|Year : 2015 | Volume
| Issue : 1 | Page : 142-148
Role of retrograde short nail in the treatment of supracondylar femoral fractures (extra-articular type A)
Hisham Mohamed Zaki Elmowafy, Bahaa Zakarya Mohamed Hassan, Ahmed Mohamed Rushdy Nassar
Department of Orthopaedic Surgery, Menoufiya University, Menoufiya, Egypt
|Date of Submission||15-Sep-2014|
|Date of Acceptance||06-Dec-2014|
|Date of Web Publication||29-Apr-2015|
Ahmed Mohamed Rushdy Nassar
Department of Orthopaedic Surgery, Tala General Hospital, Tala, Menoufiya
Source of Support: None, Conflict of Interest: None
The aim of the study was to evaluate the results of retrograde short nailing in the treatment of supracondylar femoral fractures (type A, extra-articular fracture).
The incidence of distal femur fractures is increasing in our country as traffic accidents increase. Problems with distal femur fractures may not be limited to the femur itself, but may extend to internal knee structures.
Patients and methods
This work was a prospective study of 30 patients with supracondylar femoral fractures (extra-articular type A) treated with a short retrograde femoral nail. All patients were evaluated both clinically and radiologically through routine follow-up visits and all information concerning each patient was collected and recorded using the patient information sheet and data were tabulated and evaluated.
In our study of 30 patients with type A supracondylar fractures treated with a retrograde nail, we found excellent results in eight patients, good results in 16 patients, fair results in four patients, and poor results in two patients (P > 0.040).
Treatment of supracondylar femoral fractures (type A, extra-articular fracture) with a retrograde short nail yields satisfactory results in adults.
Keywords: Fracture fixation, intramedullary, knee joint, supracondylar femoral fractures
|How to cite this article:|
Elmowafy HM, Hassan BZ, Nassar AM. Role of retrograde short nail in the treatment of supracondylar femoral fractures (extra-articular type A). Menoufia Med J 2015;28:142-8
|How to cite this URL:|
Elmowafy HM, Hassan BZ, Nassar AM. Role of retrograde short nail in the treatment of supracondylar femoral fractures (extra-articular type A). Menoufia Med J [serial online] 2015 [cited 2019 Jun 26];28:142-8. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/142/155970
| Introduction|| |
Fractures of the distal femur are those that involve the distal 15 cm of the femur including the distal femoral metaphysis (supracondylar) and the articular surface of the distal femur (intracondylar) .
Distal femoral fractures are associated with high-energy trauma (in youngsters) and osteoporotic bones (in the elderly) .
Most classification systems divide distal femoral fractures into three main groups: extra-articular, unicondylar, and bicondylar. Extra-articular fractures are the most common, and unicondylar fractures are the rarest .
Historically, traction achieved adequate results but exposed the patient to the risks of prolonged bed rest. The best results are achieved with operative methods, but complications are common and can be devastating. Complications include malunion, nonunion, hardware failure, and infection. Involvement of the articular surface demands a congruent, anatomic reduction to prevent or minimize post-traumatic arthritis and provide bone stock for later knee replacement or fusion .
A distal femoral fracture is one of the challenging injuries to orthopedic surgeons. Operative treatment has been the mainstay to obtain early mobilization of patients. Traditionally, stabilization has been achieved with open reduction using several kinds of plates. However, this conventional technique is not a biologic method; it requires large exposure, with its related risk of soft tissue damage, promoting devascularization of bone fragments and compromising fracture healing .
Procedures should be kept as simple as possible to minimize surgical time, blood loss, and physiologic stress. Early weight-bearing is possible only after successful stable fracture fixation in the lower extremity. Although anatomic restoration is important for intra-articular fractures, metaphyseal fractures are best managed by attempts to primarily achieve stability rather than anatomic reduction .
Open reduction and internal fixation yields results superior to those of nonsurgical management for supracondylar femur fractures .
Intramedullary nailing has been the standard treatment for femoral diaphyseal fractures because of its excellent stability and biologic healing. Following the same principle, retrograde nailing has been used for distal femoral fractures [7,8].
