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| ORIGINAL ARTICLE |
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| Year : 2015 | Volume
: 15
| Issue : 2 | Page : 148-152 |
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Comparative study of treatment of fracture shaft femur by intramedullary interlocking nails through piriform fossa entry and tip of the greater trochanter entry approach
Soumya Ghosh1, Joydeep Das1, Arunima Chaudhuri2, Akhilesh Kumar1, Soma Datta3, Chinmay De1
1 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| Date of Web Publication | 6-May-2015 |
Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1319-6308.156346
Background: Several techniques and tools are available for achieving fracture reduction during antegrade intramedullary nailing of femur fractures. Aims: To compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa (PF). Materials and Methods: The present pilot project was conducted in a time span of 1-year. The patients admitted with femoral diaphyseal fractures were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 15 (n = 15). Results: Complications of nailing: PE group - 6.7% infection, 20% malunion, 20% delayed union, 20% restriction of hip range of motion (ROM), 6.7% restriction of knee ROM, 13.3% limb length discrepancy, 13.3% hardware prominence. GTE group - 13.3% malunion, 13.3% delayed union, 33.3% Restriction of hip ROM, 6.7% restriction of knee ROM, 20% limb length discrepancy, 26.7% hardware prominence. Radiological union time in PE was 12-15 weeks in 5 patients, 16-19 weeks in 8 patients, 20-23 weeks in 1 and >24 weeks in 1 patient. Radiological union time in GTE was 12-15 weeks in 4 patients, 16-19 weeks in 9 patients, 20-23 weeks in 2 patients. Need for dynamization was 20% in the PE group and 13.3% in GTE group. Thoresen's scoring system showed no significant difference between the two groups. Conclusion: Femoral nailing through the greater trochanter with specifically designed nails and with attention to specific techniques for such insertion should be considered a rational alternative to femoral nailing through the PF with the benefit of reduced requirement for fluoroscopy and decreased operative time. للاخ نمو ، ةيرثمكلا ةرفحلا للاخ نم ةكباشتملا ريماسملا قيرطب ذخفلا مظع حمر رسك جلاع)ةنراقم ةسارد ( ريبكلا رودملا
. عاخنلا لخاد هتيبثت ءانثأ ذخفلا حمر رسك عاجرلأ عاجرلاا لئاسو ةدع كلانه :ثحبلا ةيفلخ
ةقيرطب اهتنراقمو ريبكلا رودملا للاخ نم اهتيبثت عم ذخفلا حمر رسك جلاع جئاتن ةنراقمل ةساردلا هذه تفده :فادهلأا.ةيرثمكلا ةرفحلا
يواستلاب اومسق ذخفلا حمر يف اروسك نوناعي اضيرم 30 رابتخا متو .ادحاو اماع ةساردلا هذه نمز قرغنسا :داوملاو جهنملا.ريبكلا رودملا للاخ نم تيبثتلا قيرطب جلاعلل اضيرم 15 عضخ امنيب ،ةيرثمكلا ةرفحلا ةقيرطب اوجلوع مهنم 15 نبتعومجم ىلإ
%20:ماحتللاا ءوس %7.6 ىودعلا :يلانلاك تناك تافعاضملا ضعب ةيرثمكلا ةرفخلا ةعومجم ترهظأ :جئاتنلا .%26,7 فارطلأا لوط يف نيابتلا %13,3ةبكرلا ةكرح دييقت %7.6 كرولا ةكرخ دييقت %20 ماحتللاا رخأت 1916 تناك ىضرم 8 دنعو ، اعوبسأ 15 12 نيب ةيرثمكلا ةرفحلا ةعومجم نم 5 نيب يعاعشلإا ماحتللاا تقو ناكو .اعوبسأ 24 نم رثكأ دحاو ضيرم دنعو ،اعوبسأ 23 20 دحاو ضيرم دنعو اعوبسأ 19 16 ىضرم 9 دنعو ،اعوبسأ ،ىضرم 9 دنع اعوبسأ 19 16 ،ىضرم 4 دنع اعوبسأ 1512 :يتلآاك ريبكلا رودملا ةعومجم يف ماحتللاا تقو ناكو ةيكيمانيدلا ىلإ ةيرثمكلا ةرفحلا ةعومجم نم 20% ةجاح ةساردلا ترهظأ .ىضرملا نم نينثا دنع اعوبسأ 23 20.نيتعومجملا نيب ةيئاصحإ ةللاد تاذ قورف ىا ةسردلارهظت مل .ريبكلا رودملا ةعومجم يف 13.3%و
نابسحلا يف ذخلأا عم صوصخم لكشبريماسملا ميمصت دعب ريبكلا رودملا ةقيرطب روسكلا تيبثت قيرط نأ :ةصلاخلا و ريظنتلل ةجاحلا ليلقت نابسحلا يف ذخلأا عم اينلاقع لايدب دعي ةيرثمكلا ةرفحلا ةقيرطب ذخفلا رسك تيبثتل ةددحم تاينقت.ةيلمعلا تقو ليلقت
Keywords: Different entry approaches, Fracture shaft femur, intramedullary nailing
How to cite this article:
Ghosh S, Das J, Chaudhuri A, Kumar A, Datta S, De C. Comparative study of treatment of fracture shaft femur by intramedullary interlocking nails through piriform fossa entry and tip of the greater trochanter entry approach. Saudi J Sports Med 2015;15:148-52 |
How to cite this URL:
