Antegrade Nailing Research Articles

Management of Unstable Tibial Shaft Fracture with Titanium Elastic Nails in Children: Unstable Tibial Shaft Fracture

Objectives: to evaluate radiological and functional outcomes of Titanium elastic nails (TEN) in pediatric patients with tibial shaft fractures. Methods: Study wasprospective design. A total number of forty patients were treated who were presented with tibial shaft fracture. Patients were treated with TEN. In every patient antegrade nailing was performed by inserting a TEN in the medial side of metaphysic and another TEN in the lateral side of the proximal metaphysis. Main outcomes were leg length inequality, union, malunion and complications. SPSS version 23 was used for data analysis. Result: Functional result (Flynn Criteria) was excellent in 38.5% patients and satisfactory was in 61.5% patients. Patients were treated with TEN. In every patient antegrade nailing was performed by inserting a TEN in the medial side of metaphysic and another TEN in the lateral side of the proximal metaphysis. Main outcomes were leg length inequality, union, malunion and complications. SPSS version 23 was used for data analysis. Result: Functional result (Flynn Criteria) was excellent in 38.5% patients and satisfactory was in 61.5% patients. Conclusion: Unstable pediatric tibial shaft fractures can be treated ideally through intramedullary fixation technique withtitanium elastic nailing even untreated cases of conservative management and those cannot be reduces due to presence of open wound or edema.

Spiral fractures in the distal third of the femoral shaft in elderly treated with antegrade nailing and STABLE-LOK Nut®: case report

We present the case of a 90-year-old woman with a traumatic a spiral distal femur shaft fracture. The patient underwent surgery for reduction and fixation of the fracture with an intramedullary antegrade nail. The patient was re-evaluated during the course of a clinical and radiographic follow-up. There were no infectious problems and the patient was able to resume normal activities for her age. Distal femur shaft factures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. They are always challenging for the surgeon, especially in terms of choosing the correct fixation method. Early reduction and stable fixation with a mini-invasive approach are essential for a good outcome in elderly patients.

Time to entry point and distal locking of intramedullary nails: a methodological phantom study comparing biplanar and uniplanar surgical imaging

BackgroundIntramedullary nailing is the method of choice for diaphyseal fractures of the femur and tibia and is also commonly used to treat trochanteric hip fractures. Perioperative imaging is essential for visualising adequate reduction, achieving an optimal entry point (EP) and performing distal locking (DL) of intramedullary nails. This methodological study aims to compare biplanar and uniplanar imaging in some steps of intramedullary nailing.MethodsWe used a biplanar preassembled imaging device (Biplanar™ 600s, Swemac Imaging) and a uniplanar imaging device (Ziehm Solo FD, Ziehm Imaging) to measure procedural and radiation times for antegrade and retrograde femoral and antegrade tibial nailing in fully soft flexible tissue encased legs with radiopaque sawbones (SKU:1515–7-11, Sawbones Europe, Malmö, Sweden). Four orthopaedic surgeons with different levels of experience performed all procedures in all three phantoms with both image techniques in random order, producing in total 12 EPs and nailings with DL with each imaging device. Time to EP, radiation times, time to DL for both devices and the number of swings of the uniplanar device for the two procedures were measured. Comparisons between the biplanar and uniplanar systems with a paired-samples t-test were conducted.ResultsUsing the biplanar device, time to optimal EP was shorter for retrograde femoral (26 s (SD15) vs 35 s (SD13), p = 0.01) and for antegrade tibial nailing (23 s (SD13) vs 49 s (SD24), p = 0.001). No statistically significant differences in time to EP, radiation time or time to DL were found for antegrade femoral nailing. A median of two swings of the uniplanar device was needed to obtain optimal EP for all procedures.ConclusionsBiplanar imaging slightly but statistically significantly reduced time to EP for retrograde femoral and antegrade tibial nailing in this methodological study comparing biplanar and uniplanar imaging techniques. Biplanar imaging can reduce time and radiation exposure when defining the EP around the knee in intramedullary nailing procedures, but the clinical relevance of these time savings remain to be defined. For antegrade femoral nailing we found no clear benefit with biplanar imaging in the investigated steps of nailing.

