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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 36  |  Issue : 2  |  Page : 8-13

Evaluation of outcomes of distal femoral fractures treated by retrograde nailing technique


1 Department of Orthopaedics, Autonomous State Medical College, Mirzapur, Uttar Pradesh, India
2 Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
3 Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
4 Department of Orthopaedics, BRD Medical College, Gorakhpur, Uttar Pradesh, India
5 Department of Orthopaedics, Dr. RMLIMS, Lucknow, Uttar Pradesh, India

Date of Submission03-Jul-2021
Date of Decision14-Jul-2021
Date of Acceptance14-Jul-2021
Date of Web Publication02-Aug-2021

Correspondence Address:
Santosh Kumar Singh
Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_8_21

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  Abstract 


Background: Distal femur fractures are less common injuries accounting for approximately 1% of fractures in the elderly. They occur due to high-velocity injury in adults and simple fall in the elderly. Management of these type injuries in the elderly is more challenging because of osteoporosis. Retrograde nailing represents an established fixation method for fractures of the distal femur and offers an alternative to the existing technique of antegrade nailing. Materials and Methods: Prospective study of 70 patients, aged between 16 and 85 years, whose distal femoral fractures were treated with a retrograde femoral nail from December 2016 to November 2018 in the department of orthopedics of a tertiary care centre in North India were followed to assess the outcome of treatment. The fracture was caused by a motor-vehicle accident in 58 patients (82.85 percent) and a fall on the ground in 12 (17.14%). 26 (37.14%) of the fractures were open. All the patients were followed up at about 3 weeks, 6 weeks, 3 months, 6 months, and 1 year. On each visit pain, functional range of movements was noted and the union was assessed clinically and radiologically at regular intervals. Results: Out of 70 patients, 60 patients were males and the remaining patients were female. Twenty-six patients had open fractures and 44 patients had closed fractures. All the patients in our study united without any case of nonunion and knee infection. The mean time required to achieve union was 5.42 ± 2.48 months in closed fractures, while in open fractures, it was 5.7 ± 1.65 months. The mean range of knee movement in open fractures was from 15.0° ± 12.57° to 113.75° ± 14.69 °, while in closed fractures, it was from 5.38° ± 6.43° to 122.18° ± 15.0°. Five patients had loosening of the distal interlocking screws impinging on the skin. Based on the criteria recommended by Schatzker the outcome was assessed as excellent in 33 (47.14%) cases, good in 27 (38.57%) cases, and fair in 7 (10%) cases. The outcome in 3 (04.29%) cases was graded as poor. Conclusions: Retrograde intramedullary nailing makes possible a biological osteosynthesis of distal femoral fractures. It also produces good functional results even in elderly patients.

Keywords: Biological fixation, retrograde femur nail, supracondylar femur fracture


How to cite this article:
Bhartiya RK, Singh SK, Singh P, Gill S P, Mishra L, Arora J. Evaluation of outcomes of distal femoral fractures treated by retrograde nailing technique. J Bone Joint Dis 2021;36:8-13

How to cite this URL:
Bhartiya RK, Singh SK, Singh P, Gill S P, Mishra L, Arora J. Evaluation of outcomes of distal femoral fractures treated by retrograde nailing technique. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:8-13. Available from: http://www.jbjd.org/text.asp?2021/36/2/8/322954




  Introduction Top


Distal femur fractures are less common injuries accounting for approximately 1% of fracture in the elderly.[1] The mode of injury is due to high-velocity trauma in adults and simple fall in the elderly. Management of these type injuries in the elderly is more challenging because of osteoporosis.[1],[2] The aims of surgical treatment are safe surgical procedure, early mobilization and weight-bearing with the sound union of the fracture.

In treating distal femur fractures, it can be difficult to maintain bony alignment, due to the unbalanced pull of thigh and calf muscles. In 1967, Neer et al.[2] recommended a nonsurgical approach to supracondylar fractures after reviewing 110 cases, noting a high rate of local complications and a low rate for patient satisfaction. Early conversion to cast bracing after a period of traction was later introduced,[3],[4] claiming better functional outcomes compared with prolonged casting across the knee. Later fixation with a lateral condylar blade plate or its modifications became popular because it allowed fixation of intraarticular fractures and early mobilization of the knee joint.[5],[6],[7] Soft-tissue disruption with open reduction and periosteal stripping for placement of the implant may interfere with the healing process, resulting in a delay in union or nonunion.[8],[9] Flexible intramedullary nailing[10],[11] modified antegrade nailing[12],[13] and external fixation[14] allowed fracture fixation with minimal exposure of the fracture site. However, the axial and rotational stability of these implants were inferior, and early mobilization of the limb could result in loss of reduction. Retrograde insertion of a standard femur nail did not allow fixation of very low fractures. In addition, freehand interlocking of the proximal end could be difficult.