Intramedullary nails have many of the same advantages as locking plates, such as percutaneous placement without disruption of blood supply, indirect fracture reduction, and success in osteoporotic bone treatment, and have been reported to lead to high healing rates in fractures of the distal femur [9,10].
| Patients and methods|| |
This work was a prospective study of 30 patients with supracondylar femoral fractures (extra-articular type A) treated with a short retrograde femoral nail from June 2012 to June 2014 with follow-up from 6 to 24 months. All patients with recent fracture of distal 15 cm of the femur including the distal femoral metaphysis (supracondylar region) were included in our study. The inclusion criteria were as follows: skeletally mature age (adult); and presence of supracondylar femur fracture type A, extra-articular. The exclusion criteria were pathological fractures, pre-existing knee deformity preventing nail insertion, and previous surgery on the ipsilateral knee.
General examination was performed to determine the patients' general condition and presence of any medical disorders. A thorough examination of polytrauma patients was carried out in order not to miss any concurrent injury. All patients were evaluated for associated medical problems and were referred to respective specialty departments and treatment was given, when necessary. Simultaneously, associated injuries were evaluated and treated.
Patients typically present with pain, swelling, and variable deformity in the supracondylar region of the femur. Gross mobility may be present at the fracture site with crepitus. Immediate assessments of the neurovascular status are essential. Proximity of neurovascular structures to the fracture area is an important consideration. Unusual and tense swelling in the popliteal area and the usual signs of pallor and lack of pulse suggest rupture of a major vessel; in these cases, duplex may be necessary.
Examination of the ipsilateral hip, knee, leg, and ankle is important, especially in polytraumatized patients .
Anteroposterior, lateral, and two oblique radiographs should be obtained. Traction views may be helpful; 45° oblique views can delineate intercondylar involvement. Radiographic evaluation of the entire involved lower extremity is warranted as concomitant injuries are common.
Contralateral views may help with comparison and may serve as a template for preoperative planning.
Computed tomography portrays the distal femur in cross-section, which helps to identify fracture lines in the frontal plane. Two-dimensional and three-dimensional reconstructions may also improve understanding of the fracture pattern in preparation for surgery.
MRI may be of value in evaluating associated injuries to ligamentous or meniscal structures.
All included patients were evaluated preoperatively for the following: personal history, pre-existing medical diseases, fracture etiology, mechanism of injury, AO grades, and fracture side. They were then subjected to the following preoperative investigations: complete blood count, alanine transaminase, aspartate transaminase, urea, creatinine, blood sugar, and prothrombin time and activity. Informed consent was taken from each patient according to ethical and legal research guidelines at El-Menoufiya University Hospitals.
Patients were given spinal anesthesia.
The patient was placed supine on a radiolucent table. The affected lower extremity and hip region were freely draped, with the knee flexed at 90°.
A medial parapatellar approach was adopted, starting at the upper border of the patella and extending downward parallel to the medial border of the patella about 5 cm in length (can be extended upward if the tendon has to be relaxed during retraction of the patellar tendon).
Determination of entry point and guidewire insertion
A Kuntscher awl was placed through the tendon portal into the intercondylar notch. A guide pin and cannulated reamer is an option to the awl. Under C-arm radiographic imaging, the tip of the awl should be centralized within the intercondylar notch just anterior to the origin of the posterior cruciate ligament with respect to the condyles and not to the alignment of the extremity. The awl must be in a neutral position to ensure proper placement of the supracondylar nail in the distal femoral segment. This was followed by fracture reduction and knee wash, connecting the handle to the nail, and insertion of the reaming rod.
Insertion of nail
After confirming satisfactory fracture reduction, the nail was inserted manually as far as possible into the femoral opening. This step was performed carefully without hammering, by using slight twisting movements of the hand. The last step was insertion of proximal and distal locking screws.
Follow-up and rehabilitation
Intraoperative and postoperative antibiotics were given. A compressive dressing was applied to the surgical incision, and postoperative control radiographs were taken routinely. All patients were followed up for at least for 6 months.
All patients were allowed immediate postoperative passive motion in the following manner: quadriceps exercise was started immediately postoperative; 30° of knee flexion and full extension was allowed in the first 5 days, 60° of knee flexion was allowed over the next 5 days, 90° of knee flexion was allowed over the next 5 days, and then full flexion and full extension was allowed.
Knee range of motion was assessed clinically, with full range of motion defined as 0° of extension or greater, to 135° of flexion. This could be performed by the patient but in almost all cases a physiotherapist was required.
