Comparing Entry Points for Antegrade Nailing of Femoral

n Feature Article
Comparing Entry Points for Antegrade
Nailing of Femoral Shaft Fractures
Ujash Sheth, MD; Chetan Gohal, BHSc; Jaskarndip Chahal, MD, MSc, FRCSC;
Aaron Nauth, MD, MSc, FRCSC; Tim Dwyer, MBBS, FRCSC
abstract
The optimal entry point for antegrade intramedullary nailing of femoral shaft
fractures remains controversial. The purpose of this systematic review was to
determine whether there is a difference in operative parameters, healing, and
functional outcome when comparing the greater trochanter (GT) and piriformis fossa (PF) entry points. A systematic search of multiple databases and 3
major orthopedic meetings (American Academy of Orthopaedic Surgeons,
Canadian Orthopaedic Association, and Orthopaedic Trauma Association)
was conducted. Four studies (570 patients) met the inclusion criteria. Mean
patient age was 34.5 years, and 60.4% were male. The GT entry point was
associated with significantly shorter operative (mean difference [MD], -20.05
minutes [95% confidence interval (CI), -23.09 to -17.02]; P<.00001) and
fluoroscopy times (MD, -24.55 seconds [95% CI, -43.23 to -5.86]; P=.01).
There was no significant difference in nonunion (risk ratio [RR], 0.74 [95%
CI, 0.35 to 1.58]; P=.44) and delayed union rates (RR, 0.94 [95% CI, 0.41
to 2.14]; P=.88) between the 2 entry points. Heterogeneity in outcome measures reported prevented pooled analysis of functional outcomes. This review
supports the use of the GT entry point during antegrade nailing of femoral
shaft fractures over the PF entry point, with regard to shorter operative and
fluoroscopy times. Healing and complication rates were not related to the
entry point. Further study is required to determine the effect of each entry
point on the surrounding soft tissue structures and ultimately its impact on
postoperative function. [Orthopedics]
T
he use of intramedullary (IM) nailing is currently the gold standard
treatment for the vast majority of
femoral shaft fractures.1-3 Despite major
advances in the design and engineering
of these devices, there remains significant
debate regarding the ideal entry point for
antegrade nailing.4,5 Kuntscher’s original
IM nail was straight and introduced in
antegrade fashion through the tip of the
greater trochanter (GT) to minimize the
risk of intracapsular infections, osteone-
crosis of the femoral head, and iatrogenic
femoral neck fractures.6,7 However, because the tip of the GT is not colinear with
the anatomic axis of the medullary canal,
the insertion of a straight nail was reported
to occasionally result in varus malreduction of the proximal fracture fragment, eccentric reaming of the medial cortex, and
fracture comminution.8 As a result, Hansen and Winquist9 recommended using an
entry point more medial to the GT at the
junction of the femoral neck and the GT.
At the same time, McMaster10 introduced
the piriformis fossa (PF) entry, which is
colinear with the medullary canal, as the
The authors are from the Division of Orthopaedic Surgery (US, CG, JC, AN, TD), University
of Toronto; the Division of Orthopaedic Surgery
(JC), Toronto Western Hospital; the Division of
Orthopaedic Surgery (AN), St Michael’s Hospital;
and the Division of Orthopaedic Surgery (TD),
Mount Sinai Hospital, Toronto, Ontario, Canada.
Dr Sheth, Mr Gohal, Dr Chahal, and Dr Dwyer have no relevant financial relationships to disclose. Dr Nauth receives grants from Synthes and
Stryker and nonfinancial support from Stryker.
The authors thank Joshua Hwang, BSc, for his
assistance with Korean-English translation.
Correspondence should be addressed to:
Ujash Sheth, MD, Division of Orthopaedic Surgery, Toronto Western Hospital, 399 Bathurst
St, 1 E 447, Toronto, Ontario M5T 2S8, Canada
([email protected]).
