Injuries to the femur occur in a bimodal distribution, with high-energy injuries affecting young males more commonly and lower-energy injuries affecting older females.1 Treatment for fractures of the femur has changed greatly, with ante-grade and retrograde nailing of the femur becoming the standard treatment due to small incisions, reliable fracture healing, and rapid patient recovery.2 Both antegrade and retrograde femoral nailing have yielded high union rates.1,3–8 Potential negatives of antegrade femoral nailing include hip abductor injury leading to Trendelenburg gait, potentially difficult starting point, heterotopic ossification, superior gluteal nerve injury, and postimplant-related pain.3,8–14 Retrograde nailing has been shown to have a similarly high union rate without deleterious effects on the knee joint or range of motion.5,15,16 Potential problems with retrograde nailing include anterior knee pain, symptomatic distal hardware, risk of septic knee, and need for second surgery for delayed union or nonunion.1,6,15,17–19
Although short- and mid-term follow-up and functional outcomes after femoral nailing are available, little evidence exists on long-term follow-up of these patients. Before initial review of their patient database, the authors hypothesized that these two patient groups would have no significant differences.
Materials and Methods
After institutional review board approval was obtained and all patients involved gave informed consent to participate, prospectively collected trauma registry data were retrospectively reviewed. A total of 547 patients were identified who underwent intramedullary nailing of an isolated femoral shaft fracture at the authors' urban level I trauma facility performed by 1 of 8 orthopedic trauma fellowship-trained orthopedic surgeons from July 1, 1997, to December 31, 2012. Patients with less than 12 months of postoperative follow-up, younger than 18 years, pregnant at the time of injury, unable to be contacted at the time of the study, having any ipsilateral extremity bony or ligamentous injury requiring surgery, and not having an AO/OTA type 32 fracture pattern were excluded.
All patients in this series were treated with either reamed antegrade or reamed retrograde intramedullary nails at the discretion of the operating surgeon. Antegrade intramedullary nails were inserted through a piriformis or greater trochanteric starting point, with the patient placed supine on a fracture table or radiolucent table; retrograde intramedullary nails were inserted through in a standard manner with patients in the supine position.4 Synthes (West Chester, Pennsylvania), Biomet (Warsaw, Indiana), or Smith & Nephew (London, United Kingdom) femoral nails were used in all instances, and all nails were locked proximally and distally using at least 1 interlocking screw on each side of the fracture (Figure 1). Patients were followed at regular intervals in the office for at least 1 year postoperatively and were contacted at the time of the study for long-term outcome assessment.
A well-healed femur fracture treated with an antegrade nail (A, B). A well-healed femoral shaft fracture treated with a retrograde nail (C, D).
Of the 547 patients initially reviewed with isolated femoral nails, 114 patients met full inclusion criteria and were able to be contacted at the time of the study; 43 antegrade and 71 retrograde femoral nails were included (Figure 2). Data were collected from hospital records, outpatient charts, and radiographs, with the data points tabulated in Excel (Microsoft, Redmond, Washington). Radiographic union was defined as bridging callus across at least 3 cortices on biplanar radiographs; clinical union was diagnosed when there was no pain with ambulation or a single leg stance and the fracture site was nontender to palpation. Patient-based functional outcome assessment was obtained with two outcome questionnaires. The visual analog scale (VAS) for pain was used to determine pain in the lower limb ranging from 0 (no pain) to 10 (most severe pain).20,21 The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a disease-specific, self-administered health measure developed to study patients with arthritis of the hip or knee. The domains of WOMAC include pain, stiffness, and physical function. Standardized total scores were calculated and reported ranging from 0 (best score) to 100 (worst score).22–25
Enrollment flow diagram.
After data collection, statistics were analyzed with means, ranges, and confidence intervals calculated for continuous variables and compared using Student's t tests. Frequencies were calculated for continuous variables and compared using Fisher's exact test for increased accuracy in small proportion analysis. P<.05 was set as significant, with a trend being defined as P between .05 and .10.