Effect of nailing technique on length of stay in isolated ballistic femoral shaft fractures.

The purpose of this study was to investigate length of stay, postoperative mobilization and discharge disposition following intramedullary nailing of ballistic femoral shaft fractures stratified by nailing technique. All adult patients with isolated ballistic femoral shaft fractures between May 1, 2018, and September 1, 2021, were reviewed. The final cohort included 69 ballistic femur fractures in 69 patients. Of the 69 patients included, 29 were treated with retrograde nailing while 40 were treated with antegrade nailing. The average length of stay of patients treated with antegrade nailing was 2.55days (SD 1.3days) compared with 3.45days (SD 2.3days) for patients treated with retrograde nailing; this was statistically significant (P = 0.04). Median steps on POD1 for antegrade nailing were 20 and 8 for retrograde. There was no significant difference in VAS pain scores between the two cohorts. All patients were discharged home. The average length of stay for patients who underwent antegrade nailing was significantly shorter when compared with the retrograde nailing. Patients in the antegrade cohort mobilized further than the retrograde cohort in the immediate postoperative setting. We found no significant difference in VAS pain scores between the two cohorts.

ANTEGRADE NAILING VERSUS LOCKING PLATE OF 2-AND 3-PART PROXIMAL HUMERUS FRACTURES.

To evaluate and compare the proportions of complications and radiographic findings of osteosynthesis of 2- and 3-part proximal humerus fractures with two methods of treatment: third-generation antegrade nailing and locking plate. 46 patients with a mean age of 58.9 ± 16.6 years between January 2020 and January 2021 were evaluated. In sixteen cases (34.8%), antegrade nailing was used, and in thirty cases (65, 2%), a locking proximal humerus plate. The method used included the rate of complications with a minimum follow-up of 6 months after surgery and radiographic evaluation. There was no difference between the groups regarding the proportion of complications (nail group 18.8%, plate group 13.3%; p = 0.681). The nail group had less residual varus loss (cervicodiaphyseal angle nail group with 132.1º ± 2.3º, plate group 123.8º ± 10.1º; p < 0.001). In the plate group, women had the lowest value (1.43 ± 0.22) of the deltoid tuberosity index (DTI) compared to men (1.58 ± 0.11) (p = 0.022). Osteosynthesis, with a locking plate and antegrade nailing, did not show differences in the proportion of complications. The nail group had less change in the postoperative cervicodiaphyseal angle, however, there were two serious complications with screw cut-out and varus deviation, requiring surgical reapproach. Level of Evidence II, Retrospective Observational Study.

Long-term functional outcome of knee after antegrade versus retrograde intramedullary nailing for femoral fracture

ObjectivesTo evaluate functional outcomes of the knee after antegrade and retrograde intramedullary nailing for femoral shaft fractures in adults.BackgroundAntegrade reamed interlocked intramedullary nailing is the treatment of choice for femoral diaphyseal fractures. More recently, retrograde intramedullary nailing of the femur has been seen as a viable alternative to the antegrade nailing.Patients and methodsThis was a prospective comparative study. A total of 40 patients were divided randomly by a closed envelope technique into two equal group: group A (antegrade nailing) and group B (retrograde nailing). A total of 20 patients with shaft femur fractures had interlocking intramedullary fixation via the antegrade nailing approach (group A), whereas another 20 patients with shaft femur fractures had fixation via the retrograde approach (group B).ResultsThe mean age of group A was 25.10 ± 10.41 years and 31.35 ± 10.11 years in group B. There were no significant adverse effects reported in both groups. The mean follow-up duration was 25.20 ± 8.39 months in group A and 25.00 ± 6.91 months in group B (P = 0.759). The mean Tegner Lysholm knee scoring scale was 94.05 ± 4.43 in group A and 82.45 ± 8.83 in the group B (P < 0.0001). Regarding Tegner Lysholm knee scoring scale categorization, group A recorded 90% as excellent, whereas group B revealed 65% as good.ConclusionOur study suggests that antegrade intramedullary femoral nailing fixation is favorable over retrograde nailing in knee function, range of motion, and knee pain for diaphyseal femoral fracture in adults using Lysholm knee function scoring.