Partial weight-bearing was allowed initially, with full weight-bearing not allowed until evidence of radiographic and clinical healing appeared (at least 6 weeks).
As radiographic and clinical healing became evident the patients were allowed gradual weight-bearing using a walker or crutches.
Full-weight bearing is allowed earlier in cases of stable fractures than in cases of comminuted and segmental fractures.
Statistical data analysis
Statistical presentation and analysis of the present study was conducted using SPSS (Statistical Package for Social Science), version 20, on an IBM compatible computer.
Descriptive statistics are presented as percentage (%) and mean value.
| Results|| |
This work was a prospective study of 30 patients with supracondylar femoral fractures (extra-articular type A) treated with a short retrograde femoral nail.
The ages of the patients in this study ranged from 35 to 84 years (mean 60.20 ± 10.912) and most of them were female (22 patients, 73.3%) (P < 0.774).
The most common mechanism of injury in this study was road traffic accident (21 patients, 70%), grade A2 was the most common fracture (16 patients, 53.3%), and most of the patients had fracture on their left side (18 patients, 60%) compared with the right (12 patients, 40%) (P < 0.414).
Time to operation
For short retrograde femoral nailing, the time to operation ranged from 2 to 8 days, with an average of 5 days.
Time of operative procedure
For short retrograde interlocking femoral nailing, the duration of the operative procedure ranged from 45 to 120 min, with an average of 85 min.
Blood loss in the operative procedure
Blood loss in the operative theater as estimated by the anesthetist ranged from 100 to 400 ml, with a mean of about 250 ml.
The shortest period of hospital stay was 5 days and the longest period was 2 weeks, with an average of about 10 days.
Time to start knee exercise
The knee joint is free to move immediately in the postoperative period as tolerated by pain. In some patients knee movement was delayed compared with the previously mentioned program.
Time to start partial weight-bearing
Patients were encouraged to start partial weight-bearing within 6-8 weeks of the operation. The time varied according to age, general health of the patient, severity of the fracture, and the presence of associated injury. Weight-bearing was delayed for about 2 weeks in the case of unstable fractures.
Time to start full weight-bearing
This depended on the factors mentioned for time to start partial weight-bearing, in addition to the presence of radiological evidence of union.
According to the criteria of Mize et al. , eight patients showed excellent results, 16 showed good results, four showed fair results, and two showed poor results (P > 0.040).
Impingement of the nail onto the patella
This occurred in two female patients aged 71 and 84 years. Both patients had preoperative osteoporosis and degenerative osteoarthritis. This was attributed to the cutting of the proximal locking screws through the cortex because of osteoporosis. Both patients showed complete union after 4 months POP. One of them refused to have the nail removed and the other (the 84-year-old) was readmitted to the hospital and the nail was removed 9 months postoperatively.
In our series copious irrigation of the knee was performed in all cases to avoid sepsis as well as to remove all debris from the knee. The knee was well washed before closure and was tightly closed without hemovac in all of our patients. There were no cases of knee sepsis.
Generally, delayed union is considered if full union is not achieved in more than 6 months but occurs subsequently without further surgical procedures . In our series this occurred in two female patients with supracondylar fracture of the femur, who were older than 60 years. Both had supracondylar comminution. All of these fractures were united after bone grafting and postoperative bracing.
The fracture is called nonunited if it remains unhealed for more than 6 months and further surgical intervention is required. In this series there were no cases of nonunion .
The following criteria were used to define malunion: the fracture united in varus or valgus by more than 5°; or the fracture united with shortening of more than 1.5 cm. The overall outcome in our series was excellent. Only two cases united in varus of 5°. Only one patient had shortening of 2 cm because of marked comminution of the knee.
Only three patients had anterior knee pain in the second to third week postoperatively, at which time their physiotherapist started to achieve full range of knee movement. The condition of two of these three patients improved after 2 months, whereas the condition of the last patient improved only after 4 months. In all of the above-mentioned cases, the pain was mild, tolerated by the patients, and resolved with analgesics and anti-inflammatory drugs.
