Retrograde Femoral Intramedullary Nail Research Articles

Retrograde intramedullary nailing of the femur: identifying the true anatomic axis for the ideal start point.

Retrograde femoral intramedullary nailing (IMN) is commonly used to treat distal femur fractures. There is variability in the literature regarding the ideal starting point for retrograde femoral IMN in the coronal plane. The objective of this study was to identify the ideal starting point, based on radiographs, relative to the intercondylar notch in the placement of a retrograde femoral IMN. A consecutive series of 48 patients with anteroposterior long-leg radiographs prior to elective knee arthroplasty from 2017 to 2021 were used to determine the femoral anatomic axis. The anatomic center of the isthmus was identified and marked. Another point 3cm distal from the isthmus was marked in the center of the femoral canal. A line was drawn connecting the points and extended longitudinally through the distal femur. The distance from the center of the intercondylar notch to the point where the anatomic axis of the femur intersected the distal femur was measured. On radiographic review, the distance from the intercondylar notch to where the femoral anatomic axis intersects the distal femur was normally distributed with an average distance of 4.1mm (SD, 1.7mm) medial to the intercondylar notch. The ideal start point, based on radiographs, for retrograde femoral intramedullary nailing is approximately 4.1mm medial to the intercondylar notch. Medialization of the starting point for retrograde intramedullary nailing in the coronal plane aligns with the anatomic axis. These results support the integration of templating into preoperative planning prior to retrograde IMN of the femur, with the knowledge that, on average, the ideal start point will be slightly medial. Further investigation via anatomic studies is required to determine whether a medial start point is safe and efficacious in patients with distal femur fractures treated with retrograde IMNs.

The surgical management of metastatic lesions of the femur

ABSTRACT BACKGROUND: Malignant tumours commonly metastasise to bone. When this occurs in the femur, surgical intervention is required to reduce pain and restore mobility post fracture, or as a prophylactic measure when fracture is anticipated. This is typically in the form of replacement with hemi- or total arthroplasty or stabilisation with an intramedullary device. The indications for one modality over the other are debatable and the reported outcomes and complications are varied. The purpose of this study is to assess the management algorithm for bony metastasis of the femur at a tertiary bone tumour unit, and the outcomes of the surgical strategies employed METHODS: A retrospective cohort study was performed of all patients presenting to our institution with femoral metastasis, both with and without pathological fracture, who were managed surgically from April 2016 to February 2020. Fractures of the femoral neck were managed with cemented arthroplasty. All other fractures were managed with intramedullary nailing, as were all lesions requiring prophylactic stabilisation. Data was recorded regarding demographics, primary pathology, location of lesion, type of surgery, and implant used. The incidence of complications including radiological failure of fixation, infection, thromboembolic phenomena, re-operation and mortality were recorded RESULTS: Eighty-five femurs in 77 patients were included (mean age 61 years, range 20-90). Lesions were located in the femoral neck (19/85, 22%), intertrochanteric (20/85, 24%), subtrochanteric (40/85, 47%), diaphyseal (2/85, 2%) and metaphyseal/per-condylar (4/85, 5%) regions of the femur. A total of 64/85 (753%) procedures were performed for fractures and 21/85 (25%) prophylactically. Eighteen of the 85 (21%) underwent long-stemmed cemented bipolar hemiarthroplasty, 1/85 (1%) long-stemmed cemented total hip replacement (THR), 62/85 (73%) cephalomedullary nailing, and 4/85 (5%) retrograde femoral intramedullary nailing. Mean follow-up was eight months (range 1-36). There were no dislocations or periprosthetic fractures in the arthroplasty group. One failure (1/66, 2%) of fixation occurred in the intramedullary nailing group. Six deaths occurred in the arthroplasty group (6/64, 9%) and 24 in the nailing group (24/66, 36%) during the study period. Four patients suffered from thromboembolic phenomena (4/77, 5%). Of the 13 patients who sustained a pathological fracture and were managed with intramedullary nailing and followed up for at least one year, all had achieved clinical and radiological union CONCLUSION: Femoral metastasis can be appropriately managed with intramedullary nailing, both prophylac-tically and in the event of fracture, with a low rate of implant failure and an expectation that healing will occur once stabilised. Intracapsular fractures can be managed with long-stemmed cemented arthroplasty with a low risk of subsequent fracture or dislocation Level of evidence: Level 4 Keywords: bone metastasis, femur, pathological fracture

Heterotopic ossification around the knee after tibial nailing and ipsilateral antegrade and retrograde femoral nailing in the treatment of floating knee injuries.

