n Feature Article

Antegrade Femoral Nailing in Acetabular Fractures Requiring a Kocher-Langenbeck Approach

Julius A. Bishop, MD; William W. Cross III, MD; James C. Krieg, MD; M.L. Chip Routt Jr, MD

abstract Full article available online at Healio.com/Orthopedics. Search: 20130821-18

Ipsilateral displaced acetabular and femoral shaft fractures represent a dilemma for orthopedic surgeons because antegrade femoral nailing may complicate a Kocher- Langenbeck acetabular exposure. The goals of this study were to review the results of ipsilateral femoral and acetabular fractures treated with antegrade femoral nailing and a Kocher-Langenbeck approach and to evaluate the assertion that this treatment strategy is associated with increased morbidity. This was a retrospective cohort study Figure: Anteroposterior radiograph 4 months at a regional Level I trauma center. after injury. The patient had no notable hip motion due to ectopic bone formation. Sixteen patients with a femoral fracture treated with antegrade nailing and an ipsilat- eral acetabular fracture treated with a Kocher-Langenbeck approach were identified. One patient died as a result of his injuries, and 2 were not available for long-term fol- low-up. One had a deep infection requiring irrigation, debridement, and intraveonous antibiotics. One patient developed a hematoma requiring irrigation and debridement. At final follow-up, 2 patients had no heterotopic ossification about the hip, 4had Brooker class I heterotopic ossification, 3 had Brooker class II heterotopic ossification, 2 had Brooker class III heterotopic ossification, and 2 patients had Brooker class IV heterotopic ossification requiring excision. Ipsilateral femoral and acetabular fractures represent a rare and severe injury constellation. Antegrade nailing of the with ipsilateral Kocher-Langenbeck exposure for fixation of the was not as- sociated with excessive rates of wound-healing complications, but the incidence of heterotopic ossification was increased.

The authors are from the Department of Orthopaedic Surgery (JAB), Stanford University School of Medicine, Palo Alto, California; the Division of Orthopedic Trauma Surgery (WWC), Mayo Clinic, Rochester, Minnesota; the Department of Orthopaedic Surgery (JCK), Jefferson University Hospitals, Philadelphia, Pennsylvania; and the Department of Orthopaedic Surgery (MLCR), University of Texas Medical School at Houston, Houston, Texas. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Julius A. Bishop, MD, Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Redwood City, CA 94063 ([email protected]). doi: 10.3928/01477447-20130821-18