Retrograde nailing is an established management option for these types of fractures.[12],[13],[14] Due to the distal position of the interlocking screws, they were later used for distal femur fractures. Fixation of intercondylar fractures was also possible with additional compression screws to stabilize the intra-articular fragments.[14],[15] In cases with severe metaphyseal comminution, supracondylar nailing offers a more biological method of fixation with less devitalization of soft tissue.[14],[15] In the treatment of osteoporotic distal femur fracture, it is very difficult to obtain sufficient implant anchorage. Schatzker et al.[6] suggested that distal locking has a major impact on the implant anchorage in osteoporotic bone, and concluded that a supracondylar nail should be considered for mobile patients where early postoperative mobilization and rehabilitation is required. We reviewed 70 patients treated with supracondylar nailing for distal femur fractures at our institution over a 2-year period, to determine the overall outcome of the treatment in this patient group.


  Materials and Methods Top


Seventy patients with supracondylar and intercondylar fractures of the femur were treated operatively at the Department of orthopedics of a tertiary care center in North India from December 2016 to September 2018. After the admission of the patient, a careful history was elicited from the patient and attendants to reveal the mechanism of injury and the severity of trauma. The patients were then assessed clinically to evaluate their general condition and the local injury. Radiographs of the knee with the distal half of the femur AP, lateral, right and left oblique views were obtained [Figure 1]. Radiographs of the pelvis with both hips (AP view) and tibia full length (AP and lateral views) were also taken to rule out other fractures. Oblique X-ray views were taken of fracture site at distal femur to delineate the extent of injury, especially if there is comminution or additional tibial plateau injury. The limb was then immobilized in Thomas splint with high tibial skeletal traction. The classification of Gustilo and Anderson[16] was used was used to classify open fractures. The extensive wounds were closed underdrain after surgical toileting and debridement. The patients were then taken up for surgery after investigations and preanesthetic fitness for surgery.
Figure 1: Preoperative radiograph

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Surgery was performed with the patient in the supine position on a standard operating table that allowed imaging of the knee with image intensifier. Knee flexion was achieved by placing bolster under the knee. No tourniquet was used. For extra-articular fractures, a midline infra-patellar incision extending through the patellar tendon was used, to assess the entry point on the intercondylar notch. For displaced intercondylar fractures, an anterior midline skin incision with parapatellar arthrotomy was performed for open reduction. The two condylar fragments were initially fixed with cancellous screws. The entry is made with an awl in the intercondylar notch, in line with the long axis of the femoral shaft in both the AP and coronal planes using blumensaat's line in the lateral view.

If the fracture extended close to or through the inter-condylar notch, the entry hole of the nail had to be created by connecting multiple drill holes, to avoid splitting of the two condyles. The distal interlocking screws of the nail provided additional fixation to the condylar fragments. In open fractures, the location of the open wound governed the skin incision and approach to the fracture. Knee joint mobilization without weight-bearing was allowed after the second postoperative day. All the patients were followed up at about 3 weeks, 6 weeks, 3 months, 6 months and 1 year. On each visit pain, functional range of movements was noted and the union was assessed radiologically at regular intervals [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 2: Immediate postoperative radiograph

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Figure 3: Follow-up radiograph at 6 months

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Figure 4: Follow-up radiograph at 18 months

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Figure 5: Clinical photograph

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  Results Top


The mean age of the patients was 39.4 years (range-16–85 years). There were 60 men and 10 women. There were 51 (72.86%) AO type A, 05 (07.14%) AO type B, and 14 (20%) AO type C fractures. The fracture was caused by a motor-vehicle accident in 58 patients (82.85%), a fall in 12 (17.14%). 75.71% of the motor-vehicle accidents involved male patients and 56% of the falls involved women. Twenty-six (37.14%) of the fractures were open with the remaining 44 (62.86%) were closed [Table 1]. In most patients, knee strengthening exercises were commenced 2 days after surgery. The duration before partial weight-bearing varied and full weight-bearing was allowed only when the fracture was assessed as clinically and radiologically united. The mean time required to achieve union was 5.42 ± 2.48 months in closed fractures while in open fractures it was 5.7 ± 1.65 months [Table 2]. Delayed union was seen in 06 (08.57%) patients. The mean time of full weight-bearing was 10.45 ± 2.25 weeks. The mean range of knee movement in open fractures was 15.0° ± 12.57° to 113.75° ± 14.69° while in closed fractures it was 5.38° ± 6.43° to 122.18° ± 15.0°. The mean duration of follow-up was 36.45 ± 4.7 weeks.
Table 1: Patient variables