Floating knee injuries are relatively uncommon injuries. We report the prevalence, location, and severity of heterotopic ossification (HO) around the knee in patients treated with antegrade tibial intramedullary nailing and ipsilateral antegrade versus retrograde femoral intramedullary nailing as well as how the severity of HO around the knee affects knee range of motion (ROM). From 2004 to 2014, 26 floating knee injuries were included. Radiographs were reviewed to determine presence, location, and severity of HO. Post-operative knee ROM was determined. A significantly higher prevalence of HO around the knee was detected in the retrograde group (90%) compared to the antegrade group (43%) (p = 0.028). There was a trend for more HO into the patellar tendon occurring in 29% of patients in the antegrade group and 74% in the retrograde group (p = 0.069). The severity of HO was higher for the retrograde group 1.6 ± 1.0 compared to the antegrade group 0.4 ± 0.5 (p = 0.004). There was poor correlation between HO severity and knee ROM. Treatment of floating knee injuries with a retrograde femoral nail was demonstrated to result in a greater likelihood of developing HO and a greater severity of HO around the knee than if treated with an antegrade femoral nail. However, this increased severity of HO is unlikely to affect ROM. III.

Le Clou Targon PH® dans l’ostéosynthèse des fractures du fémur distal chez l’enfant handicapé : à propos de trois cas

Recommendations for distal femoral fracture treatment in children with neuromuscular disease are various, including conservative, plating, nailing, and ESIN. All methods have disadvantages. Retrograde femoral intramedullary nailing using a statically interlocked Targon PH nail was performed in three cases. A right nail was used for a right femur (and vice versa). A short nail was used for supracondylar fractures, a long nail for distal femoral shaft fractures. Closed reduction was performed in all cases. Despite osteopenia, small bone dimensions and muscle dystrophy no intraoperative or postoperative complications occurred. All cases achieved primary stability, allowing immediate rehabilitation. Bone healing occurred uneventfully within four months. No deterioration of functional status or range of motion was seen. There were no peri-implant fractures or hardware removal need over a two-year-period. Retrograde femoral nailing with the Targon PH nail seems to be a reasonable treatment concept for these rare and demanding cases. Level of evidenceIV.

The Targon PH® nail for distal femoral fracture fixation in disabled children. A report of three cases

Recommendations for distal femoral fracture treatment in children with neuromuscular disease are various, including conservative, plating, nailing, and ESIN. All methods have disadvantages. Retrograde femoral intramedullary nailing using a statically interlocked Targon PH nail was performed in three cases. A right nail was used for a right femur (and vice versa). A short nail was used for supracondylar fractures, a long nail for distal femoral shaft fractures. Closed reduction was performed in all cases. Despite osteopenia, small bone dimensions and muscle dystrophy, no intraoperative or postoperative complications occurred. All cases achieved primary stability, allowing immediate rehabilitation. Bone healing occurred uneventfully within four months. No deterioration of functional status or range of motion was seen. There were no peri-implant fractures or hardware removal need over a two-year-period. Retrograde femoral nailing with the Targon PH nail seems to be a reasonable treatment concept for these rare and demanding cases. Level of evidenceIV.