Biomechanical analysis of recently released cephalomedullary nails for trochanteric femoral fracture fixation in a human cadaveric model.

Recently, two novel concepts for intramedullary nailing of trochanteric fractures using a helical blade or interlocking dualscrews have demonstrated advantages as compared to standard single-screw systems. However, these two concepts have not been subjected to a direct biomechanical comparison so far. The aims of this study were to investigate in a human cadaveric model with low bone quality (1) the biomechanical competence of nailing with the use of a helical blade versus interlocking screws, and (2) the effect of cement augmentation on the fixation strength of the helical blade. Twelve osteoporotic and osteopenic human cadaveric femoral pairs were assigned for pairwise implantation using either a short TFN-ADVANCED Proximal Femoral Nailing System (TFNA) with a helical blade head element or a short TRIGEN INTERTAN Intertrochanteric Antegrade Nail (InterTAN) with interlocking screws. Six osteoporotic femora, implanted with TFNA, were augmented with bone cement. Four groups were created: group 1 (TFNA) paired with group 2 (InterTAN), both consisting of osteopenic specimens, and group 3 (TFNA augmented) paired with group 4 (InterTAN), both consisting of osteoporotic specimens. An unstable trochanteric AO/OTA 31-A2.2 fracture was simulated and all specimens were tested until failure under progressively increasing cyclic loading. Stiffness in group 3 was significantly higher versus group 4, p = 0.03. Varus (°)and femoral head rotation around the femoral neck axis (°) after 10,000 cycles were 1.9 ± 1.0/0.3 ± 0.2 in group 1, 2.2 ± 0.7/0.7 ± 0.4 in group 2, 1.5 ± 1.3/0.3 ± 0.2 in group 3 and 3.5 ± 2.8/0.9 ± 0.6 in group 4, being significantly different between groups 3 and 4, p = 0.04. Cycles to failure and failure load (N) at 5° varus or10° femoral head rotation around the neck axisin groups 1-4 were 21,428 ± 6020/1571.4 ± 301.0, 20,611 ± 7453/1530.6 ± 372.7, 21,739 ± 4248/1587.0 ± 212.4 and 18,622 ± 6733/1431.1 ± 336.7, being significantly different between groups 3 and 4, p = 0.04. Nailing of trochanteric femoral fractures with use of helical blades is comparable to interlocking dualscrews fixation in femoral head fragments with low bone quality. Bone cement augmentation of helical blades provides significantly greater fixation strength compared to interlocking screws constructs.

Assessment of Shoulder Function after Internal Fixation of Humeral Diaphyseal Fractures in Young Adults: A Prospective Comparative Study.

Background Humeral shaft fractures are commonly encountered in casualties. There are different methods of operative internal fixation with no consensus on the best technique. The objective of this study was to assess shoulder function and rate of complications among two different options of fixation, intramedullary nailing, and minimal invasive plate osteosynthesis (MIPO) in young adults. Methods Forty-two patients with humeral shaft fractures were included in the study and divided into two equal groups: group A treated with antegrade intramedullary locked nails (IMN) and group B with MIPO. Fracture union was evaluated with serial X-rays, and shoulder function was assessed in both groups using the scale of the American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles Shoulder Scale (UCLA), and visual analog score (VAS). The mean differences between groups were recorded and considered significant if the P value was ˂0.05. Results The results were reported prospectively with no significant differences in mean age, sex, side of injury, type of fracture, mechanism of injury, and the follow-up period between the groups studied. Group A had shorter operative time and minimal blood loss than group B. Regarding shoulder function scores (ASES, UCLA, and VAS), the results in the MIPO group were better than the IMN group with shorter time of union and fewer complications. Conclusion Despite a shorter operative time and lower blood loss during locked intramedullary nail fixation in the management of humeral shaft fractures, MIPO enables more superior shoulder function with better fracture healing and lower morbidities.

