Sat., 10/18/08 Femur, Paper #49, 9:40 am OTA-2008
Piriformis versus Trochanteric Antegrade Nailing of Femoral Fractures: A Prospective Randomized Study
James P. Stannard, MD (a-Smith + Nephew, Synthes);
David A. Volgas, MD (a-Biomet (Interport-Cross), Smith + Nephew, Synthes, Pfizer);
Larry S. Bankston, MD (n); Jonathan K. Jennings (n);
Rena L. Stewart, MD (a-Synthes, Wyeth, OTA); Jorge E. Alonso, MD (e-Synthes);
The University of Alabama at Birmingham, Birmingham, Alabama, USA
Purpose: The purpose of this study is to compare functional and clinical outcomes in patients following intramedullary nailing using either the trochanteric or piriformis starting points.
Methods: This study is a prospective, randomized and blinded IRB-approved clinical trial comparing trochanteric (study) and piriformis (control) antegrade nailing. Data obtained at follow-up include: WOMAC score, weight-bearing status, radiographic healing, and clinical healing. Blinded functional evaluations were performed by a physical therapist. Patients were evaluated through use of the chair-stand test, timed up-and-go test, presence of a limp, hip abduction strength, and range of motion.
Results: 54 patients with 55 total femur fractures were randomized to the control group, and 56 patients with 59 total femur fractures to the study group. Control patients took a mean of 22.9 weeks to achieve radiographic union and 31.8 weeks to achieve clinical union. Study patients had almost identical results, with radiographic union at 23.1 weeks and clinical union at 31.4 weeks. There were 3 (5.5%) nonunions in the piriformis group compared to 1 (1.7%) in the trochanteric group. Heterotopic ossification (HO) was present in 47% of control patients compared to 31% of study patients. More importantly, grade III or IV HO was present in 10 (18.2%) control patients compared to only 1 (1.7%) study patient. WOMAC scores for the controls were 30.2 at 6 months and 25.7 at 12 months, compared to 34.6 and 25.4 for study patients. Evaluations of hip muscle strength and function in both groups showed a trend toward improved function, increased gluteus medius strength, and increased tensor fascia latae strength with the trochanteric nail start point. However, the difference is not statistically significant.
Conclusion: The trochanteric entry point is a relatively recent development in antegrade femoral nailing. We have previously reported significant differences in intraoperative results (incision length, fluoroscopy time, blood loss, surgical time) in favor of trochanteric nailing. However, some surgeons have expressed concern regarding the potential for hip abductor damage with trochanteric nailing. The Level 1 data from this study suggest that functional outcomes are equivalent between the two groups, with trends toward improved function in the trochanteric group compared with the piriformis group.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.