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psilateral fractures of the femur and technique and results of such a treatment ing point at either the piriformis fossa or acetabulum represent a severe com- protocol have not been previously report- trochanteric entry site and is followed by Ibination of injuries for which optimal ed in the literature. a corresponding skin and fascial incision management remains uncertain.1-6 When only large enough to admit the requisite confronted with this constellation of frac- Materials and Methods reamers and subsequent medullary nail. tures, most surgeons advocate stabilizing This investigation was performed at Establishing an appropriate starting point the femur fracture first and then treating Harborview Medical Center/University for the intramedullary nail can be com- the acetabulum either in the same setting of Washington, Seattle, Washington. plicated in the setting of an unreduced or as a delayed procedure.1,3,5 Although After approval from the institutional posterior hip dislocation or by medial reamed antegrade nailing is the preferred review board, review of the orthopedic displacement of the proximal femur due treatment for fractures of the femoral trauma database at the regional Level I to the acetabular fracture. When establish- shaft and is evolving into the treatment of trauma center between January 1999 and ing the femoral starting point is difficult, choice for many peritrochanteric fractures, December 2010 identified 16 patients the surgeon must remain mindful of the an ipsilateral acetabular fracture, particu- treated for an Orthopaedic Trauma As- planned Kocher-Langenbeck incision larly one for which a Kocher-Langenbeck sociation (OTA) 31A, 31B, 32A, 32B, or before making a larger incision and per- approach is anticipated, is considered by 32C femoral fracture and an ipsilateral forming a more invasive approach to the some to be a relative contraindication.3,5,6 OTA 62A, 62B, or 62C acetabular frac- proximal femur. A percutaneously placed Antegrade femoral nailing has several ture using an antegrade femoral nail and Schanz pin in the proximal femoral seg- important advantages over other treatment a Kocher-Langenbeck approach.11 Five ment can be used in these circumstances strategies. It is a versatile technique that additional patients were treated with ret- to manipulate the hip while the starting can be performed in the supine, lateral, or rograde femoral nails for fractures below point is established. A standard reamed, prone position through a piriformis or tro- acetabular fractures requiring a Kocher- locked intramedullary nailing is then per- chanteric entry portal.7,8 With the develop- Langenbeck approach and were not in- formed. At the conclusion of the proce- ment of percutaneous insertion techniques, cluded in the study group. dure, care is taken to debride any residual surgical wounds are minimized and can be reamings from the abductor musculature. incorporated into the Kocher-Langenbeck Surgical Technique The hip must also be scrutinized radio- incision, if necessary.9 Cephalomedullary Femoral nailing precedes acetabular graphically to ensure that it is reduced. If fixation can be used to treat complex prox- fracture fixation in almost all circumstanc- definitive acetabular fracture surgery is to imal femur fractures, whereas multiplanar es. If the surgeon treating the femur frac- be delayed, fine-wire distal femoral trac- distal interlocking can be used to stabilize ture does not plan to treat the acetabulum, tion adjacent to the nail is used as needed distal fractures.10 Although retrograde the acetabular surgeon should be involved to maintain reduction. nailing has been advocated as a preferable early in the decision to place an antegrade If the patient’s overall medical status alternative for ipsilateral acetabular frac- nail. It is the authors’ preference to place is appropriate and a surgeon with the re- tures, this technique has distinct disadvan- the patient supine on a radiolucent table quired expertise in acetabular fracture tages. It must be performed in the supine with a rolled blanket placed under the ipsi- surgery is available, acetabular fracture position, violates the joint, and can- lateral sacrum and lumbar spine to elevate fixation can proceed under the same anes- not be used to treat some proximal femoral the affected hip approximately 20°. The thetic. If these criteria are not met, acetab- lesions. Plate fixation is another alterna- patient’s is positioned so that the ular surgery can be performed as a staged tive for femoral shaft fixation but requires ipsilateral buttock overhangs the edge of procedure. Either way, it is the authors’ a more extensive exposure, adversely im- the table to optimize starting point access, practice to perform a Kocher-Langenbeck pacting the Kocher-Langenbeck approach and the entire limb is sterilely prepared approach in the prone position on a radio- and increasing operative time and the po- and draped in the surgical field. The surgi- lucent table. The leg is again left free and tential for blood loss. cal technique for supine antegrade femoral a standard sterile prep and drape undertak- Although some surgeons caution nailing without a fracture table has been en. The femoral nail insertion wound can against antegrade femoral nailing below previously described in the literature.12 almost always be avoided because the stab an acetabular fracture requiring a Kocher- A minimally invasive femoral nailing incisions required for proximal interlock- Langenbeck approach, the authors do not technique helps to ensure that the subse- ing can be incorporated into the vertical consider antegrade nailing to be contrain- quent Kocher-Langenbeck incision is not limb of the Kocher-Langenbeck approach dicated under these circumstances at their adversely affected. A guidewire is placed if necessary with no ill effect. Acetabular Level I trauma center.3,5,6 The surgical percutaneously into the appropriate start- fracture exposure, reduction, and fixation

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Table Open Fracture Types According to OTA, Judet, and Gustiloa Classifications

