Session II - Post-Traumatic Reconstruction

*Arthroscopically Assisted Removal of Retrograde Femoral Nails: Description of Technique and Intraarticular Findings at Long-Term Follow-Up

Christopher T. Born, MD, FACS (a-Smith + Nephew, Synthes, USA, Howmedica; b-Zimmer; e-Stryker Howmedica Osteonics); Paul J. King, MD; Lisa Khoury, MD; William G. DeLong, Jr., MD, FACS (a-Smith + Nephew, Synthes, USA, Howmedica); University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA (-AO North America Grant)

Purpose: Numerous studies have supported the use of retrograde nailing for the management of femur fractures. Many of the patients who had a femur fracture treated with retrograde nailing develop some degree of postoperative knee pain. Concern has been expressed regarding the potential for injury of the patellofemoral articulation as well as for the development of intraarticular metallosis. To date, there is little information about the long-term postoperative intraarticular milieu after retrograde nailing, especially in the patient with a painful knee. The purpose of this paper is to report the intraoperative findings, indications for, and the clinical results of knee arthroscopy at the time of retrograde femoral nail removal. We also describe the principles of the arthroscopically assisted technique that we have developed.

Methods: Over a 9-year period, 16 patients underwent arthroscopically assisted removal of retrograde femoral nails. These included 11 because the nail was considered a possible source of knee pain, 3 for chronic infection, and 1 each as a preoperative measure before additional surgery and for peace of mind. The mean time to removal was 20.5 months after insertion. The outpatient technique utilizes two standard arthroscopic portals in addition to a limited infrapatellar tendon-splitting incision. Location of the buried distal nail end is by orthogonal intraoperative fluoroscopy. Operative findings were reviewed retrospectively for the first 6 years and prospectively for the last 3 years.

Results: Fifteen of sixteen nails (94%) were successfully removed with use of this technique. One patient required a formal arthrotomy after the arthroscopy in order to remove intraarticular lag screws. In all cases (100%), the distal end of the nail and the entry portal were covered by fibrous reparative tissue. No patient was found to have any changes at the patellofemoral articulation that could be attributed directly to the nail. There was no evidence of intraarticular metallosis in any case. Fourteen of 16 patients (88%) were found to have some identifiable intraarticular pathologic condition that was treated at the time of arthroscopy, and some patients had more than one lesion. They included eight patients with osteochondral injuries, seven with significant adhesions, and two with loose bodies. The injuries were appropriately managed at the time of arthroscopy. Three patients had infections that were cultured and debrided. Five meniscal tears were found (four were debrided and one was repaired), and two ACL tears were diagnosed and debrided. There was one complication (6%) in the form of a postoperative hemarthrosis that resolved uneventfully with aspiration. In the two patients with non-painful knees who were having the nails removed either for "peace of mind" or as a precursor to a second procedure, no significant pathologic condition was found at arthroscopy.

Discussion and Conclusions: This technique allows for the evaluation and treatment of potentially painful intraarticular pathologic conditions after femur fracture and subsequent retrograde nailing. In our series, 88% of patients were found to have some identifiable pathologic condition most likely related to the index injury and not to the nail or its insertion. Despite early concerns to the contrary, the clinical impression of most orthopaedic traumatologists that the patellofemoral joint is spared after proper recessing of the nail appears to be borne out by this study. The presence of intraarticular metallosis has not been substantiated. This technique is safe, avoids the morbidity associated with open arthrotomy, allows for nail removal on an outpatient basis, and promotes accelerated rehabilitation.