WEST AFRICAN JOURNAL OF MEDICINE ORIGINAL ARTICLE
Comparison of Effect of Retrograde andAntegrade Approaches to Interlocking Nail Fixation of Femoral Diaphyseal Fractures on Ipsilateral Hip and Knee Joint Motion Comparaison des Effets des Voies Anterogrades et Retrogrades de Fixations des Clous Medullaires Verrouilles des Fractures Diaphysaires Femorales Sur la Mobilite de la Hanche et de l¶Articulation Ipsilaterale du Genou A. M. Toluse* , J. E. Asuquo , I. C. IkemÁ, O. EsanÁ, A. L. AkinyoolaÁ ABSTRACT PURPOSE: The objective of this study was toevaluate the early impact of antegrade and retrograde interlocking nail fixation of femoral diaphyseal fractures on the ipsilateral hip andknee joint range of motion. METHODS: A prospective evaluation was performed of 62 consecutive limbs with femoral diaphyseal fractures that had interlocking nail fixation through the antegrade or retrograde approaches.All participants hadpost-operative physiotherapy. Follow-up was for 9 months. RESULTS: The mean maximum hip flexion angle at 9 months was 137.50 in the antegrade group and 133.80 in the retrograde group (p = 0.150). Trendelenburg test was negative in both groups and there was no knee extension lag at 9 months. While the mean maximumknee flexion angle at 9 months was 119.90 in the retrograde group and 134.50 in the antegrade group (p = 0.023).All patients hadachieved radiologic and clinical fracture union by twenty four weeks post-operatively. CONCLUSION: There was nosignificant effect of antegrade or retrograde approach on the range of motion of the hip joint. However, knee motion improved more quickly in the groupthat had antegrade nailing. WAJM 2014; 33(1): 21±25
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Keywords: Interlocking nail, femoral diaphyseal fractures, joint motion.
Mots clps: Clou verrouillp, fractures diaphysaires fpmorales , mobilitp articulaire.
OBJECTIF: L¶objectif de cette ptude ptait d¶pvaluer l¶impact prpcoce des fixations antprogrades et rptrogrades des clous mpdullaires verrouillps des fractures diaphysaires fpmorales sur l¶amplitude de la mobilitp de la hanche et de l¶articulation ipsilatprale du genou . METHODES: Une pvaluation prospective a ptp rpalispe sur 62 conspcutifs membres inferieurs avec des fractures diaphysaires fpmorales qui ont eues une fixation de clous verrouillps par la voie antprograde ou rptrograde. Tous les participants ont eu un e physiothprapie postoppratoire . Le suivi a ptp de 9 mois . RESULTATS: L¶angle maximale moyenne de flexion de la hanche j 9 mois ptait de 137.50 dans le groupe antprograde et de 133.80 dans le groupe rptrograde (p = 0,150 ) . Le test de Trendelenburg ptait npgative dans les deux groupes et il y avait pas de recurvatum du genou j 9 mois .Alors l¶angle maximal moyen de flexion du genou j 9 mois ptait de 119.90 dans le groupe rptrograde il est de 134,50 dans le groupe antprograde (p = 0,023). Tous les patients avaient atteint une union radiologique et clinique de la fracture , vingt quatre semaines aprqs l¶oppration . CONCLUSION: Il n¶y avait pas d¶effet significatif de la voie antprograde ou rptrograde sur l¶amplitude de mobilitp de l¶articulation de la hanche . Cependant la mobilitp du genou a ptp ampliorpe plus rapidement dans le groupe qui avait eu l¶enclouage antprograde. WAJM 2014; 33(1): 21±25.
