(aspects of trauma • an original study)

Knee Pain and Leg-Length Discrepancy After Retrograde Femoral Nailing Ricardo Reina, MD, Fernando E. Vilella, MD, Norman Ramírez, MD, Richard Valenzuela, MD, Gil Nieves, MD, and Christian A. Foy, MD

Abstract an antegrade entry point at the pirifor- Materials and Methods We retrospectively studied postop- mis fossa.1,2,4,8-12 This technique has Between October 1998 and April 2000, erative knee function and leg-length several drawbacks, including a dif- a surgeon at University of Puerto Rico discrepancy (LLD) in 31 patients ficult starting point at the piriformis District Hospital and Puerto Rico with femoral diaphyseal fractures fossa, postoperative Trendelenburg Medical Center used retrograde IMN treated with retrograde intramedul- gait, iatrogenic fracture of the femo- to treat 46 femoral shaft fractures con- lary nailing (IMN) between October 1998 and April 2000. Mean follow-up ral neck, need for a fracture table secutively. For the purpose of this study, was 25 months, mean knee range of with difficult patient positioning, and we selected only those fractures motion was 126°, mean Hospital for limitations in use with concomitant located both 5 cm below the lesser Special Surgery knee scores were surgical procedures.3,5,6 trochanter14 and above the femoral 89.2 (pain) and 78.3 (function), and Over the past 20 years, retrograde condyles. Patients were contacted by mean LLD was 1.19 cm. Despite the IMN has emerged as an alternative telephone, by mail, or through local theoretically higher knee pain and that overcomes the shortcomings of government agencies. LLD rates associated with retrograde antegrade IMN in treating femoral Of the 46 patients, 15 (33%) were IMN, we believe it may offer a viable shaft fractures.1,3-5,7,8,13,14 The advan- excluded (4 had passed away, and 11 treatment option when the antegrade nailing technique is restricted.

ractures of the femoral shaft “...indications for retrograde intramedullary are associated with high- nailing have expanded...” energy trauma. Different treatments have had varied Fresults.1-3 Closed intramedullary nail- tages of retrograde IMN include no had insufficient follow-up because of ing (IMN) has been shown to be an need for fracture table, ease of entry poor patient compliance, or they were effective treatment, with high success at the intercondylar notch, and acces- unavailable for evaluation at a specif- rates and minimal complications.1-8 sibility for performing additional ic clinic). The remaining 31 patients The current standard of care for surgical procedures with the patient (67%) had a minimum follow-up of 1 femoral shaft fractures is IMN through in a supine position.5 The original year and were evaluated by the senior indications for retrograde IMN were authors at a clinic specially set up Dr. Reina is in private practice, San Juan, femoral shaft fractures with ipsilat- for this study. In accordance with the Puerto Rico. eral femoral neck fractures, femoral approved protocol of our Institutional Dr. Vilella is Third-Year Resident, Dr. shaft fractures in polytrauma patients, Review Board, all patients received a Ramírez is Director of Research, Dr. and obese patients.1,2,7-9,14 With the complete orientation to the study and Valenzuela and Dr. Nieves are First- advantages of this technique, indi- signed release and consent forms for Year Residents, and Dr. Foy is Research Fellow, Department of Orthopaedic cations for retrograde IMN have participation. Surgery, School of Medicine, University expanded. The increasing popularity The medical records of these of Puerto Rico, San Juan, Puerto Rico. of the procedure has raised concerns patients were reviewed for vari- in the orthopedic community about ables such as accident type, associ- Requests for reprints: Norman Ramírez, MD, Department of Orthopaedic Surgery, possible complications with respect ated injuries, degree of comminution, School of Medicine, University of Puerto to knee function, knee pain, and leg- open fracture classification, compli- Rico, San Juan, PR 00936 (tel, 787-264- length discrepancy (LLD) secondary cations, and need for concomitant 2066; fax, 787-264-4483; e-mail, norman- to the procedure.4,6 surgical procedures. For each patient, [email protected]). In the study reported here, we the Winquist and Hansen classifica- Am J Orthop. 2007;36(6):325-328. reviewed postoperative knee function tion for comminution of femur frac- Copyright Quadrant HealthCom Inc. and LLD after retrograde IMN for tures was used: 0 (no comminution), 2007. femoral diaphyseal fractures. 1 (insignificant butterfly fragment),