This is a very important point in the assessment of short retrograde femoral nailing techniques because the drawback of this technique is mainly said to be its destructive effect on knee cartilage and residual knee stiffness. Knee function at final review was very good, with no evidence of significant iatrogenic injury from the technique of retrograde insertion of the nail. Subjectively, patients were satisfied, with no one complaining of more than occasional knee discomfort. Range of motion of the knee averaged 120° of flexion (90-140) with only one patient demonstrating 70° flexion contracture due to prolonged immobilization for 4 months postoperatively. The elderly with osteoarthritic changes of the knee enjoy several benefits from the techniques, as the well-done arthrotomy and irrigation of the knee improved their original complaint. Manipulation of the knee in these patients is easy because of ligament laxity . No symptomatic ligamentous instability was noted in any patient at final follow-up (P > 0.025).
| Discussion|| |
A supracondylar fracture of the femur has been recognized as a major challenge by the orthopedic community, not solely for achieving fracture union but for restoration of optimal function in the shortest possible time, with minimal complications. The aim of management accordingly has shifted to achieving early mobilization, rapid rehabilitation, and quick return of individuals to premorbid home and work environment as a functionally and psychologically independent unit.
Operative treatment in the form of internal fixation permits early rehabilitation and offers the best chance of functional recovery, and hence has become the treatment of choice for virtually all supracondylar fractures of the femoral region. Among the various types of implants available, recent techniques of closed intramedullary nailing have gained popularity.
Posterior angulation with fracture displacement and shortening is frequently seen with supracondylar femoral fractures. The fracture deformity is related to forces exerted by the lower extremity musculature and the relationship between the origin and insertion of the muscles crossing the knee joint. These forces interfere with the success of nonoperative management of supracondylar fractures of the femur.
In our study, the ages of patients ranged from 35 to 84 years.
In the study by Gynning and Hansen  on the treatment of distal femoral fractures with a retrograde nail, which consisted of 29 consecutive patients with 30 distal femoral fractures, the age range was 30-94 years. With regard to sex, in our study the proportion of female patients was 73.3% of all studied members. We thus report a predominance of female patients among those suffering from supracondylar fracture of the femur [Table 1].
This agreed with the study by Gynning and Hansen , who reported a predominance of female patients with supracondylar fracture of the femur and attributed it to postmenopausal osteoporosis [Table 2],[Table 3] and [Table 4].
In our study, the follow-up was for a mean period of 6 months (range 4-8 months).
In the study by Gynning and Hansen  the follow-up was for a mean period of 5 months (range 2-8 months).
However, the optimal balance of fixation stiffness and micromotion for fracture healing is not completely known. It is known that excessive micromotion can lead to nonunion, malunion, and eventual implant failure.
In our study of 30 patients with type A supracondylar fractures treated with a retrograde nail, eight patients showed excellent patients, 16 showed good results, four showed fair results, and two showed poor results  [Table 5].
Lucas et al.  reported a series of 25 patients with type A supracondylar fractures treated with a retrograde nail with a 100% rate of union and no nail failures.
Also Iannacone et al.  reported on a larger series of 41 patients with supracondylar femoral fractures who were treated with a retrograde nail, which saw five nonunions, five delayed unions, and four fractures of the retrograde nail when a first-generation nail was used. They attributed these complications to the use of an open technique. However, no implant failures occurred in patients treated with second-generation nails and percutaneous techniques.
In a systematic review of the literature by Papadokostakis et al. , it was concluded that retrograde IM nailing was a reliable treatment with low complications for distal femoral fractures and the same conclusion was drawn by Handolin et al. . The retrograde IM nail has been shown to be efficacious in osteoporotic bones as well.
All clinical aspects must be taken into account so that the correct implant choice can be made. Poor outcomes can result from many variables, some of which are controlled by surgeons. Uncontrolled variables often include patient factors such as poor bone quality and fracture comminution. Surgeon factors can include inadequate recognition of the fracture pattern, poor preoperative planning, inadequate reduction, poor implant choice or application, and damage to soft tissue  [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6] and [Figure 7].