Newer generation straight humeral nails allow faster bone healing and better functional outcome at mid-term

PurposeAlthough proximal and diaphyseal humerus fractures are frequent, the optimal management remains controversial. Antegrade nailing prevents further damage to the soft tissues and to the vascularization, but it has been associated with postoperative shoulder pain and dysfunction. During the latest years a straight nail design was developed to minimize these problems.MethodsA total of 243 patients who had undergone surgery for antegrade intramedullary humeral nailing between January 2013 and July 2018 in A. Gemelli Trauma Center were divided into two groups according to the nail design used: straight nail group (S-group) and curvilinear nail group (C-group). Clinical data were collected using assessment forms (SF12-v2, Quick-DASH, ASES and Constant-Murley). Radiographic bone healing was assessed with RUST score at 30, 90 and 180 days after surgery.ResultsThe S-group was made up of 128 patients with a mean age of 59 ± 19 (range 18–97) and a mean follow-up of 46 ± 9 months. The C-group was made up of 115 patients with a mean age of 53 ± 16 (range 18–88) and a mean follow-up of 51 ± 8 months. The S-group had a mental component summary (MCS) score of 54.3 ± 7.7 and a physical component summary (PCS) score of 46 ± 10.2, the C-group had a MCS score of 50.9 ± 8.4 and a PCS score of 44.1 ± 7.4. Quick-DASH and ASES were respectively 18.8 ± 4.3 and 78.6 ± 8.2 in the S-group, 28.3 ± 11.6 and 72.1 ± 13.5 in the C-group with statistical significance. Constant-Murley score was 73.9 ± 9.1 in the S-group (76% of the contralateral healthy side) and 69.4 ± 10.4 in the C-group (73% of the contralateral healthy side). The radiographic union score in the S-group was 4.1 ± 0.3 at 30 days after surgery, 7 ± 0.8 at 90 days and 10 ± 1.2 at 180 days, while in the C-group it was 4.2 ± 0.4 at 30 days, 6.4 ± 0.7 at 90 days and 9 ± 0.9 at 180 days.ConclusionNewer generation straight nails allow a faster bone healing and better functional outcome at mid-term follow up.Level of evidence III.

“FUNCTIONAL OUTCOME OF RETROGRADE NAILING IN THE MANAGEMENT OF SUPRACONDYLAR AND DISTAL FEMORAL FRACTURE”

INTRODUCTION: Fractures of the Distal femur are complex injuries that pose a challenge to the orthopaedic surgeon. It constitutes about 6 % of all femoral fractures. It usually occurs during high energy trauma in younger patients and frequently are associated with concomitant injuries. In contrast, elderly patients with severe osteopenia might sustain solitary distal femoral fractures from minor trauma such as a simple fall. Proper diagnosis and treatment leads to early mobilization and rehabilitation of patients. MATERIAL AND METHODS :This prospective study was conducted in Department of Orthopedics at Dr. S. N. Medical College and Associated group of Hospital, Jodhpur ,Rajasthan ,India on 30 patients who underwent the surgery with retrograde intramedullary interlocking nail in the management of extra-articular supracondylar femoral fracture from August 2019 to November 2020. On follow up axial alignment was assessed and functional analysis was quantied using NEERS RATING SYSTEM, Radiographs was analyzed for correction, maintenance of position or loss of reduction. function around knee was accessed according to Schatzker and Lambert Criteria, measures the exion/extension , varus/valgus deformity , joint congruency and pain in operated patients. RESULTS: In our study 30 patients with supracondylar &amp; distal femoral fractures based on AO Classication on MULLER ET AL underwent retrograde supracondylar nail, long term nal result were rated using NEER'S RATING SCORE , which gives point for pain, function, working, joint movement ,gross and radiological appearance. NEER'S RATING SCORE assigned for each patient after 24 weeks of follow up. After accessing this score out of total 30 patients, 10 have excellent score, 10 have good score, 8 have fair score and next 2 have poor score. Function around knee was accessed according to Schatzker and Lambert Criteria, measures the exion/extension , varus/valgus deformity , joint congruency and pain in operated patients,out of 30 patients 9 patients have an excellent result , 8 have good ,12 have fair and only 1 patient have poor result CONCLUSION:The retrograde intramedullary locked nail provides the surgeon with a different option in treatment of specic supracondylar fracture patterns. It offers a practical advantages of simple and efcient technique for patients with polytrauma, oating knee injuries and in elderly. this technique is very useful in distal femur fracture where antegrade nailing does not provide stability and also where plate xation is not suitable due to soft tissue condition.

