Retrograde nailing for subtrochanteric femur fractures.

This study reviews the results of subtrochanteric femur fractures treated with a retrograde nail at a level 1 trauma center. Sixteen patients with 17 fractures were followed up until union. The average Injury Severity Score (ISS) was 19, and average knee range of motion was 127 degrees. Four patients required dynamization of their nail, and three healed over a prolonged period of time. Two patients required exchange nailing: one after failure of union after dynamization and one with a broken nail that was revised to an antegrade nailing. The average varus deformity was 5.06 degrees and only 35% of fractures healed in greater than 5 degrees of varus, with an average time to union of 22.4 weeks (range, 6-54 weeks). Antegrade nailing remains the treatment of choice for the vast majority of subtrochanteric femur fractures. However, retrograde femoral nailing may be an effective treatment option for some subtrochanteric fractures in a selected group of patients.

Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation.

OBJECTIVE: To determine the patellofemoral contact areas as well as mean and maximal pressures after retrograde intramedullary nailing in a cadaveric model. STUDY DESIGN: Pressure-sensitive film was used to analyze patellofemoral joint pressures after insertion of a retrograde femoral nail in a cadaveric specimen. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Office removal of tibial external fixators: an evaluation of cost savings and patient satisfaction.

OBJECTIVES: To evaluate the efficacy and patient satisfaction of office removal of tibial external fixators and to compare the cost of this procedure with the cost of removal of fixators in the operating room. DESIGN: A visual analog scale (VAS) and a questionnaire were answered by all patients after office external fixator removal. The treatment, complications, and costs were compared with those of patients having external fixator removal in the operating suite. SETTING: An urban orthopaedic trauma office with a Level I trauma center. PARTICIPANTS: Two similar groups of patients; thirty fixators removed in the office and twenty-nine fixators removed in the operating room. INTERVENTION: Office or operating room removal of tibial external fixators and application of a sterile dressing. A visual analog scale was answered by those patients who had office removal. MAIN OUTCOME MEASUREMENTS: Patient satisfaction and pain rating (VAS) with office removal of external fixators. Comparison of costs, infections, time in fixator, and surgical interventions between the office and operating room groups. RESULTS: Group I had thirty fixators (twenty-nine half-pin fixators) removed in the office. Group II had twenty-nine fixators removed in the operating room. Duration of time in the frame was not statistically different. Antibiotic usage during the fixator treatment period was 69 percent in both groups. On the visual analog scale, twenty-four members (80 percent) of the office fixator removal group rated the pain during removal as less than 25 percent of maximal, including nine (30 percent) who rated the removal as causing no pain. Cost analysis revealed an average cost of $248 for the office group versus $2,160 for the operating room group (p < 0.001). CONCLUSIONS: Due to the cost savings and patient satisfaction, without compromising clinical care, the office is our preferred location for tibial half-pin external fixator removal.

Retrograde intramedullary nailing of femoral diaphyseal fractures.

OBJECTIVES: To prospectively evaluate the results of retrograde intramedullary nailing of femoral shaft fractures. DESIGN: Prospective, consecutive series. PATIENTS AND SETTING: 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. INTERVENTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Ipsilateral fractures of the femur and tibia: treatment with retrograde femoral nailing and unreamed tibial nailing.

Between 1989 and 1995 a total of 47 patients with 50 fractures of the ipsilateral femoral and tibial shafts without significant articular involvement were treated at Tampa General Hospital. Within this group were 24 patients with 26 fractures who were treated with intramedullary fixation of both bones using a technique of retrograde insertion of a femoral nail and unreamed insertion of an interlocking tibial nail. Information concerning the injuries, treatments, and much of the follow-up was gleaned from a trauma registry. Five of the femoral fractures (19%) and 14 of the tibial fractures (54%) were open. Associated injuries were present in 18 of the 24 patients (75%) with injuries of the pelvis, other extremities, and head being most prevalent. The average Injury Severity Score was 14 (range 9-32). The femoral nails were placed either through the medial femoral condyle (n = 14) or the intercondylar notch of the distal femur (n = 12). Twenty patients with 22 extremities had sufficient follow-up at an average of 20 months (range 4-60) postinjury to be included in the review. One patient had died, and three were completely lost to follow-up. Both fractures in 14 extremities had healed or were healing uneventfully at final review. Seven of the tibiae and three of the femora had complications after initial hospitalization. Two patients developed problems in both bones. Three patients had electrical stimulation of a tibia fracture, one of which underwent simultaneous nail dynamization. A total of 18 additional operative procedures were necessary after the primary treatment in six problematic extremities. Thirteen additional operative procedures were required in five complicated tibiae (one nail dynamization, six debridement procedures, five bone grafts, and one muscle flap) after the initial hospitalization. Five additional operative procedures were required in the three complicated femora (two nail dynamizations, one bone graft, and two exchange nailing procedures). Functional results were good or excellent in 13 of the 20 patients (65%) and 15 of the 22 extremities (68%) available at final review. No significant knee problem related to the femoral nailing technique was identified. This method of treatment can be performed using a standard radiolucent table and a single medial parapatellar incision. It is expedient and allows other procedures to be performed simultaneously in this group of severely injured patients.

Fracture of the shaft of the humerus secondary to muscular violence.

Fractures of a normal humeral shaft secondary to muscular violence have been uncommonly reported in the literature since the early 1900s. These injuries have been associated with throwing javelins, hand grenades, and baseballs. We report a case of a similar injury occurring in a healthy young amateur baseball pitcher. Pertinent anatomy, pathomechanics, and electromyographic study results are discussed.