.8°), and 14.1° (range, 13.6–14.6°) at C3 vertebrae; 6.8° (range, 6.2–7.5°), 10.7° (range, 10.0–11.5°), and 14.1° (range, 13.4–14.8°) at C4 vertebrae; 6.6° (range, 6.0–7.2°), 10.1° (range, 9.3–10.8°), and 13.5° (range, 12.8–14.3°) at C5 vertebrae and 7.6° (range, 6.9–8.3°), 10.9° (range, 10.3–11.6°), and 14.3° (range, 13.7–15.0°) at C6 vertebrae. The recommended lateral angulations for Roy-Camille, Magerl, and An are 10°, 25°,and 30°, respectively. Statistically, there is a higher risk of vertebral foramen violation with the Roy-Camille technique at C3, C4 and C6 levels, P < 0.05.

Conclusions:

Magerl and An techniques have a wide margin of safety. Caution should be practised with Roy-Camille''s technique at C3, C4, and C6 levels to avoid vertebral vessels injury in Asian population.