June 2007 325 Pain and Leg-Length Discrepancy After Retrograde Femoral Nailing

In each patient, a scanogram was included for evaluation in the study. obtained to objectively determine Minimum follow-up was 1 year, LLD, defined as more than a 2-cm and mean follow-up was 25 months difference between the legs.9 (range, 12-38 months). Mean age was 33.9 years (range, 18-80 years). Surgical Technique There were 17 right and 10 left femur Each patient was placed on a radio- fractures, and 4 patients had bilat- lucent operating room table in supine eral femur fractures. The most com- position, and the affected lower mon fracture mechanism was motor extremity was prepped and draped in vehicle accident (70%) (Figures 1A, standard surgical fashion. 1B), followed by gunshot wound The knee was positioned in 40° of (17%) (Figures 2A, 2B) and fall from flexion with a bolster, and a 4-cm skin a height (13%). Ten (29%) of the 35 incision was made just medial to the fractures were open: 3 of these were patellar tendon, from the inferior pole type I, 5 were type II, and 2 were type of the patella to the tibial tubercle. III. There were 18 Winquist grade 0 The infrapatellar fat pad was partially fractures, 4 Winquist grade 1 frac- excised, and then a medial patellar tures, 6 Winquist grade 2 fractures, knee arthrotomy was performed. 4 Winquist grade 3 fractures, and 3 With the help of the fluoroscope, a Winquist grade 4 fractures. guided pin was inserted in the mid- Eleven patients had multiple inju- line just anterior to the intercondylar ries, and 20 had isolated femur frac- A B notch in the anteroposterior view. In tures. Associated injuries included Figure 1. Twenty-year-old man with the lateral view, the pin should be head trauma (2 patients), peroneal distal shaft femur fracture sustained above the Blumensaat line. A cannu- nerve palsies (2 patients), vascular in a motor vehicle accident. Antero- lated drill was used to open the dis- injuries (2 patients), 1 radioulnar posterior (A) and lateral (B) plain tal femur metaphysis. A ball-tipped fracture, 1 humeral fracture, 1 pilon films obtained 24 months after ret- guide wire was inserted through the fracture, 1 simultaneous talus and cal- rograde intramedullary nailing show fracture union. entry points just to the distal fracture caneous fracture, 1 acetabular frac- border. After the fracture was reduced, ture, 1 odontoid fracture, 1 abdominal 2 (large butterfly fragment less than the guide wire was introduced across trauma, 1 pneumothorax, 1 testicular 50% the width of the bone), 3 (large the fracture to maintain the alignment contusion, and 1 urethral injury. butterfly fragment more than 50% of the reduction. Flexible reaming the width of the bone), 4 (segmental was performed until adequate cortical comminution). Open fractures were contact was achieved. classified according to Gustilo and For implants, Russell-Taylor femo- Anderson: type I, low-energy trauma ral nails (Smith & Nephew Richards, with wound size less than 1 cm; Memphis, Tenn) were used. The type II, moderate-energy trauma with intramedullary nail was placed to wound size 10 cm or less; type III, a level below the lesser trochanter high-energy trauma with wound size proximally and flush to the chondral more than 10 cm. surface distally. The length of this Knee pain and function were nail was selected after using a radi- assessed with Hospital for Special opaque ruler, or by measuring the Surgery (HSS) knee scores.15 Patients contralateral femur in case of severe were assigned one of the standard comminution; the selected width was clinical categories: excellent (90-100 1 mm less than the largest reamer points), good (80-89 points), fair (70- diameter. Distal locking was done 79 points), poor (<70 points). Plain with the insertion handle jig, and films of the involved femur and ipsi- proximal locking was performed with lateral hip and knee were obtained. the freehand technique. Radiographic union was defined as The rehabilitation protocol was presence of a bridging callus across 3 identical for each patient. Figure 2. Fifty-five-year-old man with cortices on anteroposterior and lateral distal shaft femur fracture caused by a gunshot. Anteroposterior (A) and plain films. Clinical union was diag- Results lateral (B) plain films obtained 18 nosed when there was no pain with Thirty-one patients (25 men, 6 months after retrograde intramedul- ambulation or single leg stance.9,14 women) with 35 femur fractures were lary nailing show fracture union.