Ghosh S, Das J, Chaudhuri A, Kumar A, Datta S, De C. Comparative study of treatment of fracture shaft femur by intramedullary interlocking nails through piriform fossa entry and tip of the greater trochanter entry approach. Saudi J Sports Med [serial online] 2015 [cited 2023 Dec 4];15:148-52. Available from: https://www.sjosm.org/text.asp?2015/15/2/148/156346 |
| Introduction | |  |
Femur is the principal weight bearing bone of lower extremity and fracture of femur leads to considerable morbidity and mortality. [1],[2],[3],[4],[5] Femoral shaft fracture results from high energy trauma which may be associated with multisystem injury and considerable soft tissue injury. [2],[3] Fractures of the shaft in elderly people are frequently associated with low energy trauma (e.g., falls from standing height), the main predisposing factor of which is osteoporosis. [4],[5] Early fixation prevents some grave complications of femoral shaft fractures like fat embolism and acute respiratory distress syndrome. It also allows for early active mobilization, which prevents hip and knee stiffness as well as quadriceps and hamstring wasting. Intramedullary nail provides predictable restoration of shaft length and alignment along with load sharing. Intramedullary nails have a center of movement close to the center of bone, thus are subjected to lesser load, and hence less likely to undergo fatigue failure. Fractures are stabilized with cortical contact of major proximal and distal fragments so that the fractured bone shares the load along with the nail. Relative stability of the construct allows micromotion at the fracture site leading to union by callus formation. [1],[2],[3],[4],[5],[6],[7]
In case of close nailing, the nail is inserted into the medullary cavity through the proximal femur (piriform fossa or the tip of the greater trochanter) without disturbing the periosteal blood supply of at the fracture site. [1],[2],[3],[4],[5],[6] The piriformis fossa (PF) and the tip of the greater trochanter have each been commonly described as entry portals for antegrade femoral nailing. Both forms of nails have an anterior bowing simulating the bowing of the femur shaft in sagittal plane. But the main structural difference is that the piriform entry nails are devoid of any coronal plane angulation as the piriform fossa is collinear with the long axis of femoral shaft, whereas the trochanteric entry nails have a lateral bending of 4°-5°. [5],[6]
The piriform fossa and the tip of the greater trochanter, both the entry points have their own merits and demerits. The clinical outcomes after nail insertion through which entry point is superior with lesser complications is yet to be established firmly. [5],[6] The purpose of this study was to compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the PF with nails specifically designed for each starting point.
| Materials and methods | | |
The present pilot project was conducted in Burdwan Medical College in a time span of 1-year after taking clearance from the institutional ethics committee and informed consent of the subjects: The patients admitted with femoral diaphyseal fractures between the mentioned time frame at OPD or emergency department of this institution were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 15. Inclusion criteria: All femoral diaphyseal fracture patients < 18 years and > 60 years of age with close and open fractures (Gustilo-Anderson type I, II and IIIA fractures) were included. Exclusion criteria: Patients having concomitant fracture in ipsilateral limb or polytrauma, serious medical or surgical illness (diabetes mellitus, rheumatoid arthritis etc.), pathological fractures, fractures >3 weeks old were excluded.
Shaft femur fracture patients were treated using pyriform fossa entry and trochanteric tip entry nails in parallel series and the outcome of the treatment were evaluated both clinically and radiologically using a clinic-radiological criteria by Thoresen scoring system.
Routine investigations were done followed by preanesthetic check-up. Distance from the tip of the greater trochanter to the intra articular space of the knee (lateral joint line) on the patient's uninjured side was measured and 20-30 mm was subtracted. Nails of this size along with the next shorter and longer length were kept ready before the operation.
