Session V - Femur

Retrograde vs. Antegrade Nailing of Femoral Shaft Fractures

William M. Ricci, MD; Carlo Bellabarba, MD; Michael O'Boyle, MD; Robert G. Lewis, BA; Dolfi Herscovici, DO; Thomas DiPasquale, MD; Roy W. Sanders, MD, Washington University, St. Louis, MO; Tampa General Hospital and the Florida Orthopedic Institute, Tampa, FL

Purpose: The purpose of this study was to examine fracture reduction after intramedullary nailing of femoral shaft fractures and to compare results of antegrade versus retrograde techniques.

Methods: Between November 1992 and May 1998, 359 consecutive femoral shaft fractures were treated with intramedullary nailing. Immediate post-operative radiographs were available for review in 341 fractures (95%) and served as the study group. 175 femoral nails were inserted antegrade (51%), while 166 were placed retrograde through the intercondylar notch of the knee (49%). The choice of antegrade or retrograde insertion was at the surgeon's discretion. There were 56 proximal third fractures (41 treated antegrade and 15 retrograde), 197 middle third fractures (105 treated antegrade and 92 retrograde), and 88 distal third fractures (29 treated antegrade and 59 treated retrograde. The fracture patterns were classified according to the AO classification and the Winquist classification. Goniometric measurements were made on the AP radiograph to determine varus or valgus angulation and on the lateral radiograph to determine flexion or extension angulation. Two definitions of malreduction were used. "(5/5)" was defined as greater than five degrees of varus or valgus deformity or greater than five degrees of flexion or extension deformity. "(5/10)" was defined as greater than five degrees of varus or valgus deformity or greater than ten degrees of flexion or extension deformity.

Results: Using the (5/5) criteria for malreduction: 30% of proximal fractures, 3% of middle, and 10% of distal fractures were malreduced. Antegrade nailing was associated with 11% malreductions and retrograde nailing 7%. Malreduction of proximal third fractures occurred in 27% of cases treated antegrade and in 40% of those treated retrograde. Malreduction of middle third fractures occurred in 3% of cases treated antegrade and 2% of those treated retrograde. Malreduction of distal third fractures occurred in 17% of cases treated antegrade and in 7% of those treated retrograde.

Using the (5/10) criteria for malreduction: 23% of proximal fractures, 1% of middle, and 6% of distal fractures were malreduced. Antegrade nailing was associated with 7% malreductions and retrograde nailing 4%. Malreduction of proximal third fractures occurred in 22% of cases treated antegrade and in 27% of those treated retrograde. Malreduction of middle third fractures occurred in 1% of cases treated antegrade and in 0% of those treated retrograde. Malreduction of distal third fractures occurred in 10% of cases treated antegrade and in 4% of those treated retrograde.

Conclusions/Significance: Proximal fractures of the femoral shaft are the most difficult to reduce using intramedullary nail techniques. Proximal third fractures of the femoral shaft were better reduced with antegrade nailing ([5/5] criteria 27% malreduction, [5/10] criteria 22% malreduction) than with retrograde nailing ([5/5] criteria 40% malreduction, [5/10] criteria 27% malreduction). Excellent reduction of middle third fractures of the femoral shaft can be accomplished with either antegrade or retrograde nailing techniques (0% - 3% incidence of malreduction). Distal third fractures of the femoral shaft were better reduced with retrograde nailing ([5/5] criteria 7% malreduction, [5/10] criteria 4% malreduction) than with antegrade nailing ([5/5] criteria 17% malreduction, [5/10] criteria 10% malreduction).