Demographics for both groups of patients are presented in Table 1. No significant differences were noted in any of the demographic or injury data, with the exception of a trend of increased incidence of isolated femoral injury in the antegrade group (72.1% vs 53.5% in the retrograde group; P=.08).
Demographic and Injury Data
The reported surgical and functional outcomes at long-term follow-up are presented in Table 1. No differences were discovered between union rates in antegrade or retrograde nailing (93.0% vs 90.1%, respectively; P=.74); all 3 nonunions in the antegrade group and all 7 nonunions in the retrograde groups went onto successful union after a range of 1 to 4 secondary procedures. Secondary nonunion procedures included either exchange nailing or plating around a nail with open bone graft augmentation. No significant differences were found between overall rate of secondary procedures in this patient population.
The overall comparison of VAS and WOMAC scores for the two groups is presented in Table 2. There was no significant difference in VAS and WOMAC between the two treatment groups. Regarding pain, 44.2% of the antegrade group had moderate pain (VAS score, 4–7) at final evaluation, whereas 28.2% of the retrograde group had moderate pain (P=.10). No differences were seen in the incidence of severe pain (VAS score, 8–10) between groups (antegrade, 7.0%; retrograde, 7.0%). On further analysis, the authors identified that secondary procedures had no significant effect on VAS or WOMAC scores; they also were unable to detect any effect of length of follow-up on VAS or WOMAC scores. Location of pain differed between groups as well, with the antegrade group noting an increased rate of hip pain (25.6% vs 7.0%; P=.01), but a nonsignificant difference in the rate of thigh pain (27.9% vs 15.5%; P=.15) and knee pain (18.6% vs 26.7%; P=.49) as compared with the retrograde group.
Surgical and Follow-up Results
Intramedullary nailing is the gold standard for treatment of adult femoral shaft fractures, with antegrade or retrograde nailing techniques established as two attractive options available to surgeons. Intramedullary nailing of femur fractures has been shown to result in high union rates, low malunion rates, low complication rates, and low associated hip and knee pain.7,8,15,17–19 Although there is significant evidence readily available regarding indications, surgical techniques, and short-term functional outcomes, there is a paucity of literature available detailing long-term functional outcome follow-up. The current study evaluated the clinical and functional outcomes of patients who had an isolated femoral shaft fracture and underwent either antegrade or retrograde intramedullary nailing at an average of 8.0 years postoperatively (range, 5–17 years). To the authors' knowledge, this represents the longest and largest functional follow-up for femoral intramedullary nailing published to date.
In evaluating functional outcomes, previous research has largely focused on hip or knee pain as well as motion. Ostrum et al4 demonstrated in their prospective randomized study of 100 antegrade and retrograde femoral nails that knee motion and pain was similar for either technique, but the ante-grade group had a higher incidence of thigh pain; no differences in union rate were found despite a quicker time to union in their antegrade group. Similarly, in a retrospective review of 77 fractures, Yu et al8 demonstrated no difference in knee pain between ante-grade and retrograde femoral nailing after clinical and radiographic union. In another prospective randomized study, Tornetta and Tiburzi5 reported that at 1-year follow-up, knee pain dissipated with union of the femur fracture despite being at a higher rate with retrograde nailing initially. Comparatively, Ricci et al6 demonstrated, in their retrospective review of 198 femur fractures treated with antegrade or retrograde nails at a mean follow-up of 23 months, that retrograde nails had more knee pain (36% vs 9%; P<.001) and antegrade nails had more hip pain (10% vs 4%; P<.001). Their data are in agreement with the current study's long-term follow-up regarding increased hip pain with the antegrade group (25.6% vs 7.0%; P=.01); however, the current patient data are in agreement with those of the aforementioned investigations by Ostrum et al,4 Yu et al,8 and Tornetta and Tiburzi5 regarding no significant difference in knee pain for either group.