Patient positioning
Patient can be positioned either supine or lateral on the fracture table. Supine position is better tolerated in patients with associated pulmonary injury or preexisting pulmonary disease while use of lateral decubitus position facilitates location of the piriform fossa. Injured extremity was adducted, and hip flexed to 15°. The contralateral lower extremity was placed adjacent but either inferior to the injured extremity (scissors position) or hip and knee flexed hip abducted (banana position). Patient's trunk was adducted away from the operative table to facilitate access to the entry point and nail insertion. Correct rotational alignment was established using an image intensifier.
Operative details
An oblique skin incision was placed just proximal to the greater trochanter and extended proximally and posteriorly for 4 cm. Further dissection depended on intended entry portal. For piriform fossa entry: The fascia of gluteus maximus was bluntly dissected. PF was palpated posterior to the fibers of gluteus medius. Entry point was made in the middle of the piriform fossa in line with the femoral shaft on both sagittal and coronal planes. Entry point was created with a curved awl, entry was confirmed with a 3.2 mm guide pin. For trochanteric tip Entry: The fascia of gluteus medius was incised. The muscle was splitted in the middle of the belly to access the trochanteric tip. The entry point was in the center of the trochanter and shaft in lateral view and directed medially toward the medullary canal anteroposterior (AP) view under C-arm guidance. Entry point was made using a curved awl or guide pin and canal cutter.
Nail for piriform fossa entry
First generation antegrade intramedullary interlocking nail-Indian nail. It is a hollow tubular nail with a circular cross section. Proximal 10 cm is expanded to 12 mm to give additional strength for proximal screw fixation. It has position slots to lock the jig. Its 2 mm wall thickness gives the nail a certain flexibility on bending. Proximal end has got threads on the inner side that provides secure fixation of the threaded conical bolt for attachment of jig/extractor. Nail has a curvature to the average anatomic curvature of the femur. For locking, there are 2 holes on either side, at the proximal and distal ends of the nail. Circular holes for static locking measure 5 mm. Nails are available in diameter of 9, 10 and 11 with the length from 340 to 440 mm with increments of 20 mm. Locking bolts are self-tapping, 4.5 mm available from 25 to 95 mm in 5 mm increments.
A ball tipped guidewire with slightly bent tip attached to a T-handle chuck was placed down the femoral canal to the fracture site and the containment of the guide wire in the femoral canal was confirmed with AP and lateral views. The fracture was reduced under C-arm guidance, and the guidewire was advanced across the fracture site into the distal fragment. It is important to center the guidewire in the canal by confirming its position under C-arm in both AP and lateral views. Proper nail length was determined preoperatively and confirmed by either using 2 guide wires of equal length or by a radiolucent ruler. The femur was serially reamed by a cannulated flexile reamer over the guidewire in 0.5 mm increments starting from 8.0 mm until the desired canal diameter was achieved. Usually, the canal was over reamed by 1-1.5 mm than the desired nail size to prevent jamming of nail. The ball tipped guide wire was replaced by a straight tip guidewire using medullary exchange tube to facilitate the reduction. Selected nail was mounted to an insertion jig in such a fashion that the nail had anterior bow simulating femoral bow and proximal locking guide of the jig should point laterally. It is important to verify that the proximal targeting jig aligns with the proximal nail holes by "free fall" technique before insertion of the nail.
The nail was then advanced down the canal over the guidewire. Insertion handle was used to control the rotation and when no longer manual insertion was possible nail was driven by a hammer - assembly. As the nail was advanced one assistant verified the rotation. Once the nail was fully seated, and its position verified, proximal locking screw was inserted through the insertion jig from lateral to medial.
For distal locking, the C-arm was placed in such a way, that the X-ray beams were parallel to the distal holes and necessary adjustments were done so that the distal locking holes can be seen "perfectly circular". Distal locking was done by "free hand" technique. A second distal locking screw was inserted in an identical manner.
In cases of transverse or short oblique fractures, after doing distal locking, necessary back-hammer can be done after loosening the traction if there is a distraction at the fracture site noted. Proximal locking was done using trochar drill sleeves. Length of the screw was determined by graduated drill bit. Length was measured once the drill bit contacted the medial cortex, and then 5 mm was added to determine proximal screw length. Screw placement was avoided in the inferior femoral neck as this might act as a stress raiser. Before closing the wound, reduction, nail position and bolt sizes were verified. Wound was closed in a single layer.