The importance of reconstruction nailing for diaphyseal atypical femoral fractures: a comparative study with standard nailing

Subtrochanteric atypical femoral fractures (AFFs) usually require long cephalomedullary or reconstruction nailing to achieve satisfactory healing. Recently, this type of nailing has also been recommended to fix diaphyseal AFFs and prevent fragility fractures around the proximal femur, although standard antegrade nailing seems sufficient from a biomechanical perspective. This study aimed to compare treatment outcomes and complications between reconstruction and standard nailing for diaphyseal AFFs. A retrospective comparative study of 48 female patients with diaphyseal AFFs who underwent surgical treatment with either reconstruction or standard nailing was conducted. The reconstruction nailing group comprised 23 patients with a mean age of 74.4years and included 16 complete and 7 incomplete AFFs. The mean follow-up period was 30months. The standard nailing group comprised 25 patients with a mean age of 71.1years and included 16 complete and 9 incomplete AFFs. The mean follow-up period was 57.8months. The healing rate, time to union, and complications were analyzed and compared between the two groups. Bony union was achieved in all 23 cases (100%) of the reconstruction nailing group by a mean of 19.3weeks postoperative. In the standard nailing group, 23 of 25 cases healed (92%) by a mean of 16weeks postoperative. The standard nailing group included two delayed fragility fractures of the femoral neck (5 and 10years after the initial surgery), four cases of newly developed subtrochanteric AFFs at the distal screw of the proximal interlocking screws of the nail (one complete and three incomplete fractures), and two cases of nonunion. Complications only occurred in the standard nailing group (p = 0.01, Fisher's exact test). In diaphyseal AFFs, reconstruction nailing may achieve a satisfactory outcome and can also decrease delayed peri-implant fragility fractures of the hip, newly developed subtrochanteric AFFs, and nonunion.

Functional outcome of fracture shaft humerus treated with closed antegrade intramedullary nailing in adults

Background and objectives: The treatment of humeral shaft fractures might include plate osteosynthesis or intramedullary nailing. The fracture hematoma is maintained using intramedullary nails because they are placed in a closed way, allowing for early fracture consolidation and decreased infection rates. Interlocking provides rotational stability, allowing nearby joints to mobilize more quickly. Antegrade nailing, on the other hand, has the side effect of tightening the shoulder. in this study, we wanted to see how humeral shaft fractures treated with closed Antegrade Intramedullary nailing fared in terms of time to union, functional results, and comorbidities. Methods: Twenty adult patients with acute humeral shaft fractures were treated using antegrade closed intramedullary nailing. With an average age of 38.4 yrs., there had been 17 men and 3 females (21-65 yrs.). These patients had tracked for two years as well as the outcomes were assessed. Results: 1 (5%) fracture failed to union after an average consolidation time of 13.78 weeks (11-16 weeks). There were three occurrences of intraoperative fracture comminution (15%) that had no impact on fracture healing. 2 (10%) of the patients experienced nail impingement, 1 (5%) had shoulder stiffness, and 1 (5%) had a superficial infection. Functional outcomes were good in 17 (85%), moderate in 2 (10%), and poor in 1 (5%). Results: 1 (5%) fracture failed to union after an average consolidation time of 13.78 weeks (11-16 weeks). There were three occurrences of intraoperative fracture comminution (15%) that had no impact on fracture healing. 2 (10%) of the patients experienced nail impingement, 1 (5%) had shoulder stiffness, and 1 (5%) had a superficial infection. Functional outcomes were good in 17 (85%), moderate in 2 (10%), and poor in 1 (5%).

