Pro: Antegrade Rodding is Quick, Efficient with Few Complications: - PowerPoint PPT Presentation

Pro: Antegrade Rodding is Quick, Efficient with Few Complications: Try It! Bob Zura LSU Health, New Orleans OSET 2017 Las Vegas

Disclosures • Consultant: – Smith-Nephew – Bioventus – Cardinal Health

23 yo Fraternity Boy • Want his femur to heal • Want his hip/knee to work • Want him to return to optimal function

Antegrade Nailing: The Gold Standard http://www.coinweek.com/wp-content/uploads/2011/09/gold_standard.jpg

Healing Gold Standard – piriformis, locked – Brumback 1988,1989 – Kuntscher 1968 – Winquist 1984 – 520 fractures in 500 patients – 99.1% union rate

The epidemiology of fracture nonunion in 18 human bones – Analysis of a payer database of ~90.1 million patients Robert Zura, MD - 6 -

• Overall Nonunion rate: 4.9% • Femoral Nonunion rate: 13.9% - 7 -

Piriformis is too hard and the Trochanter is easy…… OR

Ease of Insertion • Neither starting portal is EASY • Both require accurate entry to avoid complications • Appropriate nail must be used with appropriate portal Ricci

Piriformis • Can be challenging: – Obese – Supine – But: • Lost art? – And: • Once you are in, you are in, and in the anatomic axis of the femur – The roll – lateral for entry, remove for rotation

The Trochanter is not so easy: • Malalignment • Comminution at the fracture site • Bursting of the femur at the entry site

Greater Trochanter • More subcutaneous – Easier to locate and instrument • Not co-linear with long axis – Risk of iatrogenic comminution

Greater Trochanter • Risk of varus malalignment

The effect of entry point on malalignment and iatrogenic fracture with the Synthes lateral entry femoral nail. Prasarn ML1, Cattaneo MD, Achor T, Ahn J, Klinger CE, Helfet DL, Lorich DG. J Orthop Trauma. 2010 Apr;24(4):224-9 • 227 femoral shaft fractures stabilized with the lateral entry femoral nail from 11 different trauma centers were retrospectively evaluated • There were a total of 16 iatrogenic fractures in the cohort. • The risk of valgus malalignment is nearly threefold (10% versus 25%) when the starting point is anterior as compared with the middle entry point • Conclusion: – The helical shape of the nail can result in valgus malalignment and fracture if the entry point is too anterior, and surgeons must recognize these consequences of insertion inaccuracy

The Abductors • The others will tell you that piriformis nails destroy the abductors and kill the blood supply? – Sparse literature to support this clinically • My opinion – rather go through muscle belly than abductor insertion

Retrograde Nails - The Knee 23 years old • Do you really want to do this to his cartilage? • Fat pad caclification • Length? • Destroy the knee for 3% femoral neck fractures? https://image.slidesharecdn.com/l04-femurshaftstfx-161225225551/95/l04-femur- shaft-st-fx-22-638.jpg?cb=1482706582 http://www.drhipandknee.com/wp-content/uploads/2013/09/oats-procedure.png

THANK YOU