Intramedullary Nailing Of Femoral Fractures Research Articles

Knee Pain and Functional Outcomes after Retrograde Femoral Nailing: A Retrospective Review.

To investigate the incidence and severity of knee pain following retrograde intramedullary nailing of femur fractures and to better understand functional outcomes using validated patient-reported outcome measures. Fifty-three patients with OTA 32 or 33 fractures treated by retrograde nail at a single academic Level 1 trauma center between 2009 and 2020 were retrospectively reviewed. Patients verbally completed the Oxford Knee Score (OKS) and Patient-Reported Outcome Measurement Information System (PROMIS) Short Form 6b, minimum one year postoperatively. Thirty-four (64%) patients reported the presence of pain. Of those reporting pain, 16 (47.1%) reported their pain as mild. Compared to those without pain, patients with knee pain had lower OKS (30.38 +/- 10.65, versus 41.95 +/- 6.87; P <0.001) and higher PROMIS scores (14.65 +/- 6.76 versus 10.95 +/- 7.09; P=0.066). The increasing severity of pain was inversely correlated with functional status as measured by patient-reported measures. At present, the reliability, high union rates, and otherwise low complication rates associated with retrograde femoral nailing justify its continued use. However, knee pain and functional outcomes should remain an integral part of the preoperative discussion with the patient.

Weight Bearing as Tolerated After Intramedullary Nailing of the Femur: A Retrospective Analysis of Clinical and Radiographic Outcomes.

Intramedullary nailing of femur fractures has become the standard of care, with high union rates. Few high-level studies have discussed the effect that early weight bearing has on the healing of these fractures, regardless of nail size or fracture pattern. The goal of this study was to determine the clinical and radiographic outcomes of femoral shaft fractures for patients allowed immediate weight bearing after intramedullary nailing. We performed a retrospective review of 341 femoral shaft fractures, with 131 allowed immediate weight bearing, 99 allowed partial weight bearing, and 111 kept non-weight bearing. Demographic, intraoperative, and postoperative variables were collected and analyzed. Increased fracture complexity was associated with higher likelihood of delayed weight bearing. No significant difference was found for nail size or rate of failure with different nail sizes. A total of 50 nonunions were noted (14.7%), with no difference in nonunion rates between weight bearing cohorts. The only significant predictor of nonunion was Orthopaedic Trauma Association (OTA) classification of OTA32B fractures (P=.02), which were 2 times and 4 times as likely to occur compared with OTA32A and OTA32C fractures, respectively. Failure of interlocking screws occurred among 15 patients (4.4%) and was more common with older patients, osteoporotic bone, and larger diameter nails. In summary, unilateral intramedullary nailing of adult femoral shaft fractures does not show a difference in fracture union rates or implant failure with unrestricted, immediate weight bearing, regardless of nail characteristics. [Orthopedics. 2022;45(3):e148-e153.].

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.

Does Open Reduction in Intramedullary Nailing of Femur Shaft Fractures Adversely Affect the Outcome? A Retrospective Study.

Aim This study aims to assess the results of open versus closed reduction in intramedullary nailing for femoral fractures and whether it delays union, predisposes to nonunion, or increases the rate of infection. Materials and Methods A retrospective review of all adult patients with isolated femoral shaft fractures treated by intramedullary nailing was done. The primary outcome is union rate, and the secondary outcomes are operation time and the infection rate. Results 110 isolated femoral shaft fractures, with 73 (66.4%) in the closed reduction group and 37 (33.6%) in the open reduction group, 90.4% males and 9.6% females, and the average age was 32.6 years. RTA is the most common cause of these injuries followed by the fall from height. The delayed union rate was 20% (22/110) with no difference between the two groups, p value 0.480, and the nonunion rate was 5.5% (6/110), and no statistical difference was observed between the two groups. The operation time was shorter in the closed groups, and no difference in the time to union was observed between two groups. No infection was found in the two groups. Conclusions There is no statistical difference between the healing rates in closed and open reduction in femoral shaft fractures. In cases where closed reduction is difficult, it is better to open reduce the fracture if closed reduction cannot be achieved in 15 minutes, especially in polytrauma.

Impact of Surrounding Canal Size on Time to Union After Intramedullary Nailing of Femur Fractures: Are 10-mm Nails All We Need?

