A novel technique to prevent distal anterior femoral cortical perforation

Abstract

Background: Anterograde femoral intramedullary nailing is a commonly used operative technique in orthopaedic surgery. Of its related complications, distal femoral anterior cortical breach is of special concern. Methods: We describe the steps of an anterograde femoral intramedullary nailing surgical technique performed on three patients to mitigate their risk of developing an anterior distal perforation of the femoral cortex. Results: All patients presented with a proximal intertrochanteric femoral fracture and underwent an intramedullary femoral nail placement. They all had an anatomic reduction radiographically. No complications intraoperatively or at last follow-up were recorded. Conclusions: By surgically redirecting the guidewire posteriorly before placing the nail in its desired position, our surgical technique prevents the anterior intramedullary nail abutment against the femoral cortex and the risk of anterior femoral cortical perforation. Level of Evidence: V.

Influence of greater trochanteric starting point on distal anterior cortical perforation during antegrade femoral nailing

“…Options to achieve this include the use of bent guide wires and blocking implants. [17][18][19][20][21] Our study demonstrates that 1 adjunctive intraoperative technique to avoid an anteriorly placed nail tip may be to avoid a posterior starting point.…”

“…Many surgeons therefore elect to minimize the risk of anterior distal nail placement during femoral medullary nailing. Options to achieve this include the use of bent guide wires and blocking implants 17–21. Our study demonstrates that 1 adjunctive intraoperative technique to avoid an anteriorly placed nail tip may be to avoid a posterior starting point.…”

Biomechanical Consequences of Nail Insertion Point and Anterior Cortical Perforation for Antegrade Femoral Nailing

“…Although anterior cortical perforation of the distal femur during antegrade nailing only happens at a rate of <1% [20,21], which supports the general findings of the current biomechanical analysis, there is still a finite risk of displaced supracondylar fracture requiring revision surgery [24]. Consequently, several authors describe ways of preventing it, such as bending the guidewire to allow the surgeon to direct it more posteriorly away from the anterior cortex [40,41], using the starting guide pin or the distal locking drill bit as a blocking screw to direct the guidewire posterior in the femoral shaft [40,42], or using as many as 5 bicortical Steinmann pins to guide the nail posteriorly [43]. Of course, there are other risk factors for accidental perforation beyond the control of the surgeon, like natural bowing of the femur which can have a radius of curvature from 52 to 203 cm [44,45] and the built-in bowing of different cephalomedullary nail designs whose radius of curvature has decreased over the years to prevent perforation from 186 to 300 cm (in 2004) [46] to 127 to 200 cm (in 2016) [44].…”