Received: January 8, 2015; Accepted: May
18, 2015.
doi: 10.3928/01477447-20151218-09
1
n Feature Article
Table 1
Table 2
Complete Search
Strategy for Medline
Complete Search
Strategy for Embase
No. of
Results
Step
exp femoral fractures
30,587
2
(femoral adj fracture).mp
1644
3
1 or 2
30,902
4
fracture fixation.
mp or exp fracture
fixation
48,373
5
exp fracture fixation,
intramedullary
7375
Step
1
Search Term
6
intramedullary.mp
14,914
7
5 or 6
14,914
8
nail*.mp
31,568
9
6 and 8
6822
10
4 or 7 or 9
55,018
11
trochanter.mp
3677
12
piriformis.mp
568
13
11 or 12
4195
14
3 and 10 and 13
294
entry point for antegrade nailing. In the
following years, the PF became the starting point of choice, due to its favorable
biomechanical results.11-13
The debate surrounding the optimal
entry point was revived with the advent
of the IM nail featuring a proximal valgus bend. These nails were specifically
designed to address the pitfalls associated with inserting a straight nail through
the GT.4,7 Ricci et al14 were the first to
directly compare the GT and PF entry
points during antegrade nailing of femoral
shaft fractures.15 Results from their study
demonstrated no difference in union rate
and complications between the 2 entry
points.14 However, they reported significantly shorter operative and fluoroscopy
times with the GT entry point.14 Furthermore, other investigators have advocated
the use of GT entry in obese patients, citing increased ease of use in that patient
2
Search Term
No. of
Results
1
exp femur fractures
26,161
2
(femoral adj2 fracture).mp
5708
3
1 or 2
27,087
4
exp intramedullary
nailing or exp intramedullary nail
12,027
5
exp fracture fixation
64,343
6
4 or 5
65,079
7
exp greater trochanter or trochanter.mp
4831
8
piriformis.mp
877
9
7 or 8
5617
10
3 and 6 and 9
359
population.16 Since the study by Ricci et
al,14 there have been a number of randomized, controlled trials (RCTs) and cohort
studies comparing the efficacy of the 2
entry points on various patient- and procedure-related outcomes.17-20 To the current authors’ knowledge, there has been
no systematic review of the literature on
optimal entry point during antegrade nailing of femoral shaft fractures.
The primary objective of the current
systematic review was to compare the operative and fluoroscopic time required for
IM nail fixation of femoral shaft fractures
using the GT vs the PF entry point. A secondary objective was to determine whether there were any differences in complications (nonunion and delayed union) and
functional outcomes between the 2 entry
points.
tegrade IM nail fixation of femoral shaft
fractures in adults. Case series, reviews,
and technique and basic science articles
that did not report patient-specific data
were excluded. There were no language
restrictions.
Literature Search
To identify eligible studies for inclusion, a systematic search of the electronic
databases Medline, Embase, PubMed,
Cochrane Central Register of Controlled
Trials, and clinicaltrials.gov (for ongoing registered RCTs) was performed independently by 2 authors (U.S., C.G.).
The search was conducted during the
week of October 6, 2014, and articles
were retrieved from database inception
to the search date. Complete Embase and
Medline search strategies can be found in
Table 1 and Table 2, respectively. Titles
of podium and poster presentations in
programs of 3 major orthopedic meetings (American Academy of Orthopaedic
Surgeons, Canadian Orthopaedic Association, and Orthopaedic Trauma Association) from 2011 to 2013 were reviewed for
any relevant unpublished studies. Additional studies were detected by searching
the bibliographies of eligible studies. The
“related articles” feature of PubMed was
used to identify similar relevant articles.
Materials and Methods
Study Selection
Article titles and abstracts were reviewed independently by 2 authors (U.S.,
C.G.) to determine whether they met inclusion criteria. If any ambiguity was encountered, the study was included until
full-text review could be performed. The
2 independent reviewers assessed each
full-text article for eligibility. Any disagreements were discussed between the
reviewers and, if required, a third reviewer
(J.C.) until consensus was reached.
Eligibility Criteria
The authors identified all RCTs, prospective cohort studies (PCSs), and retrospective cohort studies (RCSs) that
compared GT and PF entry points for an-
Data Extraction
Data were abstracted by 2 independent
reviewers (U.S., C.G.) into a standardized
collection form using Microsoft Excel
Copyright © SLACK Incorporated
n Feature Article
2013 (Microsoft, Redmond, Washington).
