Research Article

Research Article

Retrograde femoral nails for intercondylar femoral fractures

Abdelsalam Eid*, Shamel Elgawhary

Department of Orthopaedic Surgery, Faculty of Medicine, ZagazigUniversity, Egypt.

*Corresponding author: Dr. Abdelsalam Eid, Department of Orthopaedic Surgery, Faculty of Medicine, Zagazig University,

5 Mahfouz Street, from Ahmed Ismail Street, Zagazig, 44511, Egypt. E-mail: eid_md@yahoo.com, Tel:+201005440204.

 

 

Citation: Eid A, Elgawhary S. Retrograde femoral nailsfor intercondylar femoral fractures. J Minim Invas Orthop, 2015, 2(4), e11. doi: 10.15383/jmio.11.

Competing interests: The authors have declared that no competing interests exist.

Conflict of interest: None

Copyright: 2015 By the Editorial Department of Journal of Minimally Invasive Orthopedics. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 


Abstract:

Intercondylar femoral fractures require much effort to anatomically reduce the articular surface and to obtain stable fixation to allow knee movements until fracture healing. Open reduction and plate fixation is usually done. MIPO is becoming popular, particularly with locked plates. However, some authors reported the successful use of supranails in intercondylar femoral fractures. Ten patients with intercondylar femoral fractures AO Type C2 were treated by fixation using a retrograde femoral nail after fixing the condyles with a cannulated screw. All fractures united, including one delayed union that required a bone graft without change of fixation. Mean time to clinical union was 3.8 months. Mean time to radiological union was 5.4 months. According to the modified HSS knee score the mean level of pain was 31.5. Eight patients had a knee range of motion (ROM) > 90º. Two patients had extension lag of 10º. Three patients had minor residual valgus, one had minor residual varus. The mean modified Heidke Skill Score (HSS) was 82.6. Retrograde femoral interlocking nails could effectively fix intercondylar femoral fractures until union occurs.

Keywords: Intercondylar; femoral fracture; retrograde nail.

 

Introduction

Fractures of the distal femur are uncommon. The estimated frequency is 0.4% of all fractures and 3% of femoral fractures. A classic bimodal distribution is found with a peak in frequency in young men (in their 30s) and elderly women (in their 70s). The usual context is a high energy trauma in a young patient and a domestic accident in an elderly person[1]. Despite the advances in surgical techniques and implants, the management of distal femoral fractures remains a challenge. Different methods of fixation include: angled blade plate, dynamic condylar screw, flexible nails, intramedullary nails, supracondylar nails, locked plates, and external fixation. External fixation, (ring or hybrid) has been particularly useful in fractures with intra-articular comminution (AO type C3)[2].

For an extra-articular fracture, all therapeutic options are possible and mini-invasive surgery can be performed. Fractures of distal femur with an intra-articular extension require much effort to anatomically reduce the articular surface and to obtain stable fixation to allow knee movements until fracture healing. Open reduction and internal plate fixation is usually done. Minimally invasive plating is becoming more popular, particularly with the use of locked plates[3]. However, some authors reported the successful use of supranails in distal femoral fractures with intra-articular extension[4].

Fractures with very small distal fragments (within 6 cm from the joint line) and those with significant anterolateral extension of the fracture especially difficult are[5,6].

Our hypothesis was that retrograde femoral interlocking nails could effectively fix intercondylar femoral fractures until union occurs.

Materials and methods

Patient

This prospective study was performed, between January 2009 and December 2010, in the casualty unit of the Orthopaedic Department of our University Hospital. Institutional Review Board approval was obtained. All patients gave an informed consent before their data was included in the study.

Inclusion criteria were: (1) Distal femoral fractures AO Type C 1, 2; (2) closed or grade 1 open fractures.

Exclusion criteria were: (1) distal fragment smaller than 3 cm from joint line; (2) extra-articular or Partial articular distal femoral fractures or those with intra-articular comminution (C3); (3) open fractures grade 2 and higher.

Fourteen patients with distal femoral fractures who fit the inclusion criteria were treated surgically by fixation using a retrograde femoral nail. Four patients were excluded from the study because of inadequate follow up. The results of the remaining 10 patients who completed the minimum 2 year follow up are presented hereafter.