Retrograde Femoral Nailing in Elderly Patients: Outcome and Functional Results

Functional outcome after retrograde femoral intramedullary nailing was investigated in 35 patients older than 60 years (mean, 86 years) with 36 fractures, comprising 15 (41.7%) shaft and 21 (58.3%) distal fractures; overall, 7 (19.4%) periprosthetic fractures occured. Twenty-two (62.9%) of 35 patients were evaluated at a mean 16.5-month follow-up with the Lyshom-Gillquist score and the SF-8 questionaire. Primary union rate was 97.8%, with no significant differences in duration of surgery, bone healing, mobilization, and weight bearing among different fracture types; periprosthetic fractures revealed a significantly delayed mobilization (P=.03). Complications occured significantly more often among distal femoral fractures (P=.009), including all revision surgeries. The most frequently encountered complication was loosening of distal locking bolts (n=3). Lysholm score results were mainly influenced by age-related entities and revealed fair results in all fractures (mean in the femoral shaft fracture group, 78.1 vs mean in the distal femoral fracture group, 74.9; P=.69), except in the periprosthetic subgroup, which had good results (mean, 84.8; P=.23). This group also had increased physical parameters according to SF-8 score (P=.026). No correlation existed between SF-8 physical parameters and patient age or surgery delay, whereas a negative correlation existed between patient age and SF-8 mental parameters (P=.012). Retrograde femoral intramedullary nailing is commonly used in elderly patients due to reliable bone healing, minimal soft tissue damage, and immediate full weight bearing. It also offers a valid alternative to antegrade nailing in femoral shaft fractures.

Periprosthetic Fracture after Femoral Intramedullary Nail Use in Two Cases of Tibiotalocalcaneal Arthrodesis

Tibiotalocalcaneal arthrodesis using intramedullary nail fixation is a technically demanding procedure. Periprosthetic fracture in association with tibiotalocalcaneal arthrodesis is a rare occurrence, with relatively few instances reported. The present report describes 2 such instances that occurred after tibiotalocalcaneal arthrodesis using retrograde femoral intramedullary nail fixation. Studies have suggested that a longer nail might decrease the incidence of periprosthetic fracture. Other factors could also have an influence, including the proximal screw orientation and the presence of medical comorbidities, such as osteopenia.

Clinical Results of Retrograde Femoral Intramedullary Nail for Femoral Fracture

Clinical Results of Retrograde Femoral Intramedullary Nail for Femoral Fracture

Technical Notes and Tips: A Radiolucent Retractor for Locking Screws

During proximal locking of a retrograde femoral intramedullary nail, retraction can be difficult when using traditional radio-opaque retractors. A 50-ml syringe, such as BD Plastipak™ (BD, The Danby Building, Edmund Halley Road, Oxford Science Park, Oxford, UK), with the catheter tip cut off, either with scissors or a saw, can be placed directly onto bone via the skin incision. This easily retracts the tissues allowing access to the proximal femur with the added benefit of being radiolucent. This allows the surgeon to interpret the fluoroscopy findings accurately and position the proximal locking screw precisely. Furthermore, the surgical assistant is protected from erroneous exposure to radiation whilst screening. Figure 1 Syringe placed onto saw bone demonstrating retraction technique.

Osteonecrosis of the Femoral Head After Retrograde Intramedullary Nailing of a Femoral Shaft Fracture in an Adolescent

O steonecrosis of the capital femoral epiphysis following antegrade intramedullary nailing of femoral shaft fractures has been generally described as occurring in adolescent and pediatric patients1-10. However, a limited number of cases have been reported in adults11,12. The condition appears to represent an iatrogenic injury resulting from the proximity of the medial femoral circumflex artery to the piriformis fossa, which is the typical starting point for intramedullary nailing13. To our knowledge, there have been no previously published reports of osteonecrosis of the femoral head following retrograde intramedullary nailing of a femoral shaft fracture. Retrograde insertion techniques are applicable to adults and older adolescents, after closure of the distal femoral physis. We present the case of an adolescent male with osteonecrosis of the femoral head following retrograde femoral intramedullary nailing, and we review the osteonecrosis risk factors that may be present in patients who sustain polytrauma. Our patient and his legal guardian were informed that data concerning the case would be submitted for publication. Fig. 1-A Initial anteroposterior radiograph showing an open comminuted fracture of the right femoral shaft. There is no apparent associated fracture of the femoral neck. A seventeen-year-old boy was involved as an unrestrained, front-seat passenger in a high-energy, head-on motor-vehicle collision. Paramedics found the boy trapped under the dashboard and required more than thirty minutes to extricate him. On arrival at our institution, the patient was tachypneic (respiratory rate, 33 breaths/min), tachycardic (heart rate, 105 beats/min), and hypotensive (blood pressure, 76 mm Hg) but was alert and oriented and had a Glasgow Coma Scale score of 15. Radiographs revealed multiple long-bone fractures, including a type-I open comminuted fracture of the right femoral shaft (Fig. 1-A), according to the system of Gustilo and Anderson14, and closed diaphyseal fractures …

Treatment of floating knee injuries through a single percutaneous approach.