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Table 2: Outcome measures

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The routine removal of implants was not necessary in any of the patients. Twenty-one patients developed pain on knee movement during the postoperative period. Five patients had loosening of the distal interlocking screws impinging on the skin. One had his proximal screws backed out and migrated into subcutaneous tissue. The screw was removed under local anesthesia and reduction was maintained until the time of union. There were 3 cases of superficial infection who responded very well to antibiotic coverage. There were no cases of deep infection. There were two patients of implant breakage or loss of fracture alignment during the healing process. In 63 (90%) cases, reduction was achieved by closed methods while in the rest 7 (10%) patients, open reduction had to be done. Shortening <1 cm developed in 5 (7.14%) patients. None of the patients had shortening >1 cm. 03 (04.28%) had postoperative joint stiffness which improved after physiotherapy [Table 3].
Table 3: Complications

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The outcome was evaluated using Schatzker's criteria[17] which took into account the range of movement at the knee, shortening, pain, valgus/varus deformity and joint congruity. Fracture alignment, limb length measurement, and range of knee movements were based on the last recorded clinical evaluation. Based on the criteria recommended by Schatzker,[17] the outcome was assessed as excellent in 33 (47.14%) cases, good in 27 (38.57%) cases, and fair in 7 (10%) cases. The outcome in 3 (04.29%) cases was graded as poor. All AO type A and B patients were having excellent to good results, while AO type C in 4 patients had good results and 7 patients had fair results. Three cases in type C showed poor results.


  Discussion Top


The time to union of 5.74 ± 1.65 months with one case of nonunion seen in this study compares favourably to other treatment methods reported in the literature.[5],[18],[19] All fractures united without secondary procedures to enhance union. Closed reduction or minimal fracture exposure to facilitate the passage of the guidewire resulted in little additional injury to the adjacent soft tissue. Especially the periosteum, and fracture hematoma was preserved in most cases. The load sharing mechanism of intramedullary nailing promotes secondary bone healing, and morselized bone from medullary reaming extravasated into the fracture site serves as a bone graft. All these factors likely contributed to the good union rate seen and the low incidence of soft tissue complications, especially infection.

Retrograde nailing for femur shaft fractures has been shown to produce comparable rates of union to antegrade nailing.[20] Janzing et al.[21] recently studied outcomes for 24 elderly patients with distal femur fractures treated with supracondylar nailing. Using the Neers knee scoring system criteria,[2] they reported excellent or good results in 16 (89%) patients. In our study, 60 (85.71%) patients had excellent to good results based on Schatzker's scoring system.

Angular malunion, in either the coronal or sagittal plane, may develop due to inadequate reduction or inappropriate entry portal and subsequent displacement during bone healing.[9],[19] Schatzker classified fracture alignment of <10° varus or valgus as good in their outcome evaluation.[17] In our series, good alignment was achieved in all but one patient, and this was due to eccentric entry portal. The moment arm of varus or valgus bending force is significantly reduced with intramedullary nailing compared with the use of the lateral plate system. Four cortical fixations are also possible, with 2 well-placed distal interlocking screws. Moreover, intramedullary positioning of the nail also provides sufficient fixation of the fracture to prevent flexion/extension displacement of the distal fragment. The combination of early union and stability of fixation seen with this approach effectively reduces the risks of angular malunion.

Siliski et al.[8] reported that 15 of 52 patients in their series of patients treated for distal femur fractures had limb shortening of 1–3 cm. Shortening was intentional in 11 patients to allow impaction for better bone healing. In our series, we aimed to restore the original bone length. However, 05 (7.14%) patients had femur shortening of <1 cm which was most likely due to excessive communition, articular extension, angular malunion. Patients with open fractures and those treated with open reduction technique had more shortening compared to their counterparts.

In patients with multiple fractures, simultaneous fracture fixation in more than one limb may be desirable. Supracondylar nailing is performed supine on a normal operating table, allowing simultaneous procedures for upper limbs and the opposite lower limb. When there is an indication for life-saving procedures, such as craniotomy or laparotomy, repositioning of the patient is not necessary for subsequent fracture fixation.