Six patients (60%) were females and four patients (40%) were males. The mean age was 46.8 years (range from 33 to 60 years). The mechanism of injury was a Motor Vehicle Accident (MVA) in 7 patients (70%), and a pedestrian accident in 3 patients (30%). According to AO classification of distal femoral fractures, all fractures were type C2. All fractures were closed. Four patients (40%) had associated skeletal injuries.

All patients were examined clinically. Radiological examination included anteroposterior and lateral X rays as well as CT scan for all patients. The mean interval between the injury and operation was 18.2 hours (range 6 to 36 hours).

Surgical technique

The patients received a prophylactic third generation cephalosporin before induction of anaesthesia. General or spinal anaesthesia was administered. The patient was positioned supine on a radiolucent table with a sandbag under the involved knee to facilitate reduction of the distal fragment as well as facilitation of taking lateral view with the image intensifier. The primary step was the reduction and fixation of the articular condylar fragments by a cannulated screw. The screw was placed anteriorly to avoid blocking the insertion of the retrograde nail. Next attention was directed to insertion of the retrograde nail. A three cmtrans-patellar-tendon incision was made. A trocar was advanced through the intercondylar notch just in front of PCL insertion using a slow power drill. A ball-tipped guide wire was passed through the distal and into the proximal fragment. Reaming was performed slowly in order to protect the small distal fragment especially in intra-articular fractures. The nail was then inserted and locked.

The standard rehabilitation program included encouraging the patients to do non-weight-bearing mobilization exercises as soon as pain allowed postoperatively and to ambulate with two crutches without weight bearing for 6 weeks postoperatively. Then partial weight bearing with two crutches was allowed for 3 weeks, followed by partial weight bearing with one crutch for three more weeks, after which full weight bearing was permitted.

Follow up

Clinical examination and instructions on rehabilitation were performed every two weeks during the first six weeks, then at 9 weeks. Control X rays were obtained at two and six weeks. Subsequently, clinical and radiological follow up was performed at 12 weeks, 6 months, 12 months, and yearly afterwards. The average follow up was 28.6 months (range 24 to 36).

Results

Clinical results

Table 1 showed the clinical data of the ten patients. Eventually, all fractures united (Figure 1 and Figure 2). The mean time to reach clinical union was 3.8 months (range, 3 to 9 months). The mean time to reach radiological union was 5.4 months (range, 4 to 12 months). For clinical evaluation the modified HSS knee score was used[7]. According to this score, the mean level of pain at the final follow up was 31.5 (Range, 25 to 35). Eight patients had a knee ROM more than 90º. Two patients had extension lag of 10º. Three patients had minor residual valgus, while one had minor residual varus which led to subtractions from their HSS scores. The mean modified HSS score was 82.6 (Range: 72 to 90).

According to the mean modified HSS score at the final follow up, six patients were graded as Excellent, and four patients were graded as Good. Nine patients were satisfied with the outcome of the procedure, while one was undecided.

Complications

Two patients developed delayed union involving the metaphyseal element of the fracture. There were no signs of implant instability. Surprisingly, they were able to perform partial weight bearing with crutches. However, due to the lack of radiological signs of union they were taken to the operating room where they were managed by bone grafting. Both patients eventually showed sign of union. One patient had a prominence of the nail in the intercondylar notch. The nail was extracted after radiological union. Another patient had a prominent locking screw which was removed.


Table 1.  Patients' clinical data.

No

Age

Se

Mechanism

Associated

Interval to

Time to

Time to

Follow

HSS Score

 

 

 

 

 

Complication

 

(years)

x

of injury

injuries

operation

clinical

radiological

Up

 

 

 

 

 

s

 

 

 

 

 

 

 

 

 

Pai

Stabilit

RO

Quadricep

Subtractions

Total

 

 

 

 

 

(hours)

union

union

(months)

 

 

 

 

 

 

n

y

M

s

 

 

score

 

 

 

 

 

 

 

(months)

(months)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

  33

F

RTA

Ipsilat. tibia

12

3

4

36

35

25

25

5

 

 

90

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

40

F

RTA

Ipsilat.

24

3

4

24

30

21

20

5

-4

Extensi

72

Prominent

 

 

 

 

Tibia

 

 

 

 

 

 

 

 

 

on lag

 

nail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

53

F

RTA

-

8

4

4

36

30

21

25

10

 

 

86

Prominent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

screw

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

60

M

Fall

-

12

3

4

30

30

25

25

5

 

 

85

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

44

F

RTA

-

12

3

4

30

35

21

25

10

-2

Valgus

89

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

42

F

RTA

-

24

3

5

24

35

21

25

10

-2

Valgus

89

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

55

M

Fall

Ipsilateral

36

3

5

24

35

17

25

10

 

 

87

-

 

 

 

 

acetabular

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

fracture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

50

M

Fall

Ipsilat.