The current study is a review of 20 patients treated by percutaneous stabilization for a floating knee. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. The average Injury Severity Score was 19. Two patients died in the early postoperative period and one patient was lost to followup. The average time to union for the 17 remaining patients with femoral shaft fractures was 14.7 weeks. One patient required dynamization. Four of the 17 patients with tibia fractures required an exchange nailing procedure, one with bone graft, to achieve union. One patient required dynamization and one patient with bone loss required only a bone graft. The average time to union for the tibia fractures was 23 weeks. One patient achieved 115 degrees knee flexion and the remaining 15 patients had full knee motion by 12 weeks, which they were able to maintain. No patient had signs or symptoms of knee pain. This demanding surgical technique using a small incision has yielded good clinical results. Although it is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the mortality and tibial fracture complication rates remain high.

Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation.

To determine the patellofemoral contact areas as well as mean and maximal pressures after retrograde intramedullary nailing in a cadaveric model. Pressure-sensitive film was used to analyze patellofemoral joint pressures after insertion of a retrograde femoral nail in a cadaveric specimen. A retrograde femoral nail was inserted into seven cadaveric knees. Pressure-sensitive film was placed into the patellofemoral joint and physiologic loads (700 newtons) were applied to the knee joint at 90 degrees and 120 degrees of flexion. Testing was performed with the nail three millimeters deep to the cartilage (In), flush with the cartilage (Flush), and one millimeter prominent (Out). The intact knee served as the Control. The mean contact areas showed no statistical differences among the four groups. There was a significant increase in mean pressure at 120 degrees and maximum pressure at 90 degrees and 120 degrees for the Out group when compared with the Control, In, and Flush groups (p < 0.001). There were no significant differences in mean contact pressure, contact area, or maximum pressure among the Control, three-millimeter insertion depth, or flush insertion groups. There was, however, a significant increase in mean and maximum pressures with the nail one millimeter prominent. These results indicate that placement of a retrograde femoral intramedullary nail is critical, but that proper placement should not significantly influence the biomechanics of the patellofemoral joint.

Retrograde intramedullary nailing of femoral diaphyseal fractures.

To prospectively evaluate the results of retrograde intramedullary nailing of femoral shaft fractures. Prospective, consecutive series. All patients with a femoral shaft fracture admitted at an urban Level 1 trauma center from December 1995 to December 1996 were treated with a retrograde femoral intramedullary nail. Retrograde femoral intramedullary nailing was performed on a radiolucent operating room table. Through a three-centimeter medial parapatellar incision, a reamed ten-millimeter retrograde nail was inserted. From the time of injury until union, the following parameters were assessed: operative time, blood loss, extent of comminution, open grade, associated injuries, Injury Severity Score, body mass index, time to union, secondary procedures, range of motion in the knee. and complications. Fifty-seven patients with sixty-one fractures were available for follow-up, which averaged 43.1 weeks. Fifty-two percent of fractures demonstrated Winquist Type 3 or 4 comminution. Twenty-six percent of the fractures were open. Fifty-two fractures healed after the initial nailing, five of seven dynamized nails healed, and one patient with bone loss requiring bone graft united yielding a final union rate of 95 percent. Of the three nonunions (5 percent), two healed with exchange nailing and one remains asymptomatic at seventy-one weeks. One patient developed a late septic knee that resolved with treatment. Excellent range of motion in the knee was obtained by those patients who did not have other ipsilateral limb injuries. This consecutive series had a 95 percent union rate after nailing and dynamization as necessary. No knee problems were associated with the retrograde femoral intramedullary nailing technique. The one septic knee raises concerns about the use of retrograde nailing in severe open femoral shaft fractures. Retrograde femoral nailing should be given serious consideration as an alternative to antegrade femoral nailing.