Session IX - Femur Fractures

*Retrograde Nailing of Femur Shaft Fractures for Specific Indications: Ten Year Experience

Thomas A. DeCoster, MD, George Brown, MD, Brian Robinson, MD

University of New Mexico Medical Center, Albuquerque, New Mexico, USA

Purpose: The purpose of this study was to identify the results of selective retrograde intramedullary nailing of femur shaft fractures for specific indications over the past 10 years at our institution with one primary surgeon.

Methods: A retrospective review of 38 patients with retrograde nailing of femur shaft fractures with 1-10 year followup with identification of benefits and complications, especially those relating to the starting point, were evaluated. Ease of insertion was compared to our series of antegrade nails where the time to accomplish each step in nailing was prospectively measured. The specific indications were: A. Monomelic injuries [femur shaft plus tibia shaft (6); femur shaft plus patella (3); femur shaft plus proximal femur (5); femur shaft plus acetabulum (6); femur shaft plus thigh abrasion (1); femur shaft plus distal femur (7)] B. Multiple trauma [bilateral femoral shaft (4); femoral shaft plus unstable spine fracture (2); femoral shaft plus pelvic ring disruption (2)] C. Body type [patients greater than 400 pounds (2)].

Results: These 38 patients all healed with results similar to antegrade nailing. The theoretical advantages of ease of positioning in the OR, entry site access, and nail passage were supported by a 30% - 44% reduction in time of each step. Early knee motion was impaired but there was no permanent stiffness. The theoretical concerns of injury to the knee joint were not demonstrable in this series. There were two meniscal injuries found on initial exploration. Arthroscopically assisted nail removal has been accomplished in 10 patients without difficulty. One nail was inserted with arthroscopic assistance.

Discussion: Although antegrade nailing of femoral shaft fractures has a high success rate, there are technical problems relating to positioning multiply-injured patients on a fracture table in the OR and a variety of problems relating to entry site in the piriformis fossa (technically difficult and time consuming, difficult radiographic imaging, unrecognized malposition, heterotopic ossification, blood loss, false passage with the awl, soft tissue impedence, proximal femur fracture and fracture displacement). Although these problems can usually be overcome by the experienced surgeon, retrograde nailing with the patient supine on a regular OR table utilizing an intercondylar entry site is technically easier, less time consuming, and puts less stress on other injured body parts and allows easier access to other fractures in need of acute stabilization. Subsequent acetabular exposure is not compromised by a hip incision. Knee pathology can be directly identified and treated. The risk to the knee joint from arthrotomy and femoral penetration is a significant theoretical concern but did not result in major complications in this series, although a larger series specifically measuring this problem would be required before routinely recommending this technique.

Conclusion: Retrograde nailing of femoral shaft fractures for specific indications has given good results with no major complications over the past 10 years and specific comparative study of this technique for a variety of indications is warranted.