To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures. Retrospective review. Two Level 1 and 1 Level 2 trauma centers. Two hundred eighty-seven patients met the criteria and were included in the study. Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm. Nonunion rates, mean time to union. Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups. Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Satisfactory postoperative alignment following retrograde SIGN Fin nailing for femoral shaft fractures

Purpose:In developing countries, long bone fractures following trauma are a significant contributor to morbidity, and operating room resources are often limited in these settings. The Surgical Implant Generation Network (SIGN) Fin nail may reduce the challenges of retrograde intramedullary nailing of femoral fractures without fluoroscopy. In contrast to the traditional SIGN nail placed in a retrograde fashion, the Fin nail does not require proximal interlocking screws. Instead, the nail achieves stability through an interference fit within the proximal femoral canal. The purpose of this study is to compare postoperative alignment in femoral shaft fractures treated with either a retrograde SIGN Fin nail or a standard retrograde SIGN nail.Method:Using the SIGN online surgical database, we identified all femoral shaft fractures treated with a retrograde SIGN Fin nail at 2 African hospitals. Two examiners independently classified fracture patterns using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification system. Using an on-screen protractor tool, postoperative coronal and sagittal plane alignment were measured and recorded as deviation from anatomic alignment (DFAA), with units in degrees. Available patient demographics and surgical details were also recorded. Fin nail cases were matched in a 1:1 ratio to retrograde standard SIGN nail cases based on AO/OTA fracture type.Results:Twenty-eight retrograde Fin nail cases were identified, and 28 matched retrograde SIGN nail cases were selected. The Fin nail and retrograde SIGN nail groups were well matched in terms of demographics, AO/OTA fracture type, and surgical characteristics. There was no significant difference in postoperative coronal or sagittal plane alignment between the groups. There were no cases in either group of average postoperative malalignment >5° in any plane.Conclusion:The SIGN Fin nail appears to achieve satisfactory radiographic alignment without the need for proximal interlocking screws, making it an attractive implant for retrograde femoral shaft fracture fixation in resource-limited settings. Further research is required to validate these findings and determine long-term Fin nail clinical outcomes.

Effect of inherent tibial asymmetry on leg length discrepancy measurements after intramedullary nailing of comminuted femoral shaft fractures.

Introduction: Locked intramedullary nailing (IMN) is the standard treatment for femoral shaft fractures in adults with high rates of union and relatively low rates of complications. Leg length discrepancy (LLD) after IMN of femoral shaft fractures is common, and is reported in 20–43% of cases. A known surgical challenge when trying to obtain equal leg lengths is comminuted fracture, which results in a loss of bony landmarks that guide reduction. The purpose of this study was to assess the effect of inherent tibial asymmetry on LLD measurements after IMN. Methods: Postoperative CT scanograms were performed on 79 consecutive patients after locked IMN for comminuted femoral shaft fracture. Leg lengths were determined by measurements taken from the scout view of a CT scanogram. Calculations of discrepancy were made for both femurs, tibias, and total leg length. Assessment was also made on the frequency wherein the tibial discrepancy compounded the femoral discrepancy. In situations where a limb segment was exactly symmetric to the contralateral side, the total leg was not regarded as a having compounded asymmetry. Results: Notable discrepancies were found in tibial length that significantly departed from the null of symmetry (p < 0.0001). Forty-two patients (53.2%) were found to have a tibial asymmetry of 3 mm or more, and 20 patients (25.3%) were found to exhibit a difference of 6.3 mm or more. Median femoral discrepancy was 5.3 mm and median tibial discrepancy was 3.0 mm. Seven patients were found to be asymmetric in total leg length as a consequence of underlying tibial asymmetry. Conversely, 11 patients benefited from their tibial asymmetry, which compensated for femoral asymmetry after IMN. Conclusion: Tibial symmetry cannot be assumed. If not accounted for, inherent tibial asymmetry may influence LLD after IMN of femur fractures.

Robotic technique improves entry point alignment for intramedullary nailing of femur fractures compared to the conventional technique: a cadaveric study.

