MANAGEMENT OF FEMORAL FRACTURES MODIFICATIONS OF THE GOLD STANDARD

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MANAGEMENT OF FEMORAL FRACTURESMODIFICATIONS OF
THE GOLD STANDARD

• Madhav A. Karunakar
• Carolinas Medical Center

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GOLD STANDARD

• Debatable
• Reamed Statically Locked Antegrade Piriformis
  Entry Nail
• Supine on Fracture Table

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MODIFICATIONS

• Insertion Site Options
• Antegrade versus Retrograde
• Piriformis versusTrochanteric
• Positioning
• Fracture Table
• Supine versus Lateral
• Free leg without traction

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INSERTION OPTIONS

• ANTEGRADE
• PIRIFORMIS
• TROCHANTERIC
• VS.
• RETROGRADE

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PIRIFORMIS ENTRY

• For the past 25 years, the correct start point
  for femoral nailing has been considered to be the
  piriformis fossa (just medial to GT and posterior
  to the gluteus medius tendon)
• Palpable and seen on xray

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PIRIFORMIS ENTRY
Guide pin

Degree of overlap indicates posterior position in
piriformis fossa
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PIRIFORMIS ENTRY
Guide pin

Less overlap indicates more anterior position in
piriformis fossa, appropriate for piriformis
cephalomedullary device (eg RT Recon Nail)
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PIRIFORMIS ENTRY

• Early antegrade nails designed for this starting
  point
• Based upon anatomy of proximal femur
• Posterior piriformis fossa in line with proximal
  femoral canal
• Minimizes hoop stresses
• More important with stainless steel, less
  anatomic nail designs

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PIRIFORMIS ENTRY

• Anatomy of the proximal femur
• Hoop stresses

Graph depicts variation in hoop stresses
generated by various nail types, A-E Johnson KD,
Tencer AF. Biomechanics in Orthopaedic Trauma,
Martin Dunitz Ltd, 1994.
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PIRIFORMIS ENTRY
Johnson KD, Tencer AF. Biomechanics in
Orthopaedic Trauma, Martin Dunitz Ltd, 1994.
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ANTEGRADE PIRIFORMIS ENTRY
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PIRIFORMIS CHALLENGES

• Problem patients
• Obese
• Muscular
• Hooked trochanter

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RETROGRADE ENTRY

• RELATIVE INDICATIONS
• Ipsilateral Fractures
• Femoral Neck
• Intertrochanteric
• Acetabular
• Tibia
• Patella
• Bilateral Femurs
• Ipsilateral TKA
• Polytrauma
• Obesity
• Pregnancy
• Distal Fractures

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RETROGRADE ENTRY
PCL
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RETROGRADE ENTRY IMN
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COTS - PRCT

• Nonunion
• Reamed 2 /121 (1.6)
• Unreamed 8/107 (7.5)
• 1 deep infection
• No malunions

JBJS 2003
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CONCERNS REGARDING RETROGRADE

• Cartilage Injury?
• Patello-femoral joint mechanics
• Nonunion and implant failure with migration into
  knee
• Intraarticular infection
• Nail removal

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RISKS OF PROXIMAL INTERLOCKING
Tornetta, JOT 1998
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TROCHANTERIC ENTRY

• Gaining in popularity
• Easier to insert
• Easier in obese pts
• Versatile for proximal femur fractures
• Safer for adolescent fxs
• Less injury to abductors
• Less risk femoral neck injury

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TROCHANTERIC ENTRY

• Where is it?

Entry Portals Size Varies from 10-17 mm Hip
fracture nails versus reconstruction type nails
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PIRIFORMIS ENTRY
Piriformis starting point
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TROCHANTERIC ENTRY
Forces nail to make a turn in proximal femur
Trochanteric starting point
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TROCHANTERIC ENTRY
Guide pin
?? Need lateral image to judge
anterior-posterior position
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What about the biology of the abductors?
Trochanteric Start Point Gamma Nail
Ream away 25 - 50 of tendon
CORR (407) February 2003
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MODIFIED MEDIAL TROCHANTERIC PORTAL

• Medial tip of trochanter along trochanteric ridge
• Center of neck trochanteric junction on lateral
• No damage to the medius tendon in cadaveric study

Perez et al, JOT 2007
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TROCHANTERIC ENTRY

• Disadvantages
• Varus malreduction of proximal fractures
• Fracture comminution
• Is it really easier to access?
• How much difference is there between modified
  portal and piriformis portal.

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THOSE WHO FORGET HISTORY

• Tip of the trochanter start point
• Kuntscher, Bohler, Grosse
• Trochanteric Starting point is not collinear with
  IM canal
• Fracture Comminution and varus malalignment can
  occur
• Winquist, Johnson

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ANTEGRADE TROCHANTERIC ENTRY
Conclusions Equivalent results to Piriformis
nail
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PIRIFORMIS VS TROCHANTERIC ENTRY POINT

• No evidence that lateral start point has any
  technical advantage or that the outcomes in terms
  of function or entry point symptoms are better
  than piriformis start point
• There is a risk of fracture comminution and
  malalignment with the use of a nonlinear entry
  point

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POSITIONING IN TRACTION

• Supine

• Lateral

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POSITIONING IN TRACTION

• Advantages
• Familiar
• Need fewer hands
• Mega Traction!

• Disadvantages
• Set Up Time
• Pudendal Nerve Palsy
• Compartment Syndrome

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Compartment Syndrome
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SUPINE FRACTURE TABLE

• Advantages
• Easier setup
• Spine Clearance in polytrauma

• Disadvantages
• Starting position
• Reduction in proximal fractures
• Obese patients
• Pudendal nerve palsy

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LATERAL FRACTURE TABLE

• Advantages
• Easier insertion point
• Proximal fractures reduces flexion and varus
  deformity

• Disadvantages
• Longer positioning time
• Pudendal nerve palsy
• Rotational malunion
• Spine Clearance

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BILATERAL FEMUR FRACTURES
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FREE LEG POSITION

• Supine
• Shortest set up time
• Easy Starting portal
• Ideal for Polytrauma /- Bilaterals
• Need Extra Help

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FREE LEG POSITION TIPS

• Bump positioned too far lateral
• Patient NOT at edge of table

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SUMMARY

• Piriformis Nail is the Gold Standard
• High union rate few complications
• Retrograde Nail has role in trauma
• Trochanteric Nail still being determined
• Fracture Table still useful
• Avoid well leg holder
• Free leg in trauma center and with help