Patient Judet Classification: OTA Classification: OTA Classification: Gustilo Classification: No. Acetabulum Acetabulum Femur Femur Hip Dislocation 1 T, PW 62A1.2, 62B1.2 32A3.2 NA NA 2 T, PW 62A1.3, 62B1.3 31B2.3, 32B3.2 NA Posterior 3 BC 62C3.2 32A2.1 NA Posterior 4 PC, PW 62A2.3 31A2.2 NA NA 5 PC 62A2.2 32A2.3 NA NA 6 T 62B1.2 32B2.3 NA NA 7 T, PW 62A1.3, 62B1.3 32C3.1 3A Posterior 8 T, PW 62A1.3, 62B1.3 31A3.3, 32A3.3 NA NA 9 PW 62A1.2 32A3.3 3A Posterior 10 T, PW 62A, 62B1.3 32B2.2 NA Medial 11 T, PW 62A1.1, 62B1.2 32A2.2 NA Posterior 12 T, PW 62A1.3, 62B1.3 32B3.2 NA NA 13 T-type 62B2.2 32A3.2 NA Posteromedial 14 T, PW 62A1.3, 62B1.2 32C3.2 NA None 15 T 62B1.3 32B1.1 NA Medial 16 T, PW 62A, 62B 32C3.1 3A NAb Abbreviations: BC, both columns; NA, not available; OTA, Orthopaedic Trauma Association; PC, posterior column; PW, posterior wall; T, transverse. aGustilo classification for the acetabulum is not applicable because all acetabular fractures were closed. bInjury radiograph unavailable.

can be performed routinely according to locations associated with their acetabular M.L.C.R.) performed the acetabular surgeon preference. At the conclusion of fractures. The fracture patterns as classi- fracture fixation. The same surgeon per- the procedure, it is important to perform fied by both the OTA11 and Judet and Le- formed both surgeries in 6 (38%) cases. an aggressive excision of nonviable mus- tournel14 are summarized in the Table. Eleven (69%) nails were inserted through cle from the posterior hip to minimize het- Three (19%) patients presented with a piriformis starting point and 5 (31%) erotopic ossification formation.13 sciatic nerve palsies as a result of their through a trochanteric starting point. All Postoperatively, patients are treated injuries. Three (19%) had open femoral nails were placed using a percutaneous with perioperative antibiotics, low- shaft fractures, all of which were Gustilo technique, and nail insertion incisions molecular-weight-heparin, and pneumat- type IIIA.15 Three (19%) patients had both were not incorporated into the Kocher- ic compression devices for deep venous injuries definitively treated in a single Langenbeck wound in any case. Eleven thrombosis prophylaxis and are kept toe- procedure, whereas 13 (81%) patients un- (69%) patients had evidence of femoral touch weight bearing on the involved derwent staged treatment, initially under- medullary reaming debris in their abduc- side. The authors do not routinely use in- going antegrade reamed locked femoral tor musculature on postoperative comput- domethacin or radiation therapy for het- nailing followed by acetabular fracture ed tomography scan. Radiation therapy erotopic ossification prophylaxis. fixation under a separate anesthetic. Mean for heterotopic ossification prophylaxis time from injury to femoral nailing was was not used. Results 1.2 days (range, 0-6 days), and mean time One (8%) patient died and 2 (15%) had Mean patient age was 40 years (range, from injury to open reduction and inter- follow-up at outside institutions and were 14-76 years). Fifteen (94%) patients were nal fixation of the acetabulum was 4.5 therefore unavailable for long-term fol- men and 1 (6%) was a woman. Average days (range, 0-14 days). low-up. Of the remaining patients, 1 (8%) follow-up was 12.6 months (range, 0-84 A total of 10 surgeons performed the developed a Kocher-Langenbeck wound months). Eight (50%) patients had hip dis- femoral nailings, and 3 surgeons (J.C.K., deep infection requiring irrigation and

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A B C

D E F Figure: Anteroposterior (A) and obturator oblique (B) hip radiographs of a 22-year-old man who sustained a pelvic ring disruption, left-sided acetabular fracture- dislocation, and ipsilateral open femoral shaft fracture due to a high-speed motorcycle accident. The open femoral shaft fracture had bone loss and was treated with irrigation, debridement, and antegrade reamed locked medullary nailing (C). The pelvic and acetabular fractures were subsequently treated with open reduction and internal fixation using staged ilioinguinal and Kocher-Langenbeck exposures. The femoral nail insertion site wound was remote from the Kocher-Langenbeck expo- sure, and the proximal locking screw wounds were incorporated into the lower limb of the wound. Anteroposterior hip radiograph 4 months after injury. The patient had no notable hip motion due to ectopic bone formation (D). He underwent surgical excision of the ectopic bone mass and manipulation of the left hip joint (E). He maintained a functional range of hip motion postoperatively and returned to work as a manual laborer. His open femoral shaft fracture healed (F).