24

4

8

30

25

17

25

10

-2

Valgus

75

Delayed

 

 

 

 

distal

 

 

 

 

 

 

 

 

 

 

 

union

 

 

 

 

radius

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

44

M

RTA

-

6

3

4

28

30

25

25

5

-4

Varus

81

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

47

M

RTA

-

24

9

12

24

30

21

20

5

-4

Extensi

72

Delayed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

on lag

 

union

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Means

46.8

 

 

 

18.2

3.8

5.4

28.6

31.5

 

 

 

 

 

82.6

 

 

 


Discussion

Surgical treatment of distal femoral fractures represents a challenge to orthopedic surgeons especially those with intra-articular extension

In this series 10 patients with distal femoral intra-articular fracture were fixed by retrograde femoral nailing. The condyles were preliminarily fixed with a cannulated cancellous screw. All fractures united even though two of them required bone grafting. This supports our hypothesis that retrograde femoral interlocking nails could effectively fix intercondylar femoral fractures until union occurs.

Plating is supposed to provide greater stiffness than intramedullary nails in axial loading and less stiffness in torsional loading[8]. In this study, nails stabilized the fractures without any sign of implant instability until union occurred.

 

 

Figure 1. Clinical results in patient 1. (A) Preoperative X raya.  Preoperative X ray. (B) After unionb) After union. (C) ROM.

 

Wu and Shih 9 compared the results of 66 patients with supracondylar femoral fractures divided into two groups. One group (28 cases) was fixed with plates and the other (38 cases) with an interlocking femoral nail. They reported a higher union rate and better functional results in those treated by interlocking nails[9]

Markmiller et al[10] compared the LISSTM plate and a supracondylar nail in 32 patients with distal femoral fractures, with 16 in each group. At one year, they reported no differences in the functional outcome or complication rate between the two groups. They concluded that both implants yielded good results[10]. A similar conclusion was reached by Hierholzer et al[11]. in their comparison of retrograde femoral nails versus locked plates.

 

Figure 2. Clinical results from patient 2. (A) Preoperative X ray. (B) After Union.(C) ROM.

 

In this series, all fractures were stabilized through a trans-patellar-tendon incision, with stab incisions for the cannulated and the locking screws. The small incisions were a major factor in the satisfaction of most patients.

The small number of patients, the need for longer follow up, and the lack of a control group are the main weaknesses of this study which should be addressed in future work.

Conclusion

Retrograde femoral interlocking nails could effectively fix intercondylar femoral fractures until union occurs.

References

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2. Forster MC, Komarsamy B, Davison JN. Distal femoral fractures: a review of fixation methods. Injury. 2006;37(2):97-108.

3. Ehlinger M, Ducrot G, Adam P, Bonnomet F. Distal femur fractures. Surgical techniques and a review of the literature. Orthop Traumatol Surg Res. 2013;99(3):353-60.

4.  Garnavos C, Lygdas P, Lasanianos NG. Retrograde nailing and compression bolts in the treatment of type C distal femoral fractures. Injury. 2012;43(7):1170-5.

5.  Stover M. Distal femoral fractures: Current treatment, results and problems. Injury. 2001;32:SC3-SC13.

6. Gebhard, F, Kregor, P, Oliver C. AO Surgery Reference. Distal Femur33-A2 CRIF. AO Surg Ref Colt C ed. 2008. https://www2.aofoundation.org/wps/portal/seosurgerysummary Accessed April 5, 2013.

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8. Zlowodzki M, Williamson S, Cole Pa, et al. Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures. J Orthop Trauma. 2004;18(8):494-502.

9. Wu CC, Shih CH. Treatment of femoral supracondylar unstable comminuted fractures. Comparisons between plating and Grosse-Kempf interlocking nailing techniques. Arch Orthop Trauma Surg. 1992;111(4):232-6.

10. Markmiller M, Konrad G, Sȕdkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications? Clin Orthop Relat Res. 2004;(426):252-7.

11. Hierholzer C, von Rȕden C, Pötzel T, et al. Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis. Indian J Orthop. 2011;45(3):243-50.

 

 

 

 

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