|Figure 1: Radiograph of a type A1 supracondylar femoral fracture in a 58-year-old male patient. Anteroposterior and lateral view (preoperat ive).|
Click here to view
|Figure 2: Radiograph of a type A1 supracondylar femoral fracture (anteroposterior and lateral view) fi xed with a short retrograde supracondylar femoral nail (postoperat ive).|
Click here to view
|Figure 3: Radiograph of a type A2 supracondylar femoral fracture in a 84-yearold female patient. Anteroposterior and lateral view (preoperat ive).|
Click here to view
|Figure 4: Radiograph of a type A2 fracture postoperatively; the fracture is fixed with a short retrograde supracondylar femoral nail.|
Click here to view
|Figure 5: Radiograph of a type A3 supracondylar femoral fracture in a 60-year-old male patient. Anteroposterior and lateral view (preoperat ive).|
Click here to view
|Figure 6: Radiograph of a type A3 fracture 2 months postoperatively; the fracture is fi xed with a short retrograde supracondylar femoral nail.|
Click here to view
|Figure 7: Radiograph of a type A3 fracture 6 months postoperatively; the fracture is fixed with a short retrograde supracondylar femoral nail.|
Click here to view
| Conclusion|| |
Retrograde interlocking nailing is presented as a safe, effective, and beneficial fracture fixation method that should be added to the orthopedic surgeons' skills with recommendation that patients remain strictly non-weight-bearing for at least 6-8 weeks until adequate bridging callus has formed. When severe comminution, segmental bone loss, or large metaphyseal/diaphyseal bone defects are present, early bone grafting should be performed to promote healing.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Richard LD, Wayne V, Adam WM. Anatomy regional and applied, the English book society and Churchill living stone. 2007; 34
Higgins TF. Distal femoral fractures. J Knee Surg 2007; 20
Forster MC, Komarsamy B, Davison JN. Distal femoral fractures: a review of fixation methods Injury 2006; 37
Curtis R, Goldhahn J, Schwyn R, Regazzoni P, Suhm N. Fixation principles in metaphyseal bone - abatement based review. Osteoporoses Int 2005; 16
Thomson AB, Driver R, Kregor PJ. Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nail ing. Orthopedics 2008; 31
Charles NC. Internal fracture fixation in patients with osteoporosis J. Am Acad Orthop Surg 2005; 11
Christodoulou A, Terzidis I, Ploumis A, Metsovitis S, Koukoulidis A, Toptsis C. Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the retrograde intramedullary nail: a comparative study of the two methods. Arch Orthop Trauma Surg 2005; 125
Markmiller M, Konrad G, Südkamp 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
Hartin NL, Harris I, Hazratwala K. Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: a randomized controlled trial. ANZ J Surg 2006; 76
Fitzpatrick DC, Doornink J, Madey SM, Bottlang M. Relative stability of conventional and locked plating fixation in a model of the osteoporotic femoral diaphysis. Clin Biomech (Bristol, Avon) 2009; 24
Stover M. Distal femoral fractures: current treatment, results and problems. Injury 2001; 32
:Suppl 3 :3-13.
Mize RD, Bucholz RW, Grogan DP. Surgical treatment of displaced, comminuted fractures of the distal end of the femur. J Bone Joint Surg Am 1982; 64
Levin PE, Schoen RW Jr, Browner BD. Radiation exposure to the surgeon during closed interlocking intramedullary nailing. J Bone Joint Surg Am 1987; 69
Moed M, Berton R, Watson. Complications of retrograde intramedullary nailing of the femur. Orthop Techniques 2001; 16
Gynning JB, Hansen D. Treatment of distal femoral fractures with intramedullary supracondylar nails in elderly patients. Injury 1999; 30
HM El-Mowafi, TA Eid, AS El-Sayed, SH Zalalo. Fixation of subtrochanteric fracture femur using a proximal femoral nail. MMJ 2014; 27
Gellman RE, Palment GD, Green HD, Coughlin RR. Treatment of supracondylar fractures with retrograde intramedullary femoral nail. Clin Orthop 1996; 332
Iannacone WM, Bennett FS, DeLong WG Jr, Born CT, Dalsey RM. Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report. J Orthop Trauma 1994; 8
Papadokostakis G, Papadokostakis C, Dimitriour R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diphysical and distal femoral fractures: a systemic review of literature. Injury 2005; 36
Handolin L, Pajarinen J, Lindahl J, Hirvensale E. Retrograde intramedullary nailing in distal femur fractures. Results in a series of 46 consecutive operations. Injury 2004; 35
H Elmowafy, T Abd Elsattar, A Darwish, M Elreweny. Management of intertrochanteric fracture in elderly high-risk patients using simple external fixator. MMJ 2014; 2:249-254.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]