We aimed to test whether a robotic technique would offer more accurate access to the proximal femoral medullary cavity for insertion of an intramedullary nail compared to the conventional manual technique. The medullary cavity of ten femur specimens was accessed in a conventional fashion using fluoroscopic control. In ten additional femur specimens, ISO-C 3D scans were obtained and a computer program calculated the ideal location of the cavity opening based on the trajectory of the medullary canal. In both techniques, the surgeon opened the cavity using a drill and inserted a radiopaque tube that matched the diameter of the cavity. The mean difference in angle between the proximal opening and the medullary canal in the shaft of the femur was calculated for both groups. Robotic cavity opening was more accurate than the manual technique, with a mean difference in trajectory between the proximal opening and the shaft canal of 2.0° (95% CI 0.6°-3.5°) compared to a mean difference of 4.3° (95% CI 2.11°-6.48°) using the manual technique (P=0.0218). The robotic technique was more accurate than the manual procedure for identifying the optimal location for opening the medullary canal for insertion of an intramedullary nail. Additional advantages may include a reduction in total radiation exposure, as only one ISO-C 3D scan is needed, as opposed to multiple radiographs when using the manual technique.

Evaluation of malrotation following intramedullary nailing in a femoral shaft fracture model: Can a 3D c-arm improve accuracy?

IntroductionDifficulty determining anatomic rotation following intramedullary (IM) nailing of the femur continues to be problematic for surgeons. Clinical exam and fluoroscopic imaging of the hip and knee have been used to estimate femoral version, but are inaccurate. We hypothesize that 3D c-arm imaging can be used to accurately measure femoral version following IM nailing of femur fractures to prevent rotational malreduction. MethodsA midshaft osteotomy was created in a femur Sawbone to simulate a transverse diaphyseal fracture. An intramedullary (IM) nail was inserted into the Sawbone femur without locking screws or cephalomedullary fixation. A goniometer was used to simulate four femoral version situations after IM nailing: 20° retroversion, 0° version, 15° anteversion, and 30° anteversion. In each simulated position, 3D c-arm imaging and, for comparison purposes, perfect lateral radiographs of the knee and hip were performed. The femoral version of each simulated 3D and fluoroscopic case was measured and the results were tabulated. ResultsThe measured version from the 3D c-arm images was 22.25° retroversion, 0.66° anteversion, 19.53° anteversion, and 25.15° anteversion for the simulated cases of 20° retroversion, 0° version, 15° anteversion, and 30° anteversion, respectively. The lateral fluoroscopic views were measured to be 9.66° retroversion, 12.12° anteversion, 20.91° anteversion, and 18.77° anteversion for the simulated cases, respectively. ConclusionThis study demonstrates the utility of a novel intraoperative method to evaluate femur rotational malreduction following IM nailing. The use of 3D c-arm imaging to measure femoral version offers accuracy and reproducibility.

Early intramedullary nailing for femoral fractures in patients with severe thoracic trauma: A systemic review and meta-analysis

PurposeEarly intramedullary nailing (IMN) within the first 24 h for multiply injured patients with femoral fracture and concomitant thoracic trauma is controversial. Previously published studies have been limited in size and their outcomes have been inconclusive. A meta-analysis was conducted to evaluate the available data in order to guide care and help improve the outcomes for these patients. MethodsWe searched the literature up to December 2011 in the main medical search engines and identified 6 retrospective cohort studies that explored the safety of early IMN in patients with both femoral fracture and chest injury. Our primary outcome was the rates of pulmonary complication (pneumonia, adult respiratory distress syndrome, fat embolism syndrome), multiple organ failure (MOF) and mortality. ResultsWe found no statistically significant difference in the rate of pulmonary complications, MOF or mortality in the patients treated with early IMN. ConclusionEarly IMN for femoral fractures does not increase the mortality and morbidity in chest-injured patients in the studies analyzed.

Intraoperative Distal Femoral Fine Wire Traction to Facilitate Intramedullary Nailing of the Femur.

Many techniques have been employed to facilitate intramedullary nailing of femur fractures. Maintaining limb length during the operation can be difficult. The authors describe the use of distal femoral fine wire skeletal traction as a technique to maintain reduction while allowing intramedullary nailing of femur fractures. This technique is safe, is effective, and negates the need for a fracture table or an assistant.

Early and late intramedullary nailing of femur fracture: A single center experience.

