Session IX - Femur
Sat, 10/9/04 Femur, Paper #54, 4:41 pm
Anterograde vs. Retrograde Femoral Nailing: A Prospective Randomized Evaluation
Purpose: We compared anterograde with retrograde nailing of isolated femoral shaft fractures.
Methods: Patients with isolated femoral shaft fractures who consented were enrolled in an approved trial and randomized to anterograde (AG) or retrograde (RG) nailing. All nails were locked statically and considered canal-filling; they were placed after reaming 1 to 1.5 mm over the inner cortical diameter as judged intraoperatively by cortical chatter. Follow-up was at regular intervals, and patients were evaluated by physical examination (active and passive range of motion, gait, and strength), activity questionnaire (pain, level of activity, work capacity, putting on shoe/sock, stair-climbing, rising from seated position, walking capacity, unsupported walking, and type of pain medication used), and SF-12 outcome analysis. Union was defined as bridging callus seen on two orthogonal radiographs combined with a non-tender fracture site. A consistent rehabilitation protocol was used for both groups.
Results: Fifty-one patients with AG and 67 with RG nails were observed to fracture union or re-operation for nonunion. There was one nonunion in the AG group and two in the RG group. The average followup was 245 and 240 days, respectively. Range of motion was slightly greater at the knee in the AG group (129° vs. 124°, P = 0.08), and this group trended toward easier stair-climbing (P = 0.08). No other value approached significance, with P values ranging from 0.33 to 0.93. The average patient (for both groups) had mild pain, was able to perform light labor, was able to walk without assistance for 30 to 60 minutes, had an apparently normal gait, and took non-narcotic or no medication. Outcome data was not different between the groups, with physical component scores averaging 37 ± 10 and 36 ± 10, and mental component scores averaging 51 ± 9 and 50 ± 10 for the AG and RG groups, respectively. More patients in the RG group required implant removal for local complaints at the knee (16% vs. 8%). Shortening was more common in the RG group (7% vs. 1%), but was not >1.5 cm in any case.
Conclusions: Anterograde and retrograde nailing are both acceptable treatments for femoral shaft fractures. Although better range of motion and walking on stairs trended toward significance in the AG group, when statistical correction for multiple outcome measurements was made, no variable was significant. For adequate power for most of the outcome assessments, >3,000 patients would be needed in each group. In this series, retrograde nailing was comparable to the gold standard of anterograde nailing. Significant disability still existed in both groups of patients between union and 1-year follow-up. Surgeons should tailor their choice of nail approach to the individual patient, operative situation, and personal experience, as it is unlikely that a large difference exists between AG and RG nailing with regard to any outcome variable.