Abstract
Introduction
Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs.
Materials and methods
A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion.
Results
Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26 min (95% CI – 28.60 to – 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33 s, 95% CI – 84.441 to – 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found.
Conclusion
The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics.
Similar content being viewed by others
Data availability
The authors confirm that the data supporting the findings of this study are available within the article.
References
Buruian A, Silva Gomes F, Roseiro T, Vale C, Carvalho A, Seiça E et al (2020) Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm. EFORT Open Rev 5(7):421–429
Lucas PD, Seral B, Beano Á, Almodóvar JA, Domínguez I, Rodríguez J, Moro E (2005) Fractures of the proximal femur. The gamma Nail versus plate. Osteosynth Trauma Care 13(1):18–25
Parker MJ, Handoll HH (2010) Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database System Rev
Hussain N, Hussain FN, Sermer C, Kamdar H, Schemitsch EH, Sternheim A, Kuzyk P (2017) Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and meta-analysis. Can J Surg 60(1):19–29
Sheth U, Gohal C, Chahal J, Nauth A, Dwyer T (2016) Comparing entry points for antegrade nailing of femoral shaft fractures. Orthopedics 39(1):e43–e50
Kumar P, Neradi D, Kansal R, Aggarwal S, Kumar V, Dhillon MS (2019) Greater trochanteric versus piriformis fossa entry nails for femur shaft fractures: resolving the controversy. Injury 50(10):1715–1724
Haidukewych GJ (2009) Intertrochanteric fractures: ten tips to improve results. JBJS 91(3):712–719
Gausepohl T, Pennig D, Koebke J, Harnoss S (2002) Antegrade femoral nailing: an anatomical determination of the correct entry point. Injury 33(8):701–705
Charopoulos I, Giannoudis PV (2009) Ideal entry point in antegrade femoral nailing: controversies and innovations. Injury 40(8):791–794
Starr AJ, Hay MT, Reinert CM, Borer DS, Christensen KC (2006) Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal. J Orthop Trauma 20(4):240–246
Ostrum RF, Marcantonio A, Marburger R (2005) A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma 19(10):681–686
Thomas J, McDonald S, Noel-Storr A, Shemilt I, Elliott J, Mavergames C, Marshall IJ (2021) Machine learning reduced workload with minimal risk of missing studies: development and evaluation of a randomized controlled trial classifier for Cochrane reviews. J Clin Epidemiol 133:140–151
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898
Higgins JP, Green S (2008) Cochrane handbook for systematic reviews of interventions
Triola MF (2010) Elementary Statistics. Pearson Education, Boston
Ansari Moein C, Duis H, Oey P, Kort G, Meulen W, Werken C (2011) Intramedullary femoral nailing through the trochanteric fossa versus greater trochanter tip: a randomized controlled study with in-depth functional outcome results. Eur J Trauma Emerg Surg 37(6):615–622
Kumar A, Mittal P (2017) Comparative study of outcome of femur nail with entry from piriformisfossa vs greater trochanter. Global J Res Anal 6(11):54–56
Meena KP, Yadav MK, Devatheya D (2016) A prospective randomized comparative study between trochanteric versus piriformis entry portal for intramedullary interlock nailing in the treatment of femoral shaft fracture. Int J Res Orthop 2(1):18–24
Stannard JP, Bankston L, Futch LA, McGwin G, Volgas DA (2011) Functional outcome following intramedullary nailing of the femur: a prospective randomized comparison of piriformis fossa and greater trochanteric entry portals. J Bone Joint Surg Am 93(15):1385–1391
Bharti S, Goyal N, Chavan R (2019) Trochanteric entry VS piriformis entry in case of antegrade nailing of femoral shaft fracture treatment: a prospective randomised comparative study. Int J Orthop 5(4):1016–1022
Dalton JE, Bolen SD, Mascha EJ (2016) Publication bias: the elephant in the review. Anesth Analg 123(4):812–813
Ricci WM, Schwappach J, Tucker M, Coupe K, Brandt A, Sanders R, Leighton R (2008) Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 22:S9–S13
Chou LB, Johnson B, Shapiro LM, Pun S, Cannada LK, Chen AF et al (2022) Increased prevalence of breast and all-cause cancer in female orthopaedic surgeons. J Am Acad Orthop Surg Glob Res Rev. https://doi.org/10.5435/JAAOSGlobal-D-22-00031
Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B (2005) Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med (Lond) 55(6):498–500
Smith T, Evans J, Moriel K, Tihista M, Bacak C, Dunn J et al (2022) Cost of OR time is $46.04 per minute. J Orthop Bus 2:10–13
Orland MD, Lee RY, Naami EE, Patetta MJ, Hussain AK, Gonzalez MH (2020) Surgical duration implicated in major postoperative complications in total hip and total knee arthroplasty: a retrospective cohort study. J Am Acad Orthop Surg Glob Res Rev. 4(11):e20.00043
Wei C, Gu A, Almeida ND, Bestourous D, Quan T, Fassihi SC et al (2021) Operation time effect on rates of perioperative complications after operative treatment of distal radius fractures. J Orthop 24:82–85
Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P (2018) Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res 229:134–144
Mayo-Wilson E, Li T, Fusco N, Dickersin K (2018) Practical guidance for using multiple data sources in systematic reviews and meta-analyses (with examples from the MUDS study). Res Synth Methods 9(1):2–12
Slomski A (2020) Despite law, most clinical trial results still not posted. JAMA. 323(12):1124
DeVito NJ, Bacon S, Goldacre B (2020) Compliance with legal requirement to report clinical trial results on ClinicalTrials.gov: a cohort study. The Lancet 395(10221):361–369
Funding
No Funding or support was received for any aspect of this work.
Author information
Authors and Affiliations
Contributions
Conceptualization, DA.; Methodology, DA, DC, GMH; Investigation, DA, AS, TC,IF, MR; Writing – Original Draft, DA, AS, TC, IF, MR.; Writing – Review & Editing, DA, DC, GMH; Resources, DA; Supervision, DA, AS, DC and GMH.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no relevant financial or non-financial interests to disclose.
Ethical approval statement
This was an IRB-exempt study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Acevedo, D., Suarez, A., Checkley, T. et al. Nailing precision: a systematic review and meta-analysis of randomized controlled trials comparing piriformis and trochanteric entry points for femoral antegrade nailing. Arch Orthop Trauma Surg (2024). https://doi.org/10.1007/s00402-024-05359-6
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s00402-024-05359-6