This consecutive series had a 95 percent union rate after nailing and dynamization as necessary. No knee problems were associated with the retrograde femoral intramedullary nailing technique. The one septic knee raises concerns about the use of retrograde nailing in severe open femoral shaft fractures. Retrograde femoral nailing should be given serious consideration as an alternative to antegrade femoral nailing.
Of 133 dynamic femoral intramedullary nailing (IM) procedures performed after locking techniques became available: ■ 10.5% (n = 14) were complicated by loss of postoperative fixation and reduction. ■ 13 of the 14 femora shortened an average of 2.0 cm and one shortened slightly with clinical loss of rotational stability. ■ Errors in surgical judgment were attributed to (alone or in combination):■ Inadequate preoperative analysis of fracture patterns ■ Undetected comminution during reaming or nail insertion ■ Failure to recognize postoperatively increased comminution ■ Fracture instability Authors suggest: ■ Use of high-quality preoperative x-rays to detect nondisplaced comminution of major fracture fragments. ■ Intraoperative fluoroscopic assessment: increase in comminution secondary to reaming or nail insertion is an indication for static locked fixation. ■ Analysis of radiographs taken immediately postoperatively while patient is still under anesthesia to evaluate previously undetected instability that should be treated by static locked fixation. ■ Dynamic IM stabilization should be reserved for transverse or short oblique fractures at the femoral isthmus that have type I or type II comminution.
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