Optimal entry point for antegrade and retrograde femoral intramedullary nails / 中华创伤杂志(英文版)

Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.

A COMPARATIVE PROSPECTIVE STUDY OF DYNAMIC HIP SCREW AND PROXIMAL FEMORAL NAIL IN TREATMENT OF SUBTROCHANTERIC FRACTURE FEMUR

Subtrochanteric fractures are relatively rare, accounting for 10 - 34% of all hip fractures1,2,3. They may be very difficult to fix, and the risk of failure has been high with loss of the lesser trochanter and the medial buttresses 3,4, Various intramedullary and extramedullary devices have been developed in an attempt to address potential complications of device failure, mal- or non-union and deformities. In our prospective case series 29 subtrochanteric fractures were involved. The aim of this study is to assess fracture union and functional outcome in subtrochanteric fracture femur treated with proximal femoral nailing and dynamic hip screw, and also to evaluate advantages, disadvantages and major postoperative complications associated with the proximal femoral nailing and dynamic hip screw. Conclusion: The average functional scores for the PFN group at 6 months was 31.5 (excellent) which was significantly greater than the DHS group 27.1(good) (p = 0.03). There was no significant difference in time to union in both groups (average 5.7 months for DHS group and 5.2 months for PFN group) (p = 0.26). The intraoperative complication rate for the PFN group was 36% which was significantly higher than the DHS group (0%) (p =0.001). The PFN had a significantly better functional outcome than DHS plating at 6 months. Long term studies may be needed to observe whether the difference persists on further follow ups. The PFN had a significant advantage over the DHS with side plate in subtrochanteric fractures with regards to less blood loss, less requirement for transfusions, better functional scores, less shortening and fewer incidences of postoperative complications. From the study, we consider PFN as better alternative to DHS in the treatment of subtrochanteric fracture femur but is technically difficult procedure and requires more expertise compared to DHS.

Enclavado femoral y artroplastía total de rodilla en un tiempo en una paciente con fractura diafisaria femoral por estrés / Interlocking femoral nail and total knee Arthroplasty in one stage for a patient with a femoral diaphyseal stress fracture

Resumen: Presentamos el caso de una mujer de 81 años de edad, en seguimiento por el Servicio de Reumatología por osteoporosis y tratada con bifosfonatos durante más de cinco años. Refirió una fractura del tercio distal del fémur contralateral por mecanismo de baja energía, tratada con enclavado intramedular retrógrado el año anterior. Presentó una clínica de cruralgia y gonalgia izquierda, sin traumatismo previo. Se le realizó una gammagrafía y radiografías que apoyaron el diagnóstico de fractura de estrés del tercio distal del fémur izquierdo y osteonecrosis del cóndilo femoral interno izquierdo. Pensando en las posibles complicaciones de llevar a cabo dos intervenciones en una paciente de avanzada edad, se decidió efectuar el tratamiento en un tiempo y por el mismo abordaje quirúrgico, tratando de resolver la osteonecrosis y la fractura a la vez, con el objetivo de una rehabilitación precoz y menor morbilidad. Se realizó un enclavado profiláctico retrógrado femoral para estabilizar la fractura de estrés y se implantó una prótesis de rodilla primaria retentiva para el ligamento cruzado posterior por el mismo abordaje quirúrgico. No hubo incidencias en el postoperatorio inmediato; se inició deambulación con ayuda a las 48 horas de la intervención. La fractura consolidó y la paciente presentó un buen resultado funcional de la rodilla, tanto en el postoperatorio inmediato como a los tres años de seguimiento.

Abstract: We present the case of an 81-year-old woman who was followed up by the Rheumatology Service for osteoporosis and treated with bisphosphonates for more than five years. She reported a fracture of the distal third of the contralateral femur by a low energy mechanism, treated with retrograde intramedullary nailing the previous year. She presented a clinic of cruralgia and left gonalgia, without previous trauma. A scintigraphy and radiographs were performed to support the diagnosis of stress fracture of the distal third of the left femur and osteonecrosis of the left internal femoral condyle. Thinking about the possible complications of performing two interventions in an elderly patient, we decided to complete the treatment in a single time and by the same surgical approach, trying to resolve the osteonecrosis and the fracture at the same time, with the objective of an early rehabilitation and lower morbidity. A femoral retrograde prophylactic nailing was performed to stabilize the stress fracture and a retentive primary knee prosthesis was implanted for the posterior cruciate ligament by the same surgical approach. There were no incidents in the immediate postoperative period, with ambulation beginning with help 48 hours after the intervention. The fracture consolidated and the patient presented a good functional result of the knee, both in the immediate postoperative period and at three years of follow-up.

Venting in closed femoral nailing: A simple technique using a frazier suction tip.

A surgical technique to drain the medullary content during closed femoral nailing by using a Frazier suction tip as a vent is demonstrated. This method is simple, safe and reproducible. The medullary content can be drained outside without surrounding soft tissue contamination and the intramedullary pressure is possibly minimized when femoral canal reaming and nail insertion is performed.

Analysis of Prognostic Factors for Union Time after Unreamed Femoral Nailing

PURPOSE: To assess the evaluation of prognostic factors according to union time after unreamed femoral nailing. MATERIALS AND METHODS: From Mar. 1998 to Mar. 2002, 53 cases of bone healing were analyzed among the fifty-nine femoral shaft fractures were treated with unreamed femoral nail (AO, UFN) and had been followed for more than 12 months. Clinical bone healing time was analyzed by Kempf's method and were evaluated prognostic factors according to union time. RESULTS: Mean duration of the bone healing time was 18.7 weeks. According to Denker's classification, functional results were seen over satisfactory at all cases. Bone healing time was more faster at the low communition group than high communition group at 18.1 weeks. At the middle portion, bone healing time was fastest. Closed reduction cases were more faster than open reduction cases at 17.9 weeks. Bone healing time was faster that fracture was more close distance from isthmic portion. Bone healing time was not influenced age, isthmic ratio, operation time, associated injury. CONCLUSION: All cases were unioned within 5 months without severe complication. That was seen faster bone healing time, in that low communition, more close distance of fracture from the isthmic portion, closed reduction method.