Although short-term functional outcomes suggest potential minor differences between modes of femoral nailing, the current study suggests that there is no difference between long-term VAS and WOMAC scores for patients treated with antegrade or retrograde femoral nailing. El Moumni et al,19 in their retrospective review of 59 patients with femur fractures treated with either antegrade or retrograde nails at mid-term follow-up, showed similar results in WOMAC and VAS scores of patients treated with either method.7,20,24 Although functional outcomes in the current study were overall maintained as compared with previous analyses7,8 and no differences were seen overall between groups regarding WOMAC and VAS scores, the authors found a trend toward an increased proportion of antegrade patients who still had moderate pain (VAS score, 4–7). This would suggest that although patients may be doing well from an overall functional standpoint, pain is likely a continued finding significantly affecting their activities of daily living.
Interestingly, the current authors observed that secondary surgery, including exchange nailing, bone grafting, implant removal, or knee manipulation, had no effect on VAS or WOMAC reported scores compared with no secondary surgery. This may be due to these secondary procedures returning this group of patients back to the baseline of the average postoperative course. In addition, secondary surgical intervention for nonunion/malunion was 100% successful in providing clinical union, similar to reported rates.4,6 The current authors believe that this provides vital information for instructing patients about expected outcomes at long-term follow-up.
This study had several limitations. The largest weakness was the low relative number of study participants at long-term follow-up. Loss to follow-up prior to 1 year is common in trauma-related studies, and the extension of this investigation to 17 years only worsened the response rate. The authors attempted to minimize the loss by using a new regionally enabled computerized medical system as well as internet searches for patient contact information.26 The numbers included in this study led to decreased power and increased risk of a type II error. In addition, the authors only collected VAS and WOMAC scores. Although both are validated outcome measures to assess functional outcomes, the Harris Hip Score and the Lysholm knee score may have provided additional data that could have led to additional insight.20–22,25 The results of this study should be interpreted with caution because this was a retrospective review, which includes the biases inherent to any retrospective analysis. Future multicenter trials may be beneficial in increasing valuable information and data on the topic of this study.
Patients can be successfully treated with either antegrade or retrograde reamed femoral nails, which have excellent union rates and low complication rates. Long-term analysis of these patients from 5 to 17 years postoperatively indicated that pain and functional scores (VAS and WOMAC) were in line with previous short-term studies, indicating that these patients plateau in their recovery prior to this point in time.
Diaphyseal femur fractures are successfully treated with either antegrade or retrograde intramedullary nails without significantly differing long-term functional outcomes. The authors were able to discover an increased rate of hip pain (25.6% vs 7.0%; P=.01) in the antegrade nailing group but no difference in thigh or knee pain at final evaluation.
- Sanders DW, MacLeod M, Charyk-Stewart T, Lydestad J, Domonkos A, Tieszer C. Functional outcome and persistent disability after isolated fracture of the femur. Can J Surg. 2008;51(5):366–370. PMID:18841213
- 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):446–449. doi:10.1097/00005373-200009000-00010 [CrossRef] PMID:11003321
- 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(4):529–539. doi:10.2106/00004623-198466040-00006 [CrossRef] PMID:6707031
- Ostrum RF, Agarwal A, Lakatos R, Poka A. Orthopaedic Trauma Association Edwin G. Bovill, Jr. M.D. Award: prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma. 2000;14(7):496–501. doi:10.1097/00005131-200009000-00006 [CrossRef]11083612