debridement along with intravenous anti- Discussion The results of the current study indi- biotics. Another developed a Kocher-Lan- Ipsilateral fractures of the femur and cate that antegrade femoral nailing can be genbeck wound hematoma in the setting acetabulum are uncommon, and the op- performed in the setting of an ipsilateral of therapeutically dosed low-molecular- timal treatment strategy has not been acetabular fracture requiring a posterior weight-heparin and required evacuation. established. Although antegrade femoral approach with an acceptably low inci- At final follow-up, 2 (15%) patients had nailing is the best surgical tactic for many dence of wound-related complications. no heterotopic ossification about the hip, 4 femur fractures, some authors caution One patient treated in this fashion de- (31%) had Brooker class I heterotopic os- against this approach when an ipsilateral veloped an infection requiring irrigation sification, 3 (23%) had Brooker class II, 2 Kocher-Langenbeck approach for ac- and debridement followed by intravenous (15%) had Brooker class III, and 2 (15%) etabular fracture treatment is anticipated. antibiotics, yielding an 8% infection rate. had Brooker class IV requiring resec- Concerns have been raised over the po- This rate is comparable with published tion.16 Neither the severity nor location of tential for increased risk of wound com- infection rates after isolated acetabular the heterotopic bone formation correlated plications and heterotopic bone forma- fracture surgery.17-19 Another patient de- with the hip abductor medullary reaming tion.3,5,6 These assertions come without veloped a hematoma that required irri- material noted on the postoperative com- supportive data from the peer-reviewed gation and debridement, but this was in puted tomography scans. literature. the setting of therapeutically dosed low-