326 The American Journal of Orthopedics® R. Reina et al

Mean knee range of motion (ROM) pudendal nerve palsy, and need for a metallurgy, malunion, nonunion, and was 126° (range, 85°-130°). At fol- fracture table. Other limitations are implant failure.2,4 Incidence of knee low-up, 8 (23%) of 35 femur frac- hip stiffness, reduced walking dis- pain after retrograde IMN for femoral tures showed loss of knee ROM; of tance, Trendelenburg gait, weak hip shaft fractures has varied from 0% to these, 5 had lost more than 10° of abductors, difficult entry point, and 60%.3-5,7-9,14,21 In a comparative study ROM, and the remaining patients had hip or thigh pain.1,3,6,10,14 of retrograde versus antegrade nail- less than 10° of limitation. Mean HSS For many years, different types ing, time to union was slightly longer knee score for pain was 89.2 points of IMN have been used through a in the retrograde group compared (range, 52-100 points). Lower scores retrograde extra-articular entry with the antegrade group, and more were seen in patients with concomi- point in attempts to minimize short- secondary procedures were needed to tant comorbidity, such as extreme comings of the antegrade technique, obtain union.1,6,8,9,11,12 The retrograde age, diabetes mellitus with bilateral but there have been several complica- group had more symptomatic distal below-knee amputations, severe men- tions.3,7,8,16-18 Given the multiple com- screw pain, requiring removal.1 tal retardation, high-degree scoliosis, plications associated with an extra- In this series, mean HSS knee nonambulators, and juvenile rheuma- articular entry point, the technique scores were 89 (pain) and 78 (func- toid arthritis. Mean HSS knee score was revised to use the intercondylar tion). Patients with poor clinical sta-

“...the technique was revised to use the intercondylar entry point...” for function was 78.3 points (range, entry point, eliminating the poten- tus before trauma had the lowest 30-100 points). In spite of good mean tial complications of malreduction scores. There was no difference in knee scores for pain, 21 (68%) of the in varus and crack propagation at the knee pain and LLD between patients 31 patients complained of occasional entry point.4,5,19,20 With introduction with isolated fractures and patients knee pain, and 6 of these reported of this technique, current indications with polytrauma. Mean knee ROM their knee pain was associated with for retrograde IMN include ipsilat- was 126°, comparable to what has prominent distal screws. Five patients eral femoral shaft and neck fractures, been found previously.1,4,6-8 Clinical required a second procedure for distal obese and pregnant patients, ipsi- assessment of our patients showed screw removal. lateral pelvis and acetabular inju- that 60% of them were complaining Scanograms were available for all ries, and other polytrauma patients of occasional knee pain in spite of 31 patients. Mean LLD was 1.19 requiring concomitant surgery.1,3,4,9,14 postoperative conservative treatment. cm. Five patients (16.1%) had more Contraindications are skeletal imma- It is very interesting that only 5 (16%) than 2 cm of LLD, 11 (35.5%) had turity, past history of knee joint sep- of the 31 patients required surgical LLD between 1.0 and 1.9 cm, and 15 sis, fracture within 5 cm of the lesser treatment for knee pain (distal screw (48.4%) had less than 1 cm of LLD. trochanter, type III-b open fractures, removal). The high incidence of knee All patients with LLD of more than and severe soft-tissue injury about pain in our series could be attributed 2 cm had Winquist 3 or Winquist 4 the knee.1,5 to our follow-up being longer than femur fractures. No patient in this The technical advantages of ret- that in previous studies and the possi- study presented with complications rograde IMN include minimal dis- bility that many of our patients were associated with retrograde IMN, such section, possible use of the standard involved in legal issues. as infection, nonunion, or malalign- surgical table, easier and faster setup, We also evaluated LLD in all our ment of more than 10°. less surgical time, and less blood patients by performing scanograms at loss.13 These advantages have moti- follow-up. To the best of our knowl- Discussion vated orthopedic surgeons to stretch edge, this study is the first in which Antegrade IMN is an effective treat- the indications for retrograde IMN to LLD was objectively evaluated. Mean ment for femoral shaft fractures include isolated femoral shaft frac- LLD was 1.19 cm. As reported in the (high-energy injuries), and outcomes tures. Although retrograde IMN is Results section, 16.1% of our 31 have been reliable.1,2,4,8-12 Although an alternative for managing isolated patients had more than 2 cm of LLD, this technique has a high union rate, femoral shaft fractures, this tech- 35.5% had LLD between 1.0 and 1.9 it also has several drawbacks, such nique is not without disadvantag- cm, and 48.4% had less than 1 cm of as limited application of this opera- es. With use of these nails, serious LLD. Patients with higher LLD had a tive method to ipsilateral femoral complications have been reported, higher degree of comminution. neck fractures, possibility of hetero- including LLD, knee pain, knee joint One third of our patients had insuf- topic bone formation around the hip, stiffness, knee septic arthritis, knee ficient follow-up. Nevertheless, we