Background:Femur fracture (FF) is a common injury, and intramedullary nailing (IMN) is the standard surgical fixation. However, the time of intervention remains controversial. We aimed to describe the reamed IMN (rIMN) timing and hospital outcomes in trauma patients presenting with FF.Materials and Methods:A retrospective analysis was conducted for all patients admitted with FF and they underwent fixation at level 1 trauma unit between January 2010 and January 2012. Patients were divided into Group I with early rIMN (<12 h) and Group II with late rIMN (≥12 h). Patients’ demographics, clinical presentations, mechanism of injury, pulmonary complications, organ failure, length of stay, and mortality were described.Results:A total of 307 eligible patients with FF were identified (156 patients in Group I and 151 patients in Group II). Patients in Group II were older (36 ± 18 vs. 29 ± 9; P = 0.001) and had higher rate of polytrauma (35% vs. 18%, P = 0.001), head injury (5% vs. 12%, P = 0.68) and bilateral FF (10.7% vs. 5.1%; P = 0.07) in comparison to Group I. Group II had longer stay in Intensive Care Unit (7 [1–56] vs. 2 [1–17] days; P = 0.009) and hospital (13 [2–236] vs. 9 [1–367]; P = 0.001). There were no significant differences in outcomes between the two groups in terms of sepsis, renal failure, fat embolism, adult respiratory distress syndrome and death.Conclusions:Based on this analysis, we believe that early rIMN is safe in appropriately selected cases. In patients with traumatic FFs, early rIMN is associated with low hospital complications and shorter hospital stay. The rate of pulmonary complications is almost the same in the early and late group. Further prospective randomized studies with large sample size would be ideal using the information garnered from the present study.

Retrograde versus antegrade intramedullary nailing for femoral fractures: a meta-analysis of randomized controlled trials

Objectives:To conduct a meta-analysis of randomized controlled trials assessing the effect on clinical outcomes of intramedullary nailing for femoral fractures via a retrograde or antegrade approach.Data sources:Randomized controlled trials using PubMed, Embase, and the Cochrane Library databases.Study selection:We used the following search terms with no language or study type restrictions: femoral shaft fractures, internal fixation, treatment outcome, intramedullary nailing, and retrograde or antegrade approach.Data extraction:Two independent authors extracted the data and we assessed the quality of the included studies based on Jadad score; allocation concealment; similarity of baseline characteristics; eligibility criteria; blinding; completeness of follow-up; and intention-to-treat analysis. Our primary outcome measure was the union rate and the secondary outcome measures were nonunion, knee pain, and heterotopic ossification. A total of 240 patients from three randomized controlled trials were included.Data synthesis:Risk ratios (RRs) and 95% confidence intervals (CIs) were computed for dichotomous variables, and weighted mean differences and 95% CIs for continuous variables. Heterogeneity among studies was assessed using the I 2 statistic, with I 2 > 50% considered significant. If heterogeneity was not significant, a fixed effects model was chosen to assess the overall estimate. Otherwise, a random effects model was used. We used Egger’s regression asymmetry test and Begg’s adjusted-rank correlation to assess publication bias.Conclusions:Both retrograde and antegrade intramedullary nailing produced high union rates. We found no significant difference in union rate between the retrograde nailing group and the antegrade nailing group for femoral fractures (RR 1.02, 95% CI: 0.94–1.11, p = 0.59, I 2 = 0%).

Risk factors for complications and readmission after operative fixation of pediatric femur fractures.

PurposeOperative fixation of pediatric femur fractures with intramedullary implants has grown in popularity in recent decades. However, risk factors for short-term adverse events and readmission have not been well studied.MethodsPediatric patients who underwent intramedullary nailing of a femur fracture between 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Risk factors for any adverse event (AAE) and readmission after intramedullary nailing were evaluated using univariate and multivariate analysis.ResultsA total of 522 pediatric patients who underwent intramedullary nailing of the femur during the study period were identified. The mean age of this patient cohort was 10.2 ± 3.8 years. Review of the cases revealed that 18 (3.4 %) patients had AAE and that 20 (3.8 %) patients were readmitted, of whom 13 (2.5 %) underwent a reoperation. Independent risk factors for AAE were a cardiac comorbidity [odds ratio (OR) 12.7, 95 % confidence interval (CI) 1.5, 103.7], open fracture (OR 10.2, 95 % CI 1.4, 74.4), and prolonged operative time (OR 17.5, 95 % CI 6.1, 50.5). Independent risk factors for readmission were a central nervous system disorder (OR 4.5, 95 % CI 1.3, 16.2) and a seizure disorder (OR 4.9, 95 % CI 1.0, 23.5).ConclusionsThe results of the multivariate analysis suggest that cardiac comorbidities, open fractures, and prolonged operative time increase the risk for AAE and that central nervous system disorders and seizure disorders may increase the risk for readmission. Surgeons should be aware of these risk factors and counsel the families of pediatric patients who undergo intramedullary nailing of femur fractures.