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molecular-weight heparin. In the major- and traumatic sciatic nerve palsies in this 2. Muller EJ, Siebenrock K, Ekkernkamp A, Ganz R, Muhr G. Ipsilateral fractures of the ity of cases, femoral nailing will be per- patient population. These associated inju- pelvis and the femur—floating hip? A retro- formed prior to acetabular open reduction ries have been observed previously in the spective analysis of 42 cases. Arch Orthop and internal fixation, and with the evolu- orthopedic literature and are likely related Trauma Surg. 1999; 119:179-182. tion of contemporary percutaneous nailing to the extreme energy transfer required to 3. Kregor PJ, Templeman D. Associated in- juries complicating the management of ac- techniques, the skin incisions required for produce such an injury constellation.1,5 etabular fractures: review and case studies. nail insertion are rarely relevant to the sub- Clinicians must be particularly vigilant in Orthop Clin North Am. 2002; 33:73-95. sequent Kocher-Langenbeck approach. examining and documenting the status of 4. Liebergall M, Mosheiff R, Safran O, Peyser A, Segal D. The floating hip injury: patterns The formation of heterotopic ossifica- the soft tissue envelope as well as sciatic of injury. Injury. 2002; 33:717-722. tion about the hip can be problematic af- nerve function in this patient population. 5. Burd TA, Hughes MS, Anglen JO. The float- ter isolated acetabular surgery or femoral This study has several important limi- ing hip: complications and outcomes. J Trau- nailing alone.8,20-27 Antegrade nailing of tations. It was retrospective in nature, ma. 2008; 64:442-448. the femoral shaft has been associated with and functional outcome scores were not 6. Smith RM, Giannoudis PV. Femoral shaft fractures. In: Browner BD, Levine AM, Ju- a 10% incidence of Brooker class III or IV obtained. As is common in many stud- piter JB, Trafton PG, Krettek K, eds. Skeletal heterotopic ossification, whereas the inci- ies involving trauma patients, long-term Trauma: Basic Science, Management, and dence of clinically significant heterotopic follow-up was not available for all patients. Reconstruction. Vol 2. 4th ed. Philadelphia, PA: Saunders Elsevier; 2009:2035-2072. ossification after acetabular fracture sur- However, follow-up was sufficient to de- 7. Bishop JA, Rodriguez EK. Closed intramed- 8,18-27 gery is cited between 7% and 14%. tect acute postoperative complications. In ullary nailing of the femur in the lateral decu- As might be expected, the patients in the addition, all of the patients in this series bitus position. J Trauma. 2010; 68:231-235. current study were at risk of heterotopic had their femoral nailing performed at the 8. Stannard JP, Bankston L, Futch LA, Mc- ossification formation (Figure). Eleven authors’ institution by fellowship-trained Gwin G, Volgas DA. Functional outcome following intramedullary nailing of the fe- (85%) patients had evidence of hetero- orthopedic trauma surgeons using small mur: a prospective randomized comparison topic ossification formation at final radio- incisions and after consultation with an ac- of piriformis fossa and greater trochanteric entry portals. J Bone Joint Surg Am. 2011; graphic follow-up, but only 2 (15%) were etabular fracture surgeon. Femoral nails in- 93:1385-1391. Brooker class IV and symptomatic enough serted through larger incisions, by less ex- 9. Rhorer AS. Percutaneous/minimally invasive to require additional surgery. Formal func- perienced surgeons, or without discussion techniques in treatment of femoral shaft frac- tional outcomes measures were not avail- with an acetabular surgeon may have more tures with an intramedullary nail. J Orthop Trauma. 2009; 23:S2-S5. able in this cohort, but both patients with adverse effects on a subsequent Kocher- 10. Langford J, Burgess A. Nailing of proximal Brooker class III heterotopic ossification Langenbeck approach. and distal fractures of the femur: limitations also reported hip pain, stiffness, and func- and techniques. J Orthop Trauma. 2009; tional limitations, although additional sur- Conclusion 23:S22-S25. gery was not required. Ipsilateral fractures of the femur and ac- 11. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendi- The authors’ primary approach to mini- etabulum treated with antegrade nailing um–2007: Orthopaedic Trauma Association mizing heterotopic ossification involves and a Kocher-Langenbeck approach did classification, database and outcomes com- mittee. J Orthop Trauma. 2007; 21:S1-S133. careful debridement of the commonly not demonstrate an increased risk of wound 12. Karpos PA, McFerran MA, Johnson KD. In- present residual reamings in the abduc- complications, and, although heterotopic tramedullary nailing of acute femoral shaft tor musculature after femoral nailing and bone formation was common, it was not fractures using manual traction without a frac- aggressive excision of nonviable muscle clinically significant in most patients. ture table. J Orthop Trauma. 1995; 9:57-62. from the posterior hip.12 The incidence Based on the authors’ experience, the pres- 13. Rath EM, Russell GV Jr, Washington WJ, Routt ML. Gluteus minimus necrotic muscle of heterotopic ossification in this patient ence of an ipsilateral acetabular fracture debridement diminishes heterotopic ossifica- population was notably higher than in a requiring a Kocher-Langenbeck approach tion after acetabular fracture fixation.Injury . previous series of isolated acetabular frac- is not a contraindication to antegrade femo- 2002; 33:751-756. tures from the authors’ institution treated ral nailing. Additional measures to prevent 14. Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical though a Kocher-Langenbeck approach, heterotopic ossification formation may be approaches for open reduction. Preliminary suggesting that supplemental heterotopic warranted in some cases. report. J Bone Joint Surg Am. 1964; 46:1615- ossification prophylaxis in the form of in- 1646. domethacin or radiation may be warranted eferences 15. Gustilo RB, Mendoza RM, Williams DM. R Problems in the management of type III in this patient population.12 1. Liebergall M, Lowe J, Whitelaw GP, Wetzler (severe) open fractures: a new classification The authors also indentified a high inci- MJ, Segal D. The floating hip. Ipsilateral pel- of type III open fractures. J Trauma. 1984; vic and femoral fractures. J Bone Joint Surg 24:742-746. dence of both open femoral shaft fractures Br. 1992; 74:93-100.

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