OTA 2002 - Session 2 Session II - Post-Traumatic Reconstruction Fri., 10/11/02 Post Traumatic Reconstruction, Paper #10, 3:06 PM *Arthroscopically Assisted Removal of Retrograde Femoral Nails: Description of Technique and Intraarticular Findings at Long-Term Follow-Up Christopher T. Born, MD, FACS (a-Smith + Nephew, Synthes, USA, Howmedica; b-Zimmer; e-Stryker Howmedica Osteonics); Paul J. King, MD; Lisa Khoury, MD; William G. DeLong, Jr., MD, FACS (a-Smith + Nephew, Synthes, USA, Howmedica); University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA (-AO North America Grant) Purpose: Numerous studies have supported the use of retrograde nailing for the management of femur fractures. Many of the patients who had a femur fracture treated with retrograde nailing develop some degree of postoperative knee pain. Concern has been expressed regarding the potential for injury of the patellofemoral articulation as well as for the development of intraarticular metallosis. To date, there is little information about the long-term postoperative intraarticular milieu after retrograde nailing, especially in the patient with a painful knee. The purpose of this paper is to report the intraoperative findings, indications for, and the clinical results of knee arthroscopy at the time of retrograde femoral nail removal. We also describe the principles of the arthroscopically assisted technique that we have developed. Methods: Over a 9-year period, 16 patients underwent arthroscopically assisted removal of retrograde femoral nails. These included 11 because the nail was considered a possible source of knee pain, 3 for chronic infection, and 1 each as a preoperative measure before additional surgery and for peace of mind. The mean time to removal was 20.5 months after insertion. The outpatient technique utilizes two standard arthroscopic portals in addition to a limited infrapatellar tendon-splitting incision. Location of the buried distal nail end is by orthogonal intraoperative fluoroscopy. Operative findings were reviewed retrospectively for the first 6 years and prospectively for the last 3 years. Results: Fifteen of sixteen nails (94%) were successfully removed with use of this technique. One patient required a formal arthrotomy after the arthroscopy in order to remove intraarticular lag screws. In all cases (100%), the distal end of the nail and the entry portal were covered by fibrous reparative tissue. No patient was found to have any changes at the patellofemoral articulation that could be attributed directly to the nail. There was no evidence of intraarticular metallosis in any case. Fourteen of 16 patients (88%) were found to have some identifiable intraarticular pathologic condition that was treated at the time of arthroscopy, and some patients had more than one lesion. They included eight patients with osteochondral injuries, seven with significant adhesions, and two with loose bodies. The injuries were appropriately managed at the time of arthroscopy. Three patients had infections that were cultured and debrided. Five meniscal tears were found (four were debrided and one was repaired), and two ACL tears were diagnosed and debrided. There was one complication (6%) in the form of a postoperative hemarthrosis that resolved uneventfully with aspiration. In the two patients with non-painful knees who were having the nails removed either for "peace of mind" or as a precursor to a second procedure, no significant pathologic condition was found at arthroscopy. Discussion and Conclusions: This technique allows for the evaluation and treatment of potentially painful intraarticular pathologic conditions after femur fracture and subsequent retrograde nailing. In our series, 88% of patients were found to have some identifiable pathologic condition most likely related to the index injury and not to the nail or its insertion. Despite early concerns to the contrary, the clinical impression of most orthopaedic traumatologists that the patellofemoral joint is spared after proper recessing of the nail appears to be borne out by this study. The presence of intraarticular metallosis has not been substantiated. This technique is safe, avoids the morbidity associated with open arthrotomy, allows for nail removal on an outpatient basis, and promotes accelerated rehabilitation.

European Journal of Trauma 2001

Distal femoral fractures: A review of fixation methods M.C. Forster, , B. Komarsamy and J.N. Davison Leicester Royal Infirmary, Leicester, UK Accepted 15 February 2005. The treatment of distal femoral fractures has evolved; nevertheless, these fractures remain difficult to treat and carry an unpredictable prognosis. Over the years, many different strategies have been used with varying success. This review outlines the problems presented by distal femoral fractures and the results of current surgical techniques.

Journal of Trauma-Injury Infection & Critical Care. 38(4):648-652, April 1995. Mohr, Volker D. Maj. GFAF MC; Eickhoff, Ulrich Maj. GFAF MC; Haaker, Rolf Maj. GFAF MC; Klammer, Hans-Ludwig Col. GFAF MC Abstract: Objective: To determine whether external fixation proves to be a sensible technique for definitive stabilization in open femoral fractures. Design: Retrospective clinical study. Materials and Methods: From 1985 to 1989, 18 patients (mean ISS 25.4) with open femoral fractures (type II 11%, type III 89%) were treated by primary and definitive external fixation. After failure of closed reduction procedures, open reduction via debrided soft tissue wounds was employed in 72%. Supplemental internal fixation of large wedge fragments was required in 66%. External fixators were removed after a mean of 166 days. Early deep infections developed in 11%. Additional cast, brace, or traction were not required. Measurements and Main Results: After a mean follow-up period of 58 months, 88% of the surviving 17 patients were clinically and radiologically evaluated and 12% were interviewed by telephone. Eleven percent developed late deep infection of the femur concerned. Eighty percent have had full or slightly restricted knee motion. The mean knee flexion amounted to 130 degrees. Relevant shortening of the femur was diagnosed in 7%. Nonunions or relevant malunions were not observed in our series. Conclusions: These morphologic and functional results compare with those published for alternative stabilization techniques of femoral fractures. For special indications, external fixation is considered to be a sensible technique for primary and definitive treatment of open femoral fractures.

OTA 2002 - Session 3 Session III - Polytrauma Fri., 10/11/02 Polytrauma, Paper #16, 4:03 PM Management of Femoral Shaft Fractures in Polytrauma: From Early Total Care to Damage Control Orthopaedic Surgery Hans-Christoph Pape, MD; Boris Zelle, MD; Frank Hildebrand, MD; Christian Krettek, MD, FRACS; Hannover Medical School; Hannover, Germany

OTA 2002 - Session 8 Session VIII - Femur/Knee Sun., 10/13/02 Femur/Knee, Paper #56, 8:31 AM *Plating of Femoral Shaft Fractures: Traditional ORIF versus Submuscular Fixation Dennis Vogt, MD; Michael Zlowodzki, MD; Peter A. Cole, MD; Philip J. Kregor, MD; Vanderbilt University Medical Center, Nashville, Tennessee, USA; and the University of Mississippi Medical Center, Jackson, Mississippi, USA (a-Synthes, AO Research Foundation)

Journal of Trauma-Injury Infection & Critical Care. 54(5):930-935, May 2003. Harris, Timothy MD; Ruth, John T. MD; Szivek, John PhD; Haywood, Brett MD Conclusion : Strain patterns are altered by the degree of implant overlap in the proximal femoral diaphysis. Femora with uninstrumented intervals between retrograde nails and side plates fail at lower loads than femora without retrograde nails and those with kissing or overlapping implants. Kissing or overlapping instrumentation increases load to failure and creates a more biomechanically stable construct than gapped implants. The findings of this study suggest an overlapping implant orientation in the femur increases failure load at the implant interface.

Journal of Orthopaedic Trauma. 16(6):394-402, July 2002. Pihlajamaki, Harri K.; Salminen, Sari T.; Bostman, Ole M. Conclusions: Exchange nailing without extracortical bone grafting seems to be the most effective method to treat a disturbed union of a femoral shaft fracture after intramedullary nailing. Autogenous extracortical bone grafting alone proved to be insufficient. Dynamization predisposed to shortening of the bone.