Sat., 10/18/08 Femur, Paper #53, 10:11 am OTA-2008
Factors Affecting the Incidence of Complications with Retrograde Nailing of the Femoral Shaft
Eric Fulkerson, MD (n); H. Claude Sagi, MD (a,b,c,e-Smith + Nephew; b-AO; b,e-Stryker;
a,e-Synthes); George J. Haidukewych, MD (a,b,c,e-DePuy, A Johnson & Johnson Company;
d-Surmodics); Roy Sanders, MD (a-DJ Orthopaedics, Encor Medical, Link Orthopaedics,
Medtronic Sofamor Danek, Pfizer, Synthes, Tornier, Twin Star Medical, Zimmer; a,c-DePuy,
A Johnson & Johnson Company; a,c-Stryker; a,c,e- Smith + Nephew; c-Linvatec);
Tampa General Hospital, Florida Orthopaedic Institute, Tampa, Florida, USA
Purpose: Retrograde nailing of femoral shaft fractures has become an accepted treatment of femoral shaft fractures. This study reviews the impact of nail diameter, nail length, number of proximal locking bolts, and fracture pattern on complication rates.
Methods: Diaphyseal femur fractures (AO/OTA 32) treated at a single institution with retrograde femoral nailing were retrospectively reviewed over a 10-year period (1997-2007). All skeletally mature patients with follow-up until fracture healing were included. Exclusion criteria included patients with an ipsilateral femoral implant (eg, sliding hip screw, total hip, or total knee prosthesis). This resulted in a study population of 238 patients with 243 fractures with a mean age of 35 years (range, 15-84). There were 129 OTA type 32A, 67 32B, and 47 32C fractures. 40 were open injuries (Gustilo-Anderson type I, 10; II, 8; IIIA, 19; IIIB, 1; and IIIC, 2). Nail diameters used were less than 10 mm (n = 13), 10 mm (n = 118), and greater than 10 mm (n = 112). 119 nails had 2 or more proximal locking bolts, 110 had 1 proximal bolt, and 14 had no proximal locking bolts. Nail lengths were measured according to position relative to the lesser trochanter: 102 were proximal to, 117 at the level of, and 24 distal to the lesser trochanter. Delayed union and nonunion were defined using the criteria of Brighton. Nonunion, delayed union, loss of reduction, and infection were the complications of interest for this study.
Results: There were 25 complications that required reoperation (10.3%). There were 9 nonunions, 15 delayed unions, and 1 deep infection requiring removal of the implant. Loss of reduction or implant failure occurred only in those fractures associated with delayed or nonunion. No significant differences in complication rates with regard to nail length, number of proximal locking bolts, or OTA classification (32A,B,C) were seen. Although AO/OTA fracture classification was not statistically relevant, shaft fractures with extension into the distal metadiaphyseal junction did have a higher complication rate, resulting in 8 complications in 24 patients (P = 0.03). Finally, femoral fractures treated with a nail diameter of less than 10 mm had a significant increase in complications (P = 0.047).
Conclusion and Significance: In our series, union of femoral shaft fractures treated with retrograde nails does not appear to be dependent on the number of proximal locking bolts, or the position of the nail relative to the lesser trochanter. The fracture pattern based on the OTA fracture classification did not influence union; however, fractures with distal metadiaphyseal extension had a significantly higher complication rate. Furthermore, nail diameters of less than 10 mm were associated with a significant increase in complications. Based on these findings, we recommend the use of retrograde nails with a diameter of 10 mm or greater, and adjunctive fixation techniques when treating fractures that extend into the distal metadiaphysis.
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.