Date: Tue, 26 Aug 2003 01:02:19 +0600
Subject: Femur Fx - Antegrade or Retrograde Interlocking nail?
Hello All,
A male 28 years old was referred to our unit with segmental femoral fracture fixed by the Ilizarov 6 weeks ago. Conversion to a locked nail is planned but i am still undefined about the nail should better be inserted through either the piriformis or the knee. He also weared below knee casts because of both feet injuries. Is there any rationale for the choice except tossing a coin?
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THX in advance.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 25 Aug 2003 20:35:31 +0100
From: Chris Wilson
Having used a lot of both,I definitely vote for antegrade nail. You don't needlessly breach a joint,there are more size choices,distal locking is easier( the "distal" screws in a long retrograde nail being in the A/P orientation) and exchange nailing and reaming are easier. In view of the segmental fragments a case could be made for unreamed antegrade nail,with a view to exchange nailing if there is delayed union.
Regards
Chris Wilson
Orthopaedic Surgeon
UniversityHospital
Cardiff, UK
Date: Tue, 26 Aug 2003 01:56:09 +0600
From: Alexander Chelnokov
Hello Chris,
CW> Having used a lot of both,I definitely vote for antegrade nail. You don't needlessly breach a joint,there are more size [...]
THX for your comments. The nail is to be the same anyway - a UFN-like solid one. It can be inserted both ways, can't it? i also don't like to touch an intact joint. But reduction here looks easier with retrograde insertion so i expected maybe the approach is now strongly advocated... :-)
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 25 Aug 2003 15:53:17 -0400
From: James Carr
I'll vote for antegrade as well. If you get a septic complication in a retrograde nail, the knee joint is a major problem.
Jim Carr
Date: Tue, 26 Aug 2003 02:25:49 +0600
From: Alexander Chelnokov
Hello Enes,
EKTE> You did not tell us what was the reason to have circular ExFx frame on at the first place: any problems with soft tissues, any fractures around hip
I suppose closed nailing was not available there, so they preferred ex-fix rather than open plating or plaster cast.
EKTE> In general, it is risky (intramedullary infection) to have IM nail after pins transfixing the bone longer than 1-2 weeks
Our series of ex-fix to nail conversion now consist of more than 30 cases, and about 15 were acute conversion of fixators 3-11 months old with calm pin sites - no infection to date (knock-knock).
EKTE> Retrograde mostly if: distal fractures, bilateral femur fractures, need for
Also ipsilateral femur+tibia. But AFAIR some colleagues in the list told
about more excessive use of retrograde nails...
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Tue, 26 Aug 2003 18:21:49 +0600
From: Alexander Chelnokov
Hello veeyemeye,
vsi> I would certainly prefer an antegrade interlocking nail for the obvious reason. The proximal fragment will need reaming and can be
OK, since voting was 5:0 for antegrade, the case has just been managed this way. Fixator appeared to be in malrotation about 40 degrees. Though some difficulties were met with gaining of proper length and pushing the nail between parts of the comminuted fragment, the result seems satisfactory.
THX!
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Wed, 27 Aug 2003 10:05:10 +0600
From: Alexander Chelnokov
Hello V,
VMI> I would like to know if 1) the proximal fragment was reamed,
Yes.
VMI> 2) which nail was used solid or cannulated and the size?
Solid UFN-like 11.5 mm 40 cm.
VMI> 3) were you not worried about the potential for infection while doing nailing straightaway on removal of the fixator
I already mentioned that we haven't ever met deep infection after acute conversion of fixators up to 11 months old to solid nails. Of course without visible signs of infection. In case of drainage of pus nailing would be postponed.
VMI> 4) why not post the postop Xray.
Attached.
THX again for all colleagues discussed the situation.
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Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 1 Sep 2003 23:56:08 EDT
From: Aobonedoc
I favor antegrade approach. Retrograde in obese patients or polytrauma as you can operate on other injuries in one prep without repositioning on fracture table. I find the biggest controversy to be the issue or immediate or delayed exchange given ex-fix thin wires. What are you or did you do in terms of timing wire removal and rod insertion?
Sincerely and respectively,
M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
1100 W. Central Road, Suite 304
Arlington Heights, Illinois 60005