Prevention of Cortical Breach During Placement of an Antegrade Intramedullary Femoral Nail

Scolaro, John A.; Endress, Christina; Mehta, Samir

doi:10.3928/01477447-20130821-03

Cited by 14 publications

(7 citation statements)

References 11 publications

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“…There are various risk factors that increase the risk for nonunion, including obesity, hypertension, diabetes, fracture site at the proximal third of the femur, or a comminuted fracture pattern [ 8 - 9 ]. In addition to nonunion, another potential complication is the penetration of the femoral anterior cortex intraoperatively; several studies have explored the risk factors and prevention of this issue [ 1 - 4 ]. There are few cases in the literature of perforation of an intramedullary femoral nail into the knee joint.…”

Section: Discussionmentioning

confidence: 99%

“…This case represents a unique complication of intramedullary nailing (IMN) of a femoral fracture. While many studies have explored the incidence of anterior cortex penetration by the femoral nail intraoperatively [ 1 - 4 ], few have documented this occurrence in the postoperative period. In fact, only one report has described such a situation.…”

Section: Introductionmentioning

confidence: 99%

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Perforation of the Knee Joint Following Antegrade Intramedullary Nailing of a Comminuted Femoral Diaphyseal Fracture: A Case Report

Flood¹,

Wie²,

Sullivan³

2022

Cureus

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A 63-year-old man with a comminuted spiral femoral shaft fracture was treated with closed reduction and internal fixation with a cephalomedullary nail. Two weeks postoperatively, one of the two static distal interlocking bolts began backing out and was removed. The nail ultimately migrated distally and perforated the knee joint at four months postoperatively. The patient was successfully treated with an exchange nail and percutaneous bone graft to the fracture site. A single static distal interlocking bolt may be inadequate to maintain length in a healing comminuted spiral femur shaft. Multiple distal interlocking bolts should be in place until the completion of fracture healing.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Perforation of the Knee Joint Following Antegrade Intramedullary Nailing of a Comminuted Femoral Diaphyseal Fracture: A Case Report

Flood¹,

Wie²,

Sullivan³

2022

Cureus

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“…The anatomic average radius of curvature in the femur is 120 cm, while that of modern intramedullary nails range from 150 to 300 cm. 7 , 9 Straighter implants are associated with higher rates of penetration of the anterior cortex. 8 Additionally, the medullary canal of the femur lies slightly anterior within the distal femur and the anterior femoral cortex undergoes significant thinning with age.…”

Section: Introductionmentioning

confidence: 99%

“…This technique is designed to protect the anterior femoral cortex and may prove useful in preventing anterior cortical perforation. 9 Postoperative complications include nonunion, malunion, infection, and hardware failure. Reported rates of non-union for antegrade femoral nails range from 0.3% to 7.6%.…”

Section: Introductionmentioning

confidence: 99%

Distal femoral complications following antegrade intramedullary nail placement

et al. 2015

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While antegrade nailing for proximal and diaphyseal femur fractures is a commonly utilized fixation method with benefits including early mobilization and high rates of fracture union, both intraoperative and postoperative complications may occur. Intraoperative errors include leg length discrepancy, anterior cortical perforation, malreduction of the fracture, and neurovascular injury, and postoperative complications include nonunion, malunion, infection, and hardware failure. This case series reviews complications affecting the distal femur after intramedullary nailing including fracture surrounding a distal femoral interlocking screw (Case #1), nonunion after dynamization with nail penetration into the knee joint (Case #2), and anterior cortical perforation (Case #3). Prevention of intraoperative and postoperative complications surrounding intramedullary nailing requires careful study of the femoral anatomy and nail design specifications (radius of curvature), consideration of the necessity of distal interlocking screws, the need for close radiographic follow-up after nail placement with X-rays of the entire length of the nail, and awareness of possible nail penetration into the knee joint after dynamization.

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“…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].…”

mentioning

confidence: 99%

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

Ching

Gee

Balso

et al. 2020

BioMed Research International

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This biomechanical study assessed the influence of changing antegrade cephalomedullary nail insertion point from anterior to neutral to posterior locations relative to the tip of the greater trochanter with or without anterior cortical perforation in the distal femur. Artificial osteoporotic femurs and cephalomedullary nails were used to create 5 test groups each with 8 specimens: intact femur without a nail or perforation, anterior nail insertion point without perforation, neutral nail insertion point without perforation, posterior nail insertion point without perforation, and posterior nail insertion point with perforation. Nondestructive biomechanical tests were done at 250 N in axial, coronal 3-point bending, sagittal 3-point bending, and torsional loading in order to measure overall stiffness and bone stress. The intact femur group vs. all femur/nail groups had lower stiffness in all loading modes ( p ≤ 0.018 ), as well as higher bone stress in the proximal femur ( p ≤ 0.027 ) but not in the distal femur above the perforation ( p = 0.096 ). Compared to each other, femur/nail groups only showed differences in sagittal 3-point bending stiffness for anterior and neutral vs. posterior nail insertion points without ( p ≤ 0.025 ) and with perforation ( p ≤ 0.047 ). Although it did not achieve statistical significance ( p ≥ 0.096 ), moving the nail insertion point from anterior to neutral to posterior to posterior with perforation did gradually increase bone stress by 45% (proximal femur) and 46% (distal femur). No femur or hardware failures occurred. Moving the nail insertion point and the presence of a perforation had little effect on stiffness, but the increased bone stress may be important as a predictor of fracture. Based on current bone stress results, surgeons should use anterior or neutral nail insertion points to reduce the risk of anterior cortical perforation.

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Prevention of Cortical Breach During Placement of an Antegrade Intramedullary Femoral Nail

Cited by 14 publications

References 11 publications

Perforation of the Knee Joint Following Antegrade Intramedullary Nailing of a Comminuted Femoral Diaphyseal Fracture: A Case Report

Perforation of the Knee Joint Following Antegrade Intramedullary Nailing of a Comminuted Femoral Diaphyseal Fracture: A Case Report

Distal femoral complications following antegrade intramedullary nail placement

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

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