Long-term effects on the knee joint following nail entry through the intercondylar notch are not clear. In our experience, splitting the patellar tendon for insertion of the nail did not appear to cause any symptomatic or functional problems with the knee. Nine patients in our study complained of pain during the postoperative period. This was mainly due to improper insertion of the nail, the distal end protruding into the knee joint. Pain was also caused by prolonged knee stiffness in polytrauma patients. Loosening of locking bolts impinging over the skin and superficial infection at the site of locking bolts also contributed to pain. Anup and Mehra.[22] in their study showed one case of pain with patella-femoral arthritis due to nail protruding out of the articular surface. Scholl and Jaffe[23] in their study of 12 pathological fractures treated with retrograde nail reported no or modest pain in 90% of patients, 81% functioning with no restrictions.

In our study, three patients developed superficial infection of knee joint. No deep-seated infection occurred. The knee joint infection was nil in our study despite the joint being opened for the entry portal. This was very well supported by Leggon and Feldmann[24] with no knee joint infection among their patients. Handolin et al.,[25] in their study of over 46 patients noticed three superficial infections but no deep infections.

Hierholzer et al.[26] concluded that both retrograde intramedullary nailing and angular stable plating are adequate treatment options for distal femur fractures. Locked plating can be used for all distal femur fractures including complex type C fractures, periprosthetic fractures, as well as osteoporotic fractures. IM nailing provides favorable stability and can be successfully implanted in bilateral or multisegmental fractures of the lower extremity as well as in extra-articular fractures.

Christodoulou et al.[27] treated eighty patients with supracondylar fractures. They also followed Schatzker's criteria for outcome evaluation. Excellent results were noted in 51%, good results in 31%, fair results in 9%, and poor results in 8%. The results obtained in our study slightly differed mainly in fair category.

Although we did not observe any significant deterioration of joint congruency or reduction in the thickness of the articular space based on X-ray evaluation, no conclusion can be reached since the number of cases was small and the duration of follow-up relatively short. Moreover, it would be difficult to separate the effect of trauma from that of intercondylar nail entry. The benefits of maintaining good fracture alignment and early joint mobilisation with the use of supracondylar nailing may prove to be more important overall for the long-term integrity of the knee joint.


  Conclusions Top


Supracondylar nailing is useful for the fixation of supracondylar and less comminuted intercondylar fractures. With minimal disruption to soft tissue and good purchase of the distal bone fragment, this approach provides stable fracture fixation, allowing early joint mobilization. The rate of union is high, with a low incidence of complications. The simplicity of the procedure also facilitates fracture fixation in patients with multiple trauma, including those with multiple fractures.

Ethical standards

The protocol of this study was approved by the institutional institutional ethical committee. A well informed written consent was obtained from every case in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Gellman RE, Paiement GD, Green HD, Coughlin RR. Treatment of supracondylar femoral fractures with a retrograde intramedullary nail. Clin Orthop Relat Res 1996;(332):90-7.  Back to cited text no. 14
    
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Kumar A, Jasani V, Butt MS. Management of distal femoral fractures in elderly patients using retrograde titanium supracondylar nails. Injury 2000;31:169-73.  Back to cited text no. 15
    
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Gustilo RB, Anderson JT. Prevention of infection in the treatment of One Thousand and Twenty-five open fractures of long bones. Retrospective and prospective analysis. J Bone Joint Surg 1976;58-A: 453-8.  Back to cited text no. 16
    
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21.
Janzing HM, Stockman B, Van Damme G, Rommens P, Broos PL. The retrograde intramedullary nail: Prospective experience in patients older than sixty-five years. J Orthop Trauma 1998;12:330-3.  Back to cited text no. 21
    
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Anup K, Mehra MM. Retrograde femoral interlocking nail in complex fractures. J Orthop Surg (Hong Kong) 2002;10:17-21.  Back to cited text no. 22
    
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Scholl BM, Jaffe KA. Oncologic uses of the retrograde femoral nail. Clin Orthop Relat Res 2002;(394):219-26.  Back to cited text no. 23
    
24.
Leggon RE, Feldmann DD. Retrograde femoral nailing: A focus on the knee. Am J Knee Surg 2001;14:109-18.  Back to cited text no. 24
    
25.
Handolin L, Pajarinen J, Lindahl J, Hirvensalo E. Retrograde intramedullary nailing in distal femoral fractures – results in a series of 46 consecutive operations. Injury 2004;35:517-22.  Back to cited text no. 25
    
26.
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27.
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;125:73-9.  Back to cited text no. 27
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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