- Tornetta P III, Tiburzi D. Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial. J Bone Joint Surg Br. 2000;82(5):652–654. doi:10.1302/0301-620X.82B5.0820652 [CrossRef] PMID:10963159
- Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(3):161–169. doi:10.1097/00005131-200103000-00003 [CrossRef] PMID:11265005
- el Moumni M, Voogd EH, ten Duis HJ, Wendt KW. Long-term functional outcome following intramedullary nailing of femoral shaft fractures. Injury. 2012;43(7):1154–1158. doi:10.1016/j.injury.2012.03.011 [CrossRef] PMID:22483542
- Yu CK, Singh VA, Mariapan S, Chong STB. Antegrade versus retrograde locked intramedullary nailing for femoral fractures: which is better?Eur J Trauma Emerg Surg.2007;33(2):135–140. doi:10.1007/s00068-007-6156-z [CrossRef] PMID:26816143
- Dodenhoff RM, Dainton JN, Hutchins PM. Proximal thigh pain after femoral nailing: causes and treatment. J Bone Joint Surg Br. 1997;79(5):738–741. doi:10.1302/0301-620X.79B5.0790738 [CrossRef] PMID:9331026
- Ozsoy MH, Basarir K, Bayramoglu A, Erdemli B, Tuccar E, Eksioglu MF. Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail insertion. J Bone Joint Surg Am. 2007;89(4):829–834. doi:10.2106/JBJS.F.00617 [CrossRef] PMID: doi:10.2106/00004623-200704000-00019 [CrossRef]17403807
- Archdeacon M, Ford KR, Wyrick J, et al. 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. doi:10.1097/BOT.0b013e31816073b6 [CrossRef] PMID:18176158
- Bain GI, Zacest AC, Paterson DC, Middleton J, Pohl AP. Abduction strength following intramedullary nailing of the femur. J Orthop Trauma. 1997;11(2):93–97. doi:10.1097/00005131-199702000-00004 [CrossRef] PMID:9057142
- 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):10–15. doi:10.1097/BOT.0b013e31815f5357 [CrossRef] PMID:18176159
- Marks PH, Paley D, Kellam JF. Heterotopic ossification around the hip with intramedullary nailing of the femur. J Trauma.1988;28(8):1207–1213. doi:10.1097/00005373-198808000-00012 [CrossRef] PMID:
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- Daglar B, Gungor E, Delialioglu OM, et al. Comparison of knee function after ante-grade and retrograde intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation. J Orthop Trauma. 2009;23(9):640–644. doi:10.1097/BOT.0b013e3181a5ad33 [CrossRef] PMID:19897985
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- Papadokostakis G, Papakostidis C, Dimitriou R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury. 2005;36(7):813–822. doi:10.1016/j.injury.2004.11.029 [CrossRef] PMID:15949481
- El Moumni M, Schraven P, ten Duis HJ, Wendt K. Persistent knee complaints after retrograde unreamed nailing of femoral shaft fractures. Acta Orthop Belg. 2010;76(2):219–225. PMID:20503948
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Demographic and Injury Data
|Variable||Antegrade Group (n=43)||Retrograde Group (n=71)||P|
|Age, mean±SD (range), y||49.7±18.6 (22–92)||45.7±16.7 (23–86)||.25|
|Male, No.||22 (51.2%)||44 (62.0%)||.33|
|Time to fixation, mean±SD (range), d||1.2±2.1 (0–8)||1.0±1.6 (0–8)||.54|
| Motor vehicle collision||23 (53.5%)||31 (43.7%)||.34|
| Fall||7 (16.3%)||13 (18.3%)||.98|
| Motorcycle collision||7 (16.3%)||16 (22.5%)||.48|
| Pedestrian vs car||3 (7.0%)||3 (4.2%)||.67|
| Gunshot wound||3 (7.0%)||8 (11.3%)||.53|
|Isolated injury, No.||31 (72.1%)||38 (53.5%)||.08|
|Laterality, right, No.||18 (41.9%)||35 (49.3%)||.56|
|Open fracture, No.||6 (14.0%)||7 (9.9%)||.55|
Surgical and Follow-up Results
|Variable||Antegrade Group (n=43)||Retrograde Group (n=71)||P|
|Follow-up, mean±SD (range), y||8.6±3.9 (5–17)||7.3±3.2 (5–16)||.10|
|Union rate, No.|
| Primary||40 (93.0%)||64 (90.1%)||.74|
| Secondary||43 (100%)||71 (100%)||1.00|
|Secondary procedure, No.|
| Exchange nailing||2 (4.7%)||3 (4.2%)||.91|
| Bone grafting||2 (4.7%)||4 (5.6%)||.82|
| Interlocking screw removal/dynamization||8 (18.6%)||22 (30.1%)||.27|
| Knee manipulation||1 (2.3%)||2 (2.8%)||.88|
|VAS score for pain, mean±SD (range)||2.5±2.6 (0–8)||3.4±2.8 (0–10)||.11|
|WOMAC score, mean±SD (range)||23.5%±23.6% (0%–82.3%)||29.7%±24.0% (0%–88%)||.23|