Data collected included general study
information (author, year of publication,
study design, sample size, level of evidence), demographic data (mean or median age, sex), IM nail entry point (GT vs
PF), IM nail characteristics (manufacturer), patient positioning (supine or lateral),
follow-up data (mean duration, rate), and
outcome measures used.
Methodological Quality Assessment
The quality of eligible studies was assessed independently by 2 authors (U.S.,
C.G.). The checklist to evaluate a report
of a nonpharmacological trial (CLEARNPT) was used to assess the quality of
RCTs.21 The CLEAR-NPT is a validated
checklist used to assess the adequacy
of 10 key elements of an RCT.21 The
Newcastle-Ottawa Scale (NOS) was used
to assess quality of the nonrandomized
studies.22 The NOS uses a star system (0
to 9) to evaluate nonrandomized studies
on 3 domains: selection, comparability,
and outcome/exposure.22 Higher scores
on the NOS represent higher study quality. A consensus agreement was achieved
between reviewers.
Statistical Analysis
Data were pooled across studies; the
weighted mean difference (MD) was
calculated for continuous outcomes, and
the risk ratio (RR) was calculated for
binary outcomes. Point estimates for all
outcomes were calculated with their corresponding 95% confidence intervals
(CIs). All tests of significance (2-tailed)
were performed with an α value of 0.05.
In situations where studies only reported a
median and interquartile range (IQR), established statistical methods were used to
obtain converted mean and SD values to
allow for pooling of data across studies.23
A random-effects model was used to
account for any heterogeneity that may
have been introduced due to the variation
in the patient population, IM nail design,
and operative technique between the stud-
Figure 1: Flow diagram summarizing the search strategy and screening and selection process.
ies. The I2 statistic was used to quantify
heterogeneity, and the Cochran chi-square
test of homogeneity was used to test for
significance (ie, Q test, P<.10).24 An I2
statistic value of greater than 75% was
considered high.24 The authors could not
assess for publication bias because the
number of eligible studies was too small.
A sensitivity analysis was planned to
test the robustness of the pooled results by
sequential removal of studies one by one.
Subgroup analyses that were planned a
priori included analyzing the primary outcomes (operative and fluoroscopy time)
based on study randomization.
Results
General Study Characteristics
The search resulted in 4 studies14,17-19
that met the eligibility criteria, providing
a total of 570 patients for analysis (Figure 1). Included were 2 level I RCTs,17,18
1 level II PCS,14 and 1 level III RCS.19
All of the studies were published in peer-
reviewed journals. Of the 4 studies, 3 were
written in English14,17,18 and 1 required
translation19 (Korean to English) by a bilingual Korean-English medical student.
Mean age of participants across all eligible studies was 34.5 years. Mean clinical follow-up across the 4 studies ranged
from 10 to 48 months. Data pertaining
to sex were available for 3 studies,14,18,19
and 278 (60.4%) of the 460 patients were
male. Patients were placed supine for antegrade IM nailing in all of the eligible
studies.14,17-19 Information on body mass
index (BMI) was available for 3 of the
4 included studies.14,17,19 The frequencyweighted mean BMI across these studies
was 25.0 kg/m2 and 24.6 kg/m2 in the GTentry and PF-entry groups, respectively.
Table 3 depicts the baseline characteristics of all eligible studies.