Rehabilitation
Emphasis was placed postoperatively on muscle strengthening of the thigh as well as on the range of motion (ROM) of the knee. Active hip and knee ROM exercises were started as soon as pain subsided, usually 24-48 h after operation. Patients were ambulated within 24-48 h after surgery using toe-touching bilateral axillary crutches in cases of stable fracture and satisfactory stable fixation. Suture removal was done after 2 weeks of surgery, on the first postoperative visit. Guarded weight bearing was allowed as soon as bridging callus was seen in X-ray, usually after 4-6 weeks. Full weight bearing was started when the fracture site was completely bridged by callus and fracture site clinically became nontender. Patients were then examined at 6 weekly intervals until absolute fracture union was obtained clinicoradiographically. Patients were followed up at 6 months and 1-year. Patients who did not show normal periosteal bridging callus at end of 3 months after injury were followed up seen at 4-6 week intervals. If delayed or absent healing was noted at 4-5 months after injury, consideration was given to convert a statically locked nail to a dynamic mode by removing dynamic bolt or both the bolts from the longer fragment of the bone to encourage union (dynamization).
| Results | | |
About 6.7% Patients were within 20 years of age, 20% were in the age group of 21-30 years, 33.3% were in the age group of 31-40 years, 26.7% were in the age group of 41-50 years, 13.3% were in the age group of 51-60 years. 23.3% were males and 76.7% females. Road traffic accident was the commonest mode of injury (70%) of cases followed by fall from height in 16.7% of cases. Right femur was injured in 66.6% of cases. All cases were operated within 3 weeks of surgery. Average operative time in the PE group was 75.7 min and number of C-arm shots for the entry point was 10 while in GTE group operative time was 69.3 min and number of C-arm shots for the entry point was 8. Type of fracture in the two groups were as follows: Group PE A1 6.7%, A2 10%, A3 20%, B1 10%, B3 3.3% and Group GTE A1 10%, A2 23.3%, A3 33.3%, B1 20%, B2 6.6%, B3 6.6%.
Complications of nailing: PE group - 6.7% infection, 20% malunion, 20% delayed union, 20% restriction of hip ROM, 6.7% restriction of knee ROM, 13.3% limb length discrepancy, 13.3% hardware prominence. GTE group - 13.3% malunion, 13.3% delayed union, 33.3% restriction of hip ROM, 6.7% restriction of knee ROM, 20% limb length discrepancy, 26.7% hardware prominence. Full Weight bearing time in PE group was 2-3 days in 20%, 2-3 weeks in 53.3%, 2-3 months in 26.7%, and 2-3 days in 13.3%, 2-3 weeks in 46.7%, 2-3 months in 33.3%, >3 months in 6.7% in GTE group. Radiological union time in PE was 12-15 weeks in 5 patients, 16-19 weeks in 8 patients, 20-23 weeks in 1 and > 24 weeks in 1 patient. Radiological union time in GTE was 12-15 weeks in 4 patients, 16-19 weeks in 9 patients, 20-23 weeks in 2 patients. Need for dynamization was 20% in the PE group and 13.3% in GTE group. No Hip abduction loss developed in 80% of the PE group and in 66.7% in GTE group. No Limb length discrepancy (LLD) was seen in 86.7% in the PE group and in 80% in GTE group. Functional status estimation by Thoresen's scoring system showed no significant difference between the two groups as shown in [Table 1].
| Discussion | | |
Antegrade interlocking nailing for diaphyseal femoral fractures has been conventionally done using PF entry portals. Trochanteric entry nails for the treatment of routine diaphyseal femur fractures is a relatively contemporary approach. [6],[7],[8],[9],[10],[11] The main advantage of a PF starting point is its collinear alignment with the long axis of the femoral shaft. This reduces the risk of iatrogenic fracture comminution and varus malalignment compared to off-axis entry points such as trochanteric entry points. [6],[7],[8],[9],[10],[11] Disadvantages of this entry point include relative technical difficulty obtaining the proper entry site, especially in obese patients. [2],[3] This difficulty also reflected in comparatively higher operative time and fluoroscopy shots required in this entry portal. This entry point is also very sensitive to anterior-posterior translation, with anterior positioning being associated with extreme hoop stresses increased risk of iatrogenic bursting of the proximal segment. [6],[7],[8],[9],[10],[11]
In our study, the mean operative time of piriformis entry nailing and trochanteric entry niling was 112.7 min. and 90.7 min. respectively. This difference in operative time was statistically significant (P = 0.005). The average number of C-arm shots to perform the entry point in piriform fossa is significantly higher as compared to trochanter (mean is 10 and 8 respectively; P = 0.048).