Departments of Orthopae dic Surgery and Trauma, Obafem i Awolowo Unive rsity Teaching Hospitals¶ Complex, Ile- Ife, Nigeria. Á Orthopaedic Surgery and Trauma, Obafemi Awolowo University, Ile- Ife, Nigeria. *Correspondence: Dr Toluse AM, Department of Orthopaedic Surgery and Trauma, Obafemi Awolowo University Teaching Hospitals¶ Complex, Ile-Ife, Nigeria. Telephone: +2348033970698 Email:
[email protected] Abbreviations: SIGN, Surgical Implant Generation Network; SPSS, Statistical Package for Social Sciences
West African Journal of Medicine Vol. 33, No. 1, January±March, 2014
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A. M. Toluse and Associates
INTRODUCTION Femoral sh aft fractures are observed across all age groups and are attributable to a variety of mechanisms. Locked intramedullary nail fixation has become a standard procedure for femoral diaphyseal fractures. Intramedullary nail can be inserted via an antegrade approach (proximal to distal) or retrograde (distal to proximal). Antegrade femoral intramedullary nailing has been shown to have a high union rate. Problems of Trendelenburg gait, difficult starting point, and postunion implant-related pain have been reported following antegrade nailing.1±5 Retrograde intramedullary nailing has been shown in several series to have a high union rate without a deleterious effect on the knee joint or range of motion.6±11 The long-term effects of an insertion site on the patello-femoral articulation , symptomatic distal hardware, risk of a septic knee, and need for dynamization are some of the problems associated with this technique.12±13 Controversy still exists about the better/optimal approach to intramedullary nailing of the femur i.e antegrade or retrograde. The purpose of this study was to evaluate the early effect of antegrade an d retrograde approaches to interlocking nail fixation of femoral diaphyseal fractures on ipsilateral hip and knee joint range of motion in 62 limbs, which were prospectively followed up for a minimum of 9 months. MATERIALS AND METHODS We prospectively evaluated the results of 62 limbs in 60 patients with femoral diaphyseal fractures who had interlocking nail fixation at the author¶s institution from February 2011 to January 2012. Patients were placed alternatelyinto a study group (retrograde nailing) and a control group (antegrade nailing) in a ratio of 2:1 i.e. two retrograde nailing for every antegrade nailing. There were 42 limbs studied in the retrograde group and 20 limbs in the antegrade group. The study protocol was approved by the institution¶s Ethics and Research Committee and all patients gave informed consent for participation in the study. Inclusion criteria were adult 22
Ipsilateral Hip and Knee Joint Motion
patients, who presented with closed femoral shaft fracture; open femoral shaft fracture (Gustilo-Anderson I-IIIA); femoral shaft fracture malunion; femoral shaft fracture non-union. Exclusion criteria were patients with small medullary cavity which was not adequate for the least sized nail available i.e. 8mm nail; open femoral shaft fractures (GustiloAnderson IIIB,IIIC); infected femoral shaft fracture; pre-morbid hip/knee pathology such as osteoarth ritis, ankylosis, infection. Surgical Technique Surgical Implant Generation Network (SIGN) interlocking nail was used for fixation of all fractures in this study. Open reduction was done in all cases and stabilization achieved with the intramedullary nail via an antegrade or retrograde approach. Two locking screws were inserted distally and two locking screws proximally to lock the nail. Retrograde approach involved making a midline infra-patellar incision. The patella tendon was split longitudinallyin the direction of its fibres and the infra-patella fat pad swept aside to expose the femoral intercondylar notch. The nail insertion point was in the intercondylar notch, just anterior to the posterior cruciate ligament attachment and in line with the axis of the femoral shaft. Manual reaming of the marrow was done in all cases. The nail and interlocking screws insertion were done with the aid of an external jig and slot finders. Antegrade approach involved making a longitudinal incision over the greater trochanter. The nail insertion point was the apex of the greater trochanter. Manual reaming and locking of the nail with distal and proximal locking screws was similarly done. This
was achieved without intra-operative radiograph control. All patients had post-operative physiotherapy and were evaluated 4 weekly in the outpatient department for joint range of motion. Evaluation of joint range of motion was carried out by all the research ers with the aid of goniometer. Clinical and radiologic evidence of fracture union were also documented at this interval. Statistical Analysis Collected data was analysed using Statistical Package for Social Sciences (SPSS) version 16. Analysis included frequency distribution, cross tabulation and measures of central tendency such as means with its standard deviation. Differen ces between con tinuous variables were tested with student¶s ttest. Statistical significance was inferred at p
