Sat., 10/18/08 Femur, Paper #52, 10:05 am OTA-2008
Is It Safe to Treat Open Femur Fractures with Retrograde Nails? An Analysis of Postoperative Septic Arthritis
Kevin Riche, MD1 (n); Lisa K. Cannada, MD2 (a-Zimmer, Foundation for Orthopaedic Trauma
and Southeast Fracture Consortium; b-Smith + Nephew; e-Medtronic Sofamor Danek);
Robert V. O’Toole, MD3 (a-AO, DePuy, FOT, Smith + Nephew, Stryker, Synthes, Wyeth;
e-Synthes); Marcus F. Sciadini, MD3 (a-AO, DePuy, FOT, Smith + Nephew, Stryker, Synthes,
Wyeth; e-Stryker); Lewis Shi, MD1 (n); Mathew Woodford3 (n);
Mitchel B. Harris, MD1 (a-DePuy, Medtronic, Synthes; a,b-Zimmer; e-Globus);
1Brigham & Women’s Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA;
2Parkland Medical Center, Dallas, Texas, USA;
3R. Adams Cowley Shock Trauma Center, Department of Orthopaedics,
University of Maryland School of Medicine, Baltimore, Maryland, USA
Purpose: The use of retrograde nails for the treatment of open femur fractures has been described as a “relative contraindication” due to the presumed increased risk of septic arthritis. Our hypothesis is that the incidence of a secondary knee infection is low.
Methods: A retrospective review of the trauma registry/fracture database of four Level 1 trauma centers was utilized to identify all open femur fractures that were treated with retrograde intramedullary nailing from January 1, 2003 to February 15, 2007. Ballistic injuries were excluded, as were patients with less than 1-month follow-up. A septic knee was defined as any infection of the knee that required reoperation with arthrotomy or arthroscopy.
Results: 100 open femur fractures were identified in 100 patients. Follow-up ranged from 1 to 40 months (average 11 months). The injuries were graded by the Gustilo classification and consisted of 8 type I injuries, 16 type II injuries, and 76 type III injuries. Two of the type III injuries required flap coverage and two had associated vascular injuries. There was one septic knee identified in our combined series. This occurred 2.5 years after the index procedure, following a quadricepsplasty. The nail had been removed 1.5 years prior to the reconstruction. Four of the traumatic thigh wounds became infected and were successfully treated with local irrigation and débridement, but in none of these did the traumatic wound infection lead to septic arthritis.
Conclusions: Previous publications have argued that retrograde nailing of open femur fractures provides a conduit for knee joint infection. Our data demonstrate that the risk of a septic knee as a direct result of retrograde nailing of an open femur fracture is relatively low with our rate of 0% (0 of 100; 95% confidence interval, 0.0% to 2.9%). Additionally, despite four local wound infections, there were still no associated knee infections. The incidence of secondary knee infection is thus comparable to the only previously published literature identifying the incidence (0.18%) in the treatment of both open and closed femur fractures treated via retrograde nailing techniques. To our knowledge, this is the first case series to document the relative safety associated with retrograde nailing of open femur fractures.
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.