Comparison of antegrade locked intramedullary nails and retrograde expandable intramedullary nails in distal femur diaphysis fractures

Comparison of antegrade locked intramedullary nails and retrograde expandable intramedullary nails in distal femur diaphysis fractures

Assessment of clinical and radiographic outcomes following retrograde versus antegrade nailing of infraisthmic femoral shaft fractures without the use of intraoperative fluoroscopy in Tanzania

Objectives:To compare clinical and radiographic outcomes following antegrade versus retrograde intramedullary nailing of infraisthmic femoral shaft fractures.Design:Secondary analysis of prospective cohort study.Setting:Tertiary hospital in Tanzania.Participants:Adult patients with infraisthmic diaphyseal femur fractures.Intervention:Antegrade or retrograde SIGN intramedullary nail.Outcomes:Health-related quality of life (HRQOL), radiographic healing, knee range of motion, pain, and alignment (defined as less than or equal to 5 degrees of angular deformity in both coronal and sagittal planes) assessed at 6, 12, 24, and 52 weeks postoperatively.Results:Of 160 included patients, 141 (88.1%) had 1-year follow-up and were included in analyses: 42 (29.8%) antegrade, 99 (70.2%) retrograde. Antegrade-nailed patients had more loss of coronal alignment (P = .026), but less knee pain at 6 months (P = .017) and increased knee flexion at 6 weeks (P = .021). There were no significant differences in reoperations, HRQOL, hip pain, knee extension, radiographic healing, or sagittal alignment.Conclusions:Antegrade nailing of infraisthmic femur fractures had higher incidence of alignment loss, but no detectable differences in HRQOL, pain, radiographic healing, or reoperation. Retrograde nailing was associated with increased knee pain and decreased knee range of motion at early time points, but this dissipated by 1 year. To our knowledge, this is the first study to prospectively compare outcomes over 1 year in patients treated with antegrade versus retrograde SIGN intramedullary nailing of infraisthmic femur fractures.Level of Evidence: III

Antegrade intramedullary nailing in comminuted, open metacarpal bone fracture: maintenance of the length.

The purpose of this study was to evaluate the radiological and clinical outcomes of treatment of comminuted open fractures of the metacarpal bone (MCB) with associated injuries to soft tissues, tendons, and neurovascular structures using antegrade intramedullary nailing (AIN) at least 2years postoperatively. Between January 2008 and December 2017, a total of 27 patients who met the inclusion/exclusion criteria were included in this study. The inclusion criterion was open and comminuted fracture (with/without segmental bone defects). We evaluated simple radiograph and computed tomography (CT) findings and clinical conditions (visual analog scale [VAS] pain score and Disabilities of the Arm, Shoulder, and Hand [DASH] score), including active range of motion (ROM) at metacarpophalangeal joint (MP) and grip strength at final follow-up. The mean preoperative angulation was 29.63° ± 7.59° and the mean shortening was 9.30 ± 2.38mm. Union was achieved at mean 12.3weeks postoperatively, without any complications due to operative treatment. The dorsal angulation measured on the CT scans, shortening on simple radiographs was significantly improved (10.26 °± 3.19°, 0.52 ± 1.05mm, respectively). The final VAS and DASH scores were 0.41 ± 0.64 and 3.6 ± 2.47, respectively, indicating satisfactory outcomes. The final ROM was 85.0° ± 3.67°. The mean final grip strength was 89.56 ± 5.69% relative to the normal side. A mean extension lag at the MP joint of 12° was noted in three patients; however, it was resolved by additional tenolysis. AIN is a simple method for fixation of open comminuted metacarpal fractures accompanied by soft tissue injury. The simplicity of the method is beneficial for repairing associated injured structures and healing soft tissue. Minimized additional damage around the MCB during surgery and good stability resulted in satisfactory bony union with minimal angulation, shortening, and rotation. Level IV, Retrospective case series.

