Abstract
Purpose
In a level 1 university trauma center, an explorative randomized controlled study was performed to compare soft tissue damage and functional outcome after antegrade femoral nailing through a trochanteric fossa (also known as piriform fossa) entry point to a greater trochanter entry point in patients with a femoral shaft fracture.
Materials and methods
Nineteen patients were enrolled and randomly assigned to two nail insertion groups; ten patients were treated with an Unreamed Femoral Nail® (UFN, Synthes®, Solothurn, Switzerland) inserted at the trochanteric fossa and nine patients were treated with an Antegrade Femoral Nail® (AFN, Synthes®, Solothurn, Switzerland) inserted at the tip of the greater trochanter. The main outcome measures were pain, gait, nerve and muscle function, along with endurance. Magnetic resonance imaging (MRI), electromyography (EMG), and Cybex isokinetic testings were performed at, respectively, 2 and 6 weeks and at a minimum of 12 months after surgery.
Results
The MRI and EMG showed, in both groups, signs of iatrogenic abductor musculature lesions (four in the UFN group and four in the AFN group) and superior gluteal nerve injury (five in the UFN group and four in the AFN group). The isokinetic measurements and the patient-reported outcomes showed moderate reduction in abduction strength and endurance, as well as functional impairment with slight to moderate interference with daily life in both groups, with no appreciable differences between the groups.
Conclusions
Anatomical localization of the entry point seems to be important for per-operative soft tissue damage and subsequent functional impairment. However, the results of this study did not show appreciable differences between femoral nailing through the greater trochanter tip and nailing through the trochanteric fossa.
Similar content being viewed by others
References
Sage FP. The second decade of experience with the Küntscher medullary nail in the femur. Clin Orthop Relat Res. 1968;60:77–85.
Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am. 1984;66:529–39.
Brumback RJ, Reilly JP, Poka A, Lakatos RP, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part I: Decision-making errors with interlocking fixation. J Bone Joint Surg Am. 1988;70:1441–52.
Gibbons CL, Gregg-Smith SJ, Carrell TW, Murray DW, Simpson AH. Use of the Russell–Taylor reconstruction nail in femoral shaft fractures. Injury. 1995;26(6):389–92.
Stockenhuber N, Schweighofer F, Bratschitsch G, Szyszkowitz R. UFN system. Eine Methode der minimalinvasiven chirurgischen Versorgung von Oberschenkelschaftfrakturen [UFN system. A method of minimal invasive surgical management of femoral shaft fractures]. Langenbecks Arch Chir. 1996;381:267–74.
Starr AJ, Hay MT, Reinert CM, Borer DS, Christensen KC. 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. 2006;20(4):240–6.
Tucker MC, Schwappach JR, Leighton RK, Coupe K, Ricci WM. Results of femoral intramedullary nailing in patients who are obese versus those who are not obese: a prospective multicenter comparison study. J Orthop Trauma. 2007;21(8):523–9.
Astion DJ, Wilber JH, Scoles PV. Avascular necrosis of the capital femoral epiphysis after intramedullary nailing for a fracture of the femoral shaft. A case report. J Bone Joint Surg Am. 1995;77;1092–4.
Ansari Moein CM, Verhofstad MHJ, Bleys RLAW, van der Werken Chr. Soft tissue anatomy around the hip and its implications for choice of entry point in antegrade femoral nailing. Clin Anat. 2008;21:568–74.
Ansari Moein CM, Verhofstad MHJ, Bleys RLAW, van der Werken Chr. Soft tissue injury related to choice of entry point in antegrade femoral nailing: piriform fossa or greater trochanter tip. Injury. 2005;36(11):1337–42.
Kenny P, O’Brien CP, Synnott K, Walsh MG. Damage to the superior gluteal nerve after two different approaches to the hip. J Bone Joint Surg Br. 1999;81:979–81.
Simonian PT, Chapman JR, Selznick HS, Benirschke SK, Claudi BF, Swiontkowski MF. Iatrogenic fractures of the femoral neck during closed nailing of the femoral shaft. J Bone Joint Surg Br. 1994;76:293–6.
Danckwardt-Lillieström G, Sjögren S. Postoperative restoration of muscle strength after intramedullary nailing of fractures of the femoral shaft. Acta Orthop Scand. 1976;471:101–7.