Fracture Type
All of the eligible studies14,17-19 comprised adults with isolated femoral shaft
3
4
Level II,
PCS
Level I,
RCT
Level I,
RCT
Level
III, RCS
Study
Ricci et
al14
Stannard
et al17
Moein et
al18
Ha et
al19
GT-Entry
IM Nail
Trigen TAN
Nail (Smith
& Nephew,
Memphis, Tennessee)
Trigen TAN
Nail
Antegrade
Femoral Nail
(Synthes,
Solothurn,
Switzerland)
Sirus Femoral
Nail (Zimmer,
Cowpens,
South Carolina)
Inclusion
Criteria
Femoral shaft
or subtrochanteric
fracturea
Isolated
femoral shaft
fractures
Isolated
femoral shaft
fractures
Isolated
femoral shaft
fractures
M/DN
Femoral Nail
(Zimmer,
Warsaw,
Indiana)
Unreamed
Femoral Nail
(Synthes)
Trigen FAN
Nail
Trigen FAN
Nail
PF-Entry
IM Nail
Supine
Supine
Supine
Supine
Operative
Patient
Position
24.3
NR
28.1
24
GT-Entry
Group
23.7
NR
27.8
24
PF-Entry
Group
Mean
Age,
y
28.6
34
28.9
36.4
Sample
Size
(% Male)
91 (59.3)
110 (NR)
19 (94.7)
350
(58.9)
81%
90.5%
81%
85.7%
Follow-up
Rate
24
48
16
10
Mean
Follow-up,
mo
Operative and fluoroscopy time, blood
loss, union time,
HHS, complications
(LLD, nonunion,
delayed union,
iatrogenic fracture,
broken screw)
VAS, gait analysis,
muscle strength,
EMG, MRI
Operative and
fluoroscopy time, incision length, blood
loss, WOMAC, VAS,
union time, muscle
strength, functional
testing (chair stand
test, timed up and
go test)
Operative and
fluoroscopy time,
union time, fracture
alignment, LEM
Outcome Measures
Abbreviations: BMI, body mass index; EMG, electromyography; FAN, femoral antegrade nail; GT, greater trochanter; HHS, Harris Hip Score; IM, intramedullary; LEM, lower extremity
measure; LLD, limb-length discrepancy; MRI, magnetic resonance imaging; NR, not reported; PCS, prospective cohort study; PF, piriformis fossa; RCS, retrospective cohort study; RCT,
randomized, controlled trial; TAN, trochanteric antegrade nail; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
a
No patients with subtrochanteric fractures were part of the study.
Study
Design
Mean BMI, kg/m2
Baseline Characteristics of Eligible Studies
Table 3
n Feature Article
fractures (defined by the
Orthopaedic Trauma Association [OTA] classification system25 as 32A, B, or
C). Ricci et al14 included
patients with subtrochanteric fractures (OTA 31-A3)
in their eligibility criteria;
however, the final study
population only included
patients with femoral shaft
fractures (OTA 32-A/B/C).
A breakdown of fracture
type based on OTA classification was provided for 3
of the 4 studies.14,17,19 These
results are summarized in
Table 4.
Lateral Bend of Greater
Trochanter Entry Nail
In 2 of the 4 studies, the
TRIGEN trochanteric antegrade nail (TAN) (Smith
& Nephew, Memphis, Tennessee) that incorporates
a 4° proximal valgus bend
was used. In another study,
the antegrade femoral nail
(AFN) (Synthes, Solothurn,
Switzerland), which has a
6° proximal valgus bend,
was used. The fourth study
used a Sirus femoral nail
(Zimmer, Warsaw, Indiana),
and the degree of proximal
lateral bend was not stated
in the manuscript; however,
the manufacturer’s product
guide describes a 4° bend.
Study Quality
A summary of the methodological quality assessment of included studies
using the CLEAR-NPT
and NOS is provided in Table 5 and Table 6, respectively. In general, both of
the RCTs were of moderate
Copyright © SLACK Incorporated
n Feature Article
methodological quality. One study did not
provide enough information to determine
whether generation of allocation sequence
and surgeon experience was adequate.18
The other study failed to use the intentionto-treat principle for analysis.17 The nonrandomized studies14,19 had study populations (within studies) that were well
matched on important demographic and
prognostic variables (eg, mechanism of
injury, fracture classification, and BMI).
One study failed to mention how outcomes were collected.19 Overall, these cohort studies14,19 were found to be of high
methodological quality and were noted to
have NOS scores of 9 and 7, respectively,
of a possible 9 stars.
ing the GT entry point (2 studies [201
patients]; MD, -20.88 [95% CI, -36.55 to
-5.20]; P=.009).
Fluoroscopy Time. Three of the 4
studies reported total fluoroscopy time
(in seconds) during IM nailing of femoral shaft fractures.14,17,19 The results of
the pooled statistical analysis showed a
significant difference in fluoroscopy time
favoring the GT entry IM nail by approximately 25 seconds (3 studies [551
patients]; MD, -24.55 [95% CI, -43.23 to
-5.86]; P=.01) (Figure 2). A similar result
was found during subgroup analysis using only data from RCTs (2 studies [201
patients]; MD, -36.36 [95% CI, -59.46 to
-13.26]; P=.002).