To study the outcome of retrograde nailing in distal one-third femoral shaft fractures

Objectives: With antegrade nailing, it is difficult to achieve perfect reduction of distal shaft femur fracture because of mismatch of size of medullary canal. Short juxta-articular segment is under the influence of deforming muscle forces and the large metaphyseal volume does not allow the intramedullary nail to have cortical contact that can aid in the reduction of the fracture. Distal femur fractures typically shorten and displace into recurvatum in the sagittal plane. In the coronal plane, the fractures have a tendency to displace or angulate according to the fracture morphology. This study was performed to assess the outcome of “Distal One-Third Shaft Femur Fracture” with Retrograde Intramedullary Interlocking Nail. Its intraoperative and postoperative complications and ease of surgery using retrograde intramedullary nailing. Using intraoperative time taken for completion of surgery and total number of C-Arm exposures.Materials and Methods: The study will include 30 cases with distal one third shaft femur fractures, who will undergo surgery using retrograde nail. Patients will be followed up for a period of 6 months at 1st, 3rd and 6th month. Patients will be assessed on the basis of Demographic analysis, Mode of injury, Classification of fracture based on AO Classification, Duration of surgery, number of C-ARM exposures, Outcome of fracture, Sagittal/Coronal plane deformity, Limb Length Discrepancy/Rotational, alignment, Range of motion. Pain, functional outcome of knee using lysholm knee score and Complications observed. Results: Two patients shows malalignment rest twenty patients had normal alignment. In our study radiological union was seen in 16(72.7%) patients and nonunion was observed in 6(27.3%) patients.Conclusion: We strongly recommend the use of Retrograde Intramedullary Nail with multiple distal locking options in the patients with distal one-third femoral shaft fractures, keeping the distal end of the nail in subchondral bone.

Potential pitfalls of lateral radiographic assessment of the nail position in the distal femur.

Antegrade nailing of proximal femur fractures is a widely accepted treatment that relies on lateral radiographs to assess distal nail positioning. However, the distal femur is trapezoidal in cross section, consequently standard lateral radiographs may be insufficient. This study aimed to utilise 3D modelling to virtually assess the accuracy of lateral radiographs in defining the position of a femoral nail in the distal femur, specifically considering distal cortical encroachment. Three-dimensional models of a commonly used nail, were positioned in 3D models of 63 femora, generated from CT scans. Lateral projections, representative of lateral radiographs, were generated and measurements of the closest point distance between the distal nail and anterior inner cortex were recorded. Axial slices through the model at the same distal position were produced for any nails located in the canal's anterior 1/5th and used to quantify the shortest nail to anterior cortex distance. A significant (p = 0.000) difference exists between the positions of the nail in the lateral projection (- 1.7 ± 1.24mm) compared with axial position (- 0.23 ± 1.41mm) with reference to the inner cortical surface. In the lateral projection, 30 nails were located in the canal's anterior 1/5th, of these, 14 nails were identified in the axial position as perforating the inner cortex, with four also perforating the outer cortex surface. Femoral nails are often anteriorly located in the distal femur and reviewed using lateral radiographs. However, this research demonstrates that owing to the geometry of the distal femur, a lateral radiograph may be inadequate for determining the true position of a femoral nail within the distal femur. Accurately assessing the position of femoral nails may help to address and prevent thigh pain, and iatrogenic fracture or perforation which have been associated with anterior positioning.

Antegrade nailing in femoral shaft fracture patients - comparison of outcomes of isolated fractures, multiple fractures and severely injured patients

Introduction: Femoral shaft fractures in adults are high-energy fractures typically accompanied by additional fractures of the upper and lower extremities and brain, thoracic, or abdominal injuries. Intramedullary nailing enables early ambulation with a few complications, but rates of non-union remain high. Therefore, we aimed to compare bone union after femoral shaft fractures in adults (20–65 years old) depending on the injury severity and presence of multiple fractures.Patients and methods: This study retrospectively examined 178 patients (145 male and 33 female) who underwent intramedullary nailing for a femoral shaft fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 32 type) between January 2014 and December 2018 and were followed up for at least 1 year. Patients who underwent intramedullary nailing after the preliminary application of an external fixator were excluded. Patients were divided into groups with isolated femoral shaft fractures (IS group), an injury severity score of ≤14, and multiple fractures of the extremities and the pelvic bone (at least three locations), including a femoral shaft fracture (MU group), and severely injured (injury severity score ≥15) with femoral shaft fractures (SE group). Non-union rate by group and risk factors related to bone union and bone union rate according to time to full weight bearing were analyzed.Results: In total, 29, 54, and 95 patients were assigned to the IS group, MU group, and SE group, respectively. Non-union was observed in two patients in the IS group (6.9%), six patients in the MU group (11.1%), and 11 patients in the SE group (11.6%). There were no significant differences in the bone union rate, according to multiple fractures (p=0.515) and injury severity score (p=0.561). Additionally, no differences in the bone union rate were observed according to the time to full weight bearing. Depending on open fracture (p=0.004) and fracture severity (p=0.011), the non-union rate showed a difference of up to four times or greater.Conclusions: When intramedullary nailing is performed to treat femoral shaft fractures, multiple fractures and severe trauma do not directly affect bone union. However, it should be noted that open fracture and greater fracture severity lead to higher chances of non-union.

Combined antegrade femur lengthening and distal deformity correction: a case series

BackgroundLeg length discrepancy is often associated with distal femur angular deformities such as valgus or flexion. This study aims to report a new technique for simultaneous limb lengthening and acute distal femoral angular correction.MethodsA retrospective chart review of patients undergoing a single procedure was conducted. Patients included had a single operation where they underwent distal femur osteotomy stabilized with a plate followed by antegrade nailing with a magnetically controlled intramedullary lengthening nail (PRECICE, Ellipse Technologies, Inc., Irvine, CA, USA) using a trochanteric entry.ResultsSeven femurs from 7 patients were included. The average age at operation was 13.6 years, and the leg length difference was 51 mm (range 30–105 mm). Associated deformities were valgus (4), knee flexion contracture (2), and both valgus and flexion contracture (1). Lengthening achieved was 43 mm (P = 0.0036), with a consolidation index of 27 days/cm and reliability of 0.87 (6/7). The 5 patients with angulation had an improvement of valgus from 12 to 4° (P = 0.006) and of the mechanical axis deviation from 34 to 3 mm (P = 0.0001). The range of motion also improved in the 3 patients with contractures. Preoperative gait disturbance, hip and knee pain, and functional scoliosis resolved after the limb deformities were corrected.ConclusionCombining a magnetic internal lengthening nail with a second distal osteotomy stabilized with a plate can successfully correct limb length and distal femur deformity acutely without altering the expected result of each procedure.

Evaluation of outcomes of distal femoral fractures treated by retrograde nailing technique

Background: Distal femur fractures are less common injuries accounting for approximately 1% of fractures in the elderly. They occur due to high-velocity injury in adults and simple fall in the elderly. Management of these type injuries in the elderly is more challenging because of osteoporosis. Retrograde nailing represents an established fixation method for fractures of the distal femur and offers an alternative to the existing technique of antegrade nailing. Materials and Methods: Prospective study of 70 patients, aged between 16 and 85 years, whose distal femoral fractures were treated with a retrograde femoral nail from December 2016 to November 2018 in the department of orthopedics of a tertiary care centre in North India were followed to assess the outcome of treatment. The fracture was caused by a motor-vehicle accident in 58 patients (82.85 percent) and a fall on the ground in 12 (17.14%). 26 (37.14%) of the fractures were open. All the patients were followed up at about 3 weeks, 6 weeks, 3 months, 6 months, and 1 year. On each visit pain, functional range of movements was noted and the union was assessed clinically and radiologically at regular intervals. Results: Out of 70 patients, 60 patients were males and the remaining patients were female. Twenty-six patients had open fractures and 44 patients had closed fractures. All the patients in our study united without any case of nonunion and knee infection. The mean time required to achieve union was 5.42 ± 2.48 months in closed fractures, while in open fractures, it was 5.7 ± 1.65 months. The mean range of knee movement in open fractures was from 15.0° ± 12.57° to 113.75° ± 14.69 °, while in closed fractures, it was from 5.38° ± 6.43° to 122.18° ± 15.0°. Five patients had loosening of the distal interlocking screws impinging on the skin. Based on the criteria recommended by Schatzker the outcome was assessed as excellent in 33 (47.14%) cases, good in 27 (38.57%) cases, and fair in 7 (10%) cases. The outcome in 3 (04.29%) cases was graded as poor. Conclusions: Retrograde intramedullary nailing makes possible a biological osteosynthesis of distal femoral fractures. It also produces good functional results even in elderly patients.