Comparative study of treatment of fracture shaft femur by intramedullary interlocking nails through piriform fossa entry and tip of the greater trochanter entry approach

Background: Several techniques and tools are available for achieving fracture reduction during antegrade intramedullary nailing of femur fractures. Aims: To compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa (PF). Materials and Methods: The present pilot project was conducted in a time span of 1-year. The patients admitted with femoral diaphyseal fractures were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 15 (n = 15). Results: Complications of nailing: PE group - 6.7% infection, 20% malunion, 20% delayed union, 20% restriction of hip range of motion (ROM), 6.7% restriction of knee ROM, 13.3% limb length discrepancy, 13.3% hardware prominence. GTE group - 13.3% malunion, 13.3% delayed union, 33.3% Restriction of hip ROM, 6.7% restriction of knee ROM, 20% limb length discrepancy, 26.7% hardware prominence. Radiological union time in PE was 12-15 weeks in 5 patients, 16-19 weeks in 8 patients, 20-23 weeks in 1 and >24 weeks in 1 patient. Radiological union time in GTE was 12-15 weeks in 4 patients, 16-19 weeks in 9 patients, 20-23 weeks in 2 patients. Need for dynamization was 20% in the PE group and 13.3% in GTE group. Thoresen's scoring system showed no significant difference between the two groups. Conclusion: Femoral nailing through the greater trochanter with specifically designed nails and with attention to specific techniques for such insertion should be considered a rational alternative to femoral nailing through the PF with the benefit of reduced requirement for fluoroscopy and decreased operative time.

Complications after intramedullary nailing of femoral fractures in a low-income country

Background Some surgeons believe that internal fixation of fractures carries too high a risk of infection in low-income countries (LICs) to merit its use there. However, there have been too few studies from LICs with sufficient follow-up to support this belief. We first wanted to determine whether complete follow-up could be achieved in an LIC, and secondly, we wanted to find the true microbial infection rate at our hospital and to examine the influence of HIV infection and lack of follow-up on outcomes.Patients and methods 137 patients with 141 femoral fractures that were treated with intramedullary (IM) nailing were included. We compared outcomes in patients who returned for scheduled follow-up and patients who did not return but who could be contacted by phone or visited in their home village.Results 79 patients returned for follow-up as scheduled; 29 of the remaining patients were reached by phone or outreach visits, giving a total follow-up rate of 79%. 7 patients (5%) had a deep postoperative infection. All of them returned for scheduled follow-up. There were no infections in patients who did not return for follow-up, as compared to 8 of 83 nails in the group that did return as scheduled (p = 0.1). 2 deaths occurred in HIV-positive patients (2/23), while no HIV-negative patients (0/105) died less than 30 days after surgery (p = 0.03).Interpretation We found an acceptable infection rate. The risk of infection should not be used as an argument against IM nailing of femoral fractures in LICs. Many patients in Malawi did not return for follow-up because they had no complaints concerning the fracture. There was an increased postoperative mortality rate in HIV-positive patients.

Femoral Version of the General Population

The purpose of this study was to compare various gender and ethnic groups to characterize differences in baseline version and rates of retroversion. Retrospective. Level 1 trauma center. Between 2000 and 2009, 417 consecutive patients with femur fractures were treated with an intramedullary nail at level I trauma and tertiary referral center. Of these, 328 with computed tomography scanogram of the normal, uninjured contralateral femur were included in this study. Femoral version. The mean alignment for the all patients was 8.84 ± 9.66° of anteversion. There were no statistically significant differences in mean version between African American, white, and Hispanic patients for males or females. Although there were also no significant differences in rates between ethnicities, retroversion was found to be common in white males (21.4%), African American males (15.1%), and all groups of females (>14.3%). Furthermore, nearly 6% of both African American males and females exhibited >10° retroversion. Although there may not be a significant difference in average femoral version between ethnic and gender groups, retroversion is relatively common, and retroversion >10° was observed in nearly 6% of the African American population. This may have important implications in proper alignment restoration and successful clinical outcomes after intramedullary nailing of femur fractures.