Primary Outcomes
Operative Time. Data on operative
time were available for 3 of the 4 included studies.14,17,19 The pooled mean difference (MD) in operative time across all
studies significantly favored the GT-entry
IM nail by approximately 20 minutes (3
studies [551 patients]; MD, -20.05 [95%
CI, -23.09 to -17.02]; P<.00001) (Figure
2). Subgroup analysis using data from
RCTs alone also demonstrated a significant difference in operative time favor-
Secondary Outcomes
Nonunion. The pooled nonunion rate
among all patients in this study was 4.6%
(26 of 570). The overall pooled nonunion
rate was 3.9% (11 of 283) and 5.2% (15
of 287) for patients treated with GT-entry and PF-entry IM nails, respectively.
Pooled summary of all 4 studies demonstrated no statistically significant difference in the overall risk of nonunion between patients treated with a GT-entry vs
PF-entry IM nail (4 studies [570 patients];
Table 4
OTA Classification of
Treated Fracturesa
No. (%) of Fractures
Treated
OTA
Classification
With
GT-Entry
IM Nail
With
PF-Entry
IM Nail
32-A
137 (50)
100 (36)
32-B
70 (25)
103 (37)
32-C
70 (25)
75 (27)
Total
277 (100)
278 (100)
Abbreviations: GT, greater trochanter;
IM, intramedullary; OTA, Orthopaedic
Trauma Association; PF, piriformis
fossa.
a
Note: Only 3 of the 4 included studies
provided data on fracture classification.
RR, 0.74 [95% CI, 0.35 to 1.58]; P=.44)
(Figure 2).
Delayed Union. The number of delayed
unions was reported in 3 of 4 studies.14,17,19
The pooled delayed union rate among all
patients in the current review was 4.2% (23
of 551). The overall pooled delayed union
rate was 3.6% (10 of 274) and 4.7% (13 of
277) for patients treated with GT-entry and
PF-entry IM nails, respectively. A pooled
Table 5
Methodological Quality Assessment for 2 Eligible RCTs Using CLEAR-NPT Guidelines
CLEAR-NPT Criteriona
Study
1
2
3
4
5
6
7
8
9
10
Explanation
Stannard et al17
Y
Y
Y
Y
U
1. U
2. Y
3. Y
1. U
2. Y
3. Y
Y
Y
U
4. Primary surgeon was senior resident; similar in each
arm but may not have had same level of expertise as
experienced surgeon. 5. Not applicable to surgical intervention. 7. Not feasible. 10. No mention of analysis
for missing data.
Moein et al18
U
Y
Y
U
U
1. N
2. Y
3. Y
1. U
2. Y
3. Y
1. U
2. Y
3. Y
Y
Y
1. Patients randomized through envelopes. No information given whether envelopes introduced bias (eg,
no mention of sealed opaque, etc) 4. No mention
of surgeons’ expertise. 5. Not applicable to surgical
intervention. 7. Not feasible. 8. No mention of who
outcome assessors were.
Abbreviations: N, no; RCTs, randomized, controlled trials; U, unclear; Y, yes.
a
1. Adequate generation of allocation sequence; 2. Treatment allocation concealed; 3. Details of each intervention available; 4. Expertise similar
in each arm; 5. Participant adherence assessed; 6. Adequate participant blinding; 7. Care providers blinded; 8. Outcome assessors adequately
blinded; 9. Similar follow-up between groups; 10. Used intention-to-treat analysis.
5
n Feature Article
Table 6
Methodological Quality Assessment of 1 Eligible PCS and 1
Eligible RCS Using Newcastle-Ottawa Scale
Newcastle-Ottawa Scale Criterion
Selection
Study (Study Type)
15
Ricci et al
(PCS)
Ha et al19 (RCS)
Comparability
Exposure/Outcome
1
2
3
4
1
1
2
3
*
*
*
*
**
*
*
*
*
*
*
*
**
0
*
0
Abbreviations: PCS, prospective cohort study; RCS, retrospