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The effect of antegrade femoral nailing on femoral head perfusion: a comparison of piriformis fossa and trochanteric entry points

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

Piriformis fossa entry antegrade femoral nailing is a common method for stabilizing diaphyseal femur fractures. However, clinically significant complications such as chronic hip pain, hip abductor weakness, heterotopic ossification and femoral head osteonecrosis have been reported. A recent cadaveric study found that piriformis entry nailing damaged either the deep branch of the medial femoral circumflex artery (MFCA) or its distal superior retinacular artery branches in 100 % of specimens and therefore recommended against its use. However, no study has quantitatively assessed the effect of different femoral entry points on femoral head perfusion.

Materials and methods

Twelve fresh-frozen cadaveric lower extremity specimens were randomly allocated to either piriformis fossa or trochanteric entry nailing using a 13-mm reamer. The contralateral hip served as an internal matched control. All specimens subsequently underwent gadolinium-enhanced fat-suppressed gradient-echo sequence MRI to assess femoral head perfusion. Gross dissection was also performed to assess MFCA integrity and distance to the opening reamer path.

Results

MRI quantification analysis revealed near full femoral head perfusion with no significant difference between the piriformis and trochanteric starting points (95 vs. 97 %, p = 0.94). There was no observed damage to the deep MFCA in either group. The mean distance from the reamer path to the deep MFCA was 3.2 mm in the piriformis group compared to 18.5 mm in the trochanteric group (p = 0.001). Additionally, there was a significantly greater number of mean terminal superior retinacular vessels damaged by the opening reamer in the piriformis cohort (1 vs. 0; p = 0.007).

Conclusions

No statistically significant difference in femoral head perfusion was found between the two groups. Therefore, we cannot recommend against the use of piriformis entry femoral nails. However, we caution against multiple errant starting point attempts and recommend meticulous soft tissue protection during the procedure.

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Acknowledgments

We would like to thank Joseph T. Nguyen, MPH, for his help with the statistical analysis. This research was supported by a grant from DePuy Synthes, Inc. (West Chester, PA, USA).

Conflict of interest

The authors declare no conflicts of interest related to the present study and do not have a financial relationship with DePuy Synthes. The authors were in full control of all primary data and agree to allow the journal to review their data if requested.

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Authors and Affiliations

  1. Orthopaedic Trauma Service, Memorial Hermann Hospital, University of Texas Health Science Center at Houston, 6400 Fannin St, Suite 1700, Houston, TX, 77030, USA

    Patrick C. Schottel

  2. Weill Cornell Medical College, 525 East 68th St, New York, NY, 10065, USA

    Jonathan P. Dyke

  3. Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, 535 East 70th St, New York, NY, 10021, USA

    Lionel E. Lazaro, Craig Klinger & David L. Helfet

  4. Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th St, New York, NY, 10065, USA

    Richard M. Hinds, Amelia Ni & Dean G. Lorich

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  1. Patrick C. Schottel
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Correspondence to Patrick C. Schottel.

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Schottel, P.C., Hinds, R.M., Lazaro, L.E. et al. The effect of antegrade femoral nailing on femoral head perfusion: a comparison of piriformis fossa and trochanteric entry points. Arch Orthop Trauma Surg 135, 473–480 (2015). https://doi.org/10.1007/s00402-015-2169-y

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  • DOI: https://doi.org/10.1007/s00402-015-2169-y

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