Bednar DA, Ali P. Intramedullary nailing of femoral shaft fractures: reoperation and return to work. Can J Surg. 1993;36(5):464–6.
Benirschke SK, Melder I, Henley MB, Routt ML, Smith DG, Chapman JR, Swiontkowski MF. Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review. J Orthop Trauma. 1993;7(2):118–22.
Archdeacon M, Ford KR, Wyrick J, Paterno MV, Hampton S, Ludwig MB, Hewett TE. A prospective functional outcome and motion analysis evaluation of the hip abductors after femur fracture and antegrade nailing. J Orthop Trauma. 2008;22(1):3–9.
Ansari Moein CM, ten Duis HJ, Oey PL, de Kort GAP, van der Meulen W, van der Werken Chr. Functional outcome after antegrade femoral nailing: a comparison of piriform fossa versus trochanteric entry point. J Orthop Trauma. (in press).
Simmermacher RK, Bosch AM, van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures. Injury. 1999;30(5):327–32.
van Doorn R, Stapert JW. The long gamma nail in the treatment of 329 subtrochanteric fractures with major extension into the femoral shaft. Eur J Surg. 2000;166(3):240–6.
Ricci WM, Schwappach J, Tucker M, Coupe K, Brandt A, Sanders R, Leighton R. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 2006;20(10):663–7.
Pfirrmann CWA, Chung CB, Theumann NH, Trudell DJ, Resnick D. Greater trochanter of the hip: attachment of the abductor mechanism and a complex of three bursae—MR imaging and MR bursography in cadavers and MR imaging in asymptomatic volunteers. Radiology. 2001;221:469–77.
Konishiike T, Makihata E, Tago H, Sato T, Inoue H. Acute fracture of the neck of the femur. An assessment of perfusion of the head by dynamic MRI. J Bone Joint Surg Br. 1999;81:596–9.
Hirata T, Konishiike T, Kawai A, Sato T, Inoue H. Dynamic magnetic resonance imaging of femoral head perfusion in femoral neck fracture. Clin Orthop Relat Res. 2001;393:294–301.
Oh SJ, editor. Clinical Electromyography. Nerve conduction studies. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 409–19.
Dodenhoff RM, Dainton JN, Hutchins PM. Proximal thigh pain after femoral nailing. Causes and treatment. J Bone Joint Surg Br. 1997;79:738–41.
Hardcastle Ph, Nade S. The significance of the Trendelenburg test. J Bone Joint Surg Br. 1985;67:741–6.
Markhede G, Grimby G. Measurement of strength of hip joint muscles. Scand J Rehabil Med. 1980;12:169–74.
Burnett CN, Betts EF, King WM. Reliability of isokinetic measurements of hip muscle torque in young boys. Phys Ther. 1990;70(4):244–9.
Emery CA, Maitland ME, Meeuwisse WH. Test–retest reliability of isokinetic hip adductor and flexor muscle strength. Clin J Sports Med. 1999;9:79–85.
Helmy N, Jando VT, Lu T, Chan H, O’Brien PJ. Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures. J Orthop Trauma. 2008;22(1):10–5.
Kapp W, Lindsey RW, Noble PC, Rudersdorf T, Henry P. Long-term residual musculoskeletal deficits after femoral shaft fractures treated with intramedullary nailing. J Trauma. 2000;49(3):446–9.
Dora C, Leunig M, Beck M, Rothenfluh D, Ganz R. Entry point soft tissue damage in antegrade femoral nailing: a cadaver study. J Orthop Trauma. 2001;15(7):488–93.
Orler R, Hersche O, Helfet DL, Mayo KA, Ward T, Ganz R. Die avaskuläre Hüftkopfnekrose als schwerwiegende Komplikation nach Femurmarknagelung bei Kindern und Jugendlichen [Avascular necrosis of the femoral head as a serious complication following femoral nailing in children and adolescents]. Unfallchirurg. 1998;101:495–9.
Bain GI, Zacest AC, Paterson DC, Middleton J, Pohl AP. Abduction strength following intramedullary nailing of the femur. J Orthop Trauma. 1997;11(2):93–7.
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ansari Moein, C.M., ten Duis, H.J., Oey, P.L. et al. 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, 615–622 (2011). https://doi.org/10.1007/s00068-011-0086-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00068-011-0086-5