Session IX - Femur Fractures

*Retrograde Intramedullary Nailing of Femoral Diaphyseal Fractures

Robert F. Ostrum, MD, Joseph DiCicco, DO, Ronald Lakatos, MD, Attila Poka, MD

Grant Medical Center, Columbus, Ohio, USA

Purpose (Hypothesis): Retrograde nailing of femoral diaphyseal fractures has many advantages, especially in the multiply-traumatized patient. The purpose of this study was to critically examine a prospective series of femoral shaft fractures treated with a retrograde intramedullary nail to assess the results and problems associated with this device.

Methods: All patients with femoral shaft fractures from the lesser trochanter to the supracondylar femur (OTA types 32 and 33 A & C), without exception, had a reamed intramedullary nail inserted through a retrograde technique. Fifty-three patients with fifty-five fractures were treated in a prospective, consecutive series. All nails were statically locked and inserted with the nail tip proximal to the base of the lesser trochanter. The following data was collected for all patients: operative time, blood loss, extent of comminution, open grade, associated injuries, ISS, knee range of motion, Body Mass Index (BMI), time to union, secondary procedures and complications.

Results: Fifty-five femoral shaft fractures were treated with reamed retrograde femoral nailing in a consecutive series. The average ISS was 16.6 with only ten patients having an isolated femur fracture. Two patients died in the early post-injury period and five patients were lost to follow-up. These are the results of our initial forty-eight fractures. Follow-up ranged from 4.5 to 14 months. There were 7 ipsilateral femoral neck and shaft fractures, 7 subtrochanteric, 28 isthmal, 19 infra-isthmal, and 10 supracondylar fractures of which 4 had intra-articular extension. Thirteen fractures were open: four Grade 1, three Grade 2, and six were Grade 3. Utilizing the Winquist classification for comminution there were fourteen type 1, sixteen type 2, nine type 3, and sixteen type 4. Ten patients were severely overweight (BMI 31-45) and one morbidly obese (BMI>45). The average operative time was 83.3 minutes and the estimated blood loss was 228 cc.

Forty-three of the forty-eight (90%) fractures healed after the initial nailing procedure. The average estimated time to union was 12.6 weeks. One patient with segmental bone loss required a bone graft and united. Four patients (8 %) required dynamization to achieve union. There was only one nonunion (2%) with rod fatigue failure in a subtrochanteric fracture. This healed with an exchange antegrade nailing. No patient with an open fracture developed infection or a septic joint. All patients without associated complications achieved full extension and flexion of at least to within ten degrees of their contralateral limb within twelve weeks. One patient with a dislocated knee and one patient with compartment syndrome and heterotopic bone in the quadriceps did not achieve full motion. Twenty-three patients were treated with a CPM machine in the early postoperative period. There was no difference in the twelve-week or final knee motion when compared to those without CPM. Complications included one broken nail, one broken screw, and seven patients (15%) desired removal of symptomatic distal screws.

Discussion: Retrograde femoral nailing has been recommended for patients with ipsilateral pelvic, femoral neck or acetabular fractures, pregnant patients, obese patients, and multiply-traumatized patients. There have been concerns about the effect of an intraarticular starting point on knee function. Our results show a 90% union rate with the primary nailing procedure and only one nonunion of a subtrochanteric fracture. All patients without associated complications attained full extension and near full flexion. The procedure was easier to perform in the multiply-injured patient and should be considered the treatment of choice for ipsilateral femoral neck fractures and floating knees.

Conclusions: Retrograde femoral nailing yielded an excellent union rate with no associated knee morbidity. It should be given serious consideration as an alternative to antegrade nailing of femoral shaft fractures. The role of retrograde nailing in subtrochanteric fractures requires further investigation.