June 2007 327 Pain and Leg-Length Discrepancy After Retrograde Femoral Nailing believe that retrograde nailing may Authors’ Disclosure 9. Leggon RE, Feldmann DD. Retrograde femo- ral nailing: a focus on the knee. Am J Knee offer a different treatment option Statement Surg. 2001;14:109-118. for femoral shaft fractures. Its indi- The authors report no actual or poten- 10. Moed BR, Watson JT. Retrograde nailing of cations, however, must be limited tial conflict of interest in relation to the femoral shaft. J Am Acad Orthop Surg. 1999;7:209-216. to specific situations in which the this article. 11. Brumback RJ, Reilly JP, Poka A, Lakatos antegrade nailing technique may be RP, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part I: deci- restricted, as in cases of concomitant References sion-making errors with interlocking fixation. 1. Ostrum RF, DiCicco J, Lakatos R, Poka A. femoral neck fractures, acetabular J Bone Joint Surg Am. 1988;70:1441- Retrograde intramedullary nailing of femo- 1452. fractures, multiple injuries, obesity, ral diaphyseal fractures. J Orthop Trauma. 12. Winquist RA, Hansen STJ, Clawson DK. 1998;12:464-468. and pregnancy. Results from recent Closed intramedullary nailing of femoral frac- 2. Patterson BM, Routt MLJ, Benirschke SK, tures. A report of five hundred and twenty clinical and experimental studies sup- Hansen STJ. Retrograde nailing of femoral cases. J Bone Joint Surg Am. 1984;66:529- port use of retrograde nailing in cer- shaft fractures. J Trauma. 1995;38:38-43. 539. 3. Ricci WM, Bellabarba C, Evanoff B, Herscovici tain situations. 13. Helfet DL, Lorich DG. Retrograde intramedul- D, DiPasquale T, Sanders R. Retrograde lary nailing of supracondylar femoral fractures. Clin Orthop. 1998;350:80-84. 14. DiCicco JD III, Jenkins M, Ostrum RF. “Our findings preclude recommending Retrograde nailing for subtrochanteric femur fractures. Am J Orthop. 2000;29(9 suppl): 4-8. its [retrograde intramedullary nailing] 15. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating routine use for stabilization of isolated system. Clin Orthop. 1989;248:13-14. 16. Rush LV. Dynamic intramedullary fracture- femoral shaft fractures.” fixation of the femur. Reflections on the use of the round rod after 30 years. Clin Orthop. 1968;60:21-27. versus antegrade nailing of femoral shaft frac- 17. Casey MJ, Chapman MW. Ipsilateral concom- Clinical studies are still answer- tures. J Orthop Trauma. 2001;15:161-169. itant fractures of the hip and femoral shaft. ing questions about the long-term 4. Herscovici DJ, Whiteman KW. Retrograde J Bone Joint Surg Am. 1979;61:503-509. nailing of the femur using an intercondylar 18. Swiontkowski MF, Hansen STJ, Kellam J. consequences of retrograde IMN in approach. Clin Orthop. 1996;332:98-104. Ipsilateral fractures of the femoral neck and 1,5,13,14 isolated femoral shaft fractures. 5. Moed BR, Watson JT, Cramer KE, Karges DE, shaft. A treatment protocol. J Bone Joint Surg Our findings preclude recommend- Teefey JS. Unreamed retrograde intramedul- Am. 1984;66:260-268. lary nailing of fractures of the femoral shaft. 19. Iannacone WM, Bennett FS, DeLong WGJ, ing its routine use for stabilization J Orthop Trauma. 1998;12:334-342. Born CT, Dalsey RM. Initial experience with of isolated femoral shaft fractures. 6. Ostrum RF, Agarwal A, Lakatos R, Poka A. the treatment of supracondylar femoral frac- Antegrade IMN continues to be the Prospective comparison of retrograde and tures using the supracondylar intramedullary antegrade femoral intramedullary nailing. nail: a preliminary report. J Orthop Trauma. standard of care for isolated femoral J Orthop Trauma. 2000;14:496-501. 1994;8:322-327. shaft fractures. However, particular 7. Sanders R, Koval KJ, DiPasquale T, Helfet DL, 20. Moed BR, Watson JT. Retrograde intramedul- Frankle M. Retrograde reamed femoral nailing. lary nailing, without reaming, of fractures of clinical situations would dictate use J Orthop Trauma. 1993;7:293-302. the femoral shaft in multiply injured patients. of the retrograde over the antegrade 8. Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka J Bone Joint Surg Am. 1995;77:1520-1527. technique despite theoretically more A, Bathon GH, Burgess AR. Intramedullary 21. Tornetta PR, Tiburzi D. Antegrade or retro- nailing of femoral shaft fractures. Part II: frac- grade reamed femoral nailing. A prospec- knee pain and larger LLD associated ture-healing with static interlocking fixation. tive, randomised trial. J Bone Joint Surg Br. with retrograde IMN. J Bone Joint Surg Am. 1988;70:1453-1462. 2000;82:652-654.

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328 The American Journal of Orthopedics®