Prospective study of 30-cases of fracture distal third femur managed by retrograde distal femoral intramedullary nail

Abstract

Background and objectives: Fracture of distal third of femur is encountered because these fractures most often result from high velocity injuries as femur is the largest bone of the body. It is one of the principal load bearing bones in the lower extremity [1]. One must have a high index of suspicion for complications or other injuries as it can cause prolonged morbidity and extensive disability like joint stiffness due to post traumatic arthritis unless treatment is appropriate. Distal femur fractures make up to 6% of all femoral fractures. Most high energy distal femoral fractures occur in males 15-50 years and low energy fractures occur in osteoporotic women more than 50. Most commonly RTA 53% and fall at home 33% [7]. In rural India, workplace injury such as fall from height is also common. Currently surgery is indicated for femur fractures because of high rate of union, low rate of complication and advantage of early stabilization which decreases morbidity and mortality in patients. Regardless of the method of treatment, the following principles are agreed upon i.e. restoration of alignment, rotation and length, preservation of blood supply to aid union, prevent infection, rehabilitation of the extremity and there by the patient [4]. A method closely approaching this perfection is retrograde intramedullary interlocking nailing which improves the torsional and axial stability and offers a more biological method of fixation with less devitalisation of soft tissues [4, 8]. It has improved post-operative knee function with decreased operative time, blood loss, bone grafting, and non-union rates [8]. Result is early recovery, lesser hospital stay, early rehabilitation with good results and is economical [6]. Surgical stabilization of osteoporotic bones and pathological fractures has increased due to retrograde nails [6].The present study is to understand the functional outcome and to minimize operative mistakes and complications of surgical management of distal femur fractures with retrograde nailing.Methods: 30 patients with supracondylar femur fracture were studied, in Anil Neerkonda Hospital, NRI institute of Medical Sciences. Visakhapatnam in between June 2016 to May 2018. RIS nail was inserted through intercondylar notch. These nails have advantage of being load shearing devices, requiring little soft tissue dissection, infrequently needing bone grafting and technically easier. Preserving fracture hematoma, decreased blood loss, less operative time and decreased infection.Results: In 30 patients, male predominate (93.3%) in this study. RTA was the chief cause of fracture. Surgery was performed within 1.9 days average, there were 5 open type and 25 closed type of fracture. radiological union was seen in 16-24 weeks. Average patient was followed up for 6 months. Average knee flexion was 115°. 1 died, 1 screw breakage and 2 had pulmonary embolism. 3 shortening of limb, 3 stiffness and 7 delayed union. 15(51.7%) excellent results, 6(20.6%) good results, 7(24. %) fair results and 1(3.4%) poor result.Interpretation and Conclusion: Retrograde intramedullary nailing is a good fixation system for supracondylar femur fractures with less operative time and blood loss. By closed reduction, not disturbing fracture hematoma and even in open reduction less soft tissue dissection and thus reducing complications like infection, stiffness, distal screw related local symptom is a common problem and is related to implant and technique and has a definite learning curve. Utmost aseptic precaution great care required to prevent infection. Non-requirement of bone graft decreases the morbidity. Early surgery, closed reduction, at least two screws in each fragment and early post-operative knee mobilization are essential for good union and good knee range of motion.