Retrograde nailing of femoral fractures.

PURPOSE OF THE STUDY: Retrograde nailing represents an established fixation method for fractures of the distal femur and offers in femoral shaft fractures an alternative to the existing technique of antegrade nailing. The aim of this study was to investigate in a retrospective analysis the results of retrograde nailing in distal femoral fractures and selected cases of femoral shaft fractures. Emphasis was posed on long- term functional outcome, especially in daily activities.

MATERIAL: Retrograde femoral nailing was used from 1999 until 2006 in two Level 1 trauma centers for the treatment of distal femoral (AO/ASIF-type 33) and femoral shaft fractures (AO/ASIF - type 32) in 40 patients with 41 fractures. The mean age of patients was 63,7 years (min: 21 / max.: 103) and 70, 7% presented with ipsilateral local pathologies or associated entities. A pre-existing reduced activity level was found in 12 /40 patients (30%) and was equally caused by neurologic conditions and geriatric entities.

METHODS: Indication for retrograde nailing was left in AO/ASIF fracture-type 33 to the individual estimation of the surgeon, while it was restricted in AO /ASIF fracture- type 32 to problematic cases. For fracture fixation the Distal Femoral Nail (28/41 68,3%) of Synthes Int.(R) and a spupracondylar /; retrograde modified sc - UFN (13 /41 31,7%) produced by Synthes(R) Austria were used. Patients were followed till fracture healing and invited to a functional follow-up using the Lysholm / Gilquist score and the Tegner /Lysholm score.

RESULTS: Osseous healing occured in shaft fractures in 18,1 weeks on an average compared to 16,5 weeks in supracondylar fractures. Postoperative complications requiring re-intervention were seen in 6/41 (14,6%) fractures. 28/40 patients (70%) were evaluated with a mean follow-up period of 20,4 months using the functional score of Lysholm /Gilquist and the activity score of Tegner/ Lysholm. Both scores were balanced among shaft fractures and distal femoral fractures (Lysholm - mean: 87,7 pts shaft. vs. 80,1 pts. distal Tegner-mean: 5,2 pts. shaft vs. 3,9 pts. distal), while motion showed better results in shaft fractures (arc of motion - mean: 120 degrees ) than in distal femoral fractures (arc of motion - mean: 105).

DISCUSSION: Despite a high age of patients (average 63,7 years) and a reduced activity level with many local co-morbitities, retrograde nailing resulted in the majority (95,1%) in reliable osseous healing. Thus, achievement of a painless fracture-site and a stable knee-joint provides early mobilization even in problematic cases. Impairment of functional outcome, mirrored in an over-all Lysholm /Gilquist score of 83,3 pts. and an over-all Tegner /Lysholm score of 4,4 pts. , was mainly related to preexisting restrictions of the loco-motor system.

CONCLUSION: Retrograde nailing represents a reliable fixation method for extra-articular (33 - A1-3) and simple intra-articular (33 - C1-2) fractures of the supracondylar area. In femoral shaft fractures retrograde inserted nails offer a valuable alternative, especially when the proximal femoral approach is obstructed.