Can Fluoroscopy-based Computer Navigation Improve Entry Point Selection for Intramedullary Nailing of Femur Fractures?

The entry point is crucial to an accurate reduction in femoral nailing. Fluoroscopy-based navigation was developed to aid in reducing femur fractures and selecting entry points. We asked: (1) Can the piriformis fossa (PF) and tip of the greater trochanter (TT) be identified with high reproducibility? (2) What is the range of nonneutral images clinically acceptable for entry point selection? (3) Does navigation improve accuracy and precision of landmarking the TT and PF? And (4) does off-angle fluoroscopy within the acceptable range affect landmark accuracy? Three orthopaedic surgeons digitized the PF and TT under direct visualization on 10 cadaveric femurs, quantifying the reproducibility of the targeted PF and TT landmarks. Arcs of acceptable AP and lateral images of each femur were acquired in increments of 5° with a C-arm. An experienced orthopaedic surgeon rejected or accepted images for entry point selection by qualitatively assessing the relative positions and sizes of the greater trochanter, lesser trochanter, and femoral neck. Entry points were identified on each image using fluoroscopy and navigation. Hierarchical linear modeling was used to compare accuracy and precision between navigation and fluoroscopy and the effects of image angle. A 29° average arc of acceptable images was found. Reproducibility of the target landmarks for the PF and TT under direct visualization was excellent. Navigation had similar accuracy to fluoroscopy for PF localization but less for TT. Navigation increased precision compared to fluoroscopy for both PF and TT. Image angle affected accuracy of the PF and TT under fluoroscopy and navigation. Nonorthogonal images reduce accuracy of PF and TT identification with both navigation and fluoroscopy. Navigation increased precision but decreased accuracy and cannot overcome inaccuracies induced by nonorthogonal images.

Sa3.9 Expandable intramedullary nailing for femoral fractures: our experience in the treatment of complications

Sa3.9 Expandable intramedullary nailing for femoral fractures: our experience in the treatment of complications

CT scanogram for limb length discrepancy in comminuted femoral shaft fractures following IM nailing

IntroductionLeg length discrepancy (LLD) following intramedullary nailing of femoral fractures is not uncommon. We designed a prospective study to evaluate the efficacy of routine postoperative computed tomography (CT) scanograms for evaluation of limb length discrepancy in patients with comminuted Winquist III or IV femoral shaft fractures treated with intramedullary nailing. MethodsThe study consisted of 15 patients with Winquist III and 13 with a Winquist IV femoral shaft fracture pattern with an average age of 37 years. The mechanisms of injury were motor vehicle collision (13), gunshot wound (12) and falls (three). All patients were treated with a statically locked intramedullary femoral nail (18 antegrade and 10 retrograde). A CT scanogram evaluated limb length in all patients. A discrepancy of greater than 20mm was considered for correction during the same admission. An LLD of 15–20mm was discussed with the patient extensively for correction. ResultsIn the 28 patients included in our study, the average limb length discrepancy was 9.1mm with a range of −43.5mm short to 10.3mm long. The LLD was less than 10mm in 18 patients (64%), 10–15mm in four patients (14%), 15–20mm in three patients (11%) and more than 20mm in three patients (11%). Measurement of discrepancy as small as 0.5mm showed that 18 patients were fixed with shortening and in 10 patients the operated femur was longer. Tibia lengths were also evaluated separately. Though none of the tibiae had a previous fracture, only three patients (10%) had tibiae of equal length. In 13 patients, an unequal tibia partially corrected the LLD whilst in 12 it added to the discrepancy. Five patients with LLD of greater than 15mm underwent correction. ConclusionsA postoperative scanogram in patients with comminuted femoral shaft fractures treated with intramedullary nailing is useful to evaluate LLD and allows for early intervention. The ideal length where correction is necessary remains unclear.