This result corroborates with study of Ricci et al. [6] One-hundred and eight patients were treated with either nailing through a greater trochanter starting point with the trigen TAN nail (GT group) (n = 38) or through a PF starting point with the trigen FAN nail (PF group) (n = 53). Thirty-seven of the 38 fractures from the GT group and 52 of the 53 fractures from the PF group healed after the index procedure. One patient from the GT group had external rotation malalignment of 12°. There were no other malalignments or iatrogenic fracture comminution. There were 2 infectious complications, 1 from each group. The average operative time was 75 min for piriformis insertion using the FAN nail and 62 min for trochanteric insertion using the TAN nail (P = 0.08). The average fluoroscopy time was 61% greater for the PF group (153 s) than for the GT group (95 s) (P, 0.05). These differences were magnified in patients who were obese (body mass index. 30) where the operative time was 30% greater (P, 0.05) and the fluoroscopy time was 73% higher in the PF group (P, 0.02). Patients from both groups had asimilar initial decline and subsequent improvement in function over time (P < 0.05).
In our study, one patient in either group developed superficial wound infection, which was successfully treated by repeated dressing and oral antibiotics according to culture-sensitivity report. One patient in piriform entry group developed deep infection at proximal locking bolt site which was managed by bolt removal, sinus tract excision and parenteral antibiotic injections according to culture-sensitivity report. About 93.3% patients of piriform entry group and 100% patients of trochanteric entry showed union after index procedure. There was no statistically significant difference in union rates between two study groups. Majority of piriform entry (85.7%) and trochanteric entry (80%) patients showed radiological union before 20 weeks (P = 0.92).
In the present study, majority of cases of PE group and GTE group could be allowed for full weight bearing between 16-19 weeks (42.8%) and 20-23 weeks (40%) respectively (P = 0.803). ROM of hip and knee joint in the study subjects were almost within normal limits. However, abduction loss within 10°-20° range is slightly higher among the GTE group (13.3%) than the PE group but it was statistically insignificant (P = 0.47). Two patient in the PE group and three patients in GTE group had limb length discrepancies (0.69) but all limb shortenings were within an acceptable range (≤2 cm). Two patients in PE group and three patients in GTE group had hardware prominences. Among them, one patient of either group had prominence at distal locking sites; one case in PE group and three cases in GTE group had nail prominence at entry sites but this difference had no statistical significance (P = 41). However, these hardware prominences had not severe enough to warrant implant removal.
Functional status assessment was done using Thoresen's Scoring System. Excellent functional status was seen more in the PE group (85.7%) than the GTE group (80%) but this had no statistical significance (P = 68). A retrospective clinical and radiographic review by Keeler et al. in 2009 [7] of 78 children and adolescents with 80 femoral shaft fractures who underwent IM nail fixation through the lateral aspect of the greater trochanter, with a mean follow-up of 99 weeks, was performed. All patients went on to union in good clinical alignment without loss of reduction. No nonunions, delayed unions or malunions were observed. Two patients developed infections postoperatively (2.5%).
| Conclusion | | |
Based on these results, femoral nailing through the greater trochanter with specifically designed nails and with attention to specific techniques for such insertion should be considered a rational alternative to femoral nailing through the PF with the benefit of reduced requirement for fluoroscopy and decreased operative time in situations where difficult piriform entry is anticipated.
| References | | |
| 1. | Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: Current concepts. J Am Acad Orthop Surg 2009;17:296-305.  |
| 2. | Court-Brown CM. The management of femoral and tibial diaphyseal fractures. J R Coll Surg Edinb 1998;43:374-80. |
| 3. | Farhang K, Desai R, Wilber JH, Cooperman DR, Liu RW. An anatomical study of the entry point in the greater trochanter for intramedullary nailing. Bone Joint J 2014;96-B: 1274-81. |
| 4. | Riehl JT, Widmaier JC. Techniques of obtaining and maintaining reduction during nailing of femur fractures. Orthopedics 2009;32:581. |
| 5. | Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma 2006;20:190-6. |
| 6. | Ricci WM, Schwappach J, Tucker M, Coupe K, Brandt A, Sanders R, et al. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma 2006;20:663-7. |
| 7. | Keeler KA, Dart B, Luhmann SJ, Schoenecker PL, Ortman MR, Dobbs MB, et al. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. J Pediatr Orthop 2009;29:345-51. |
| 8. | Huang FT, Lin KC, Yang SW, Renn JH. Comparative study of the proximal femoral nail antirotation versus the reconstruction nail in the treatment of comminuted proximal femoral fracture. Orthopedics 2012;35:e41-7. |
| 9. | Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma 2005;19:681-6. |
| 10. | Ricci WM, Devinney S, Haidukewych G, Herscovici D, Sanders R. Trochanteric nail insertion for the treatment of femoral shaft fractures. J Orthop Trauma 2005;19:511-7. |
| 11. | Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am 2005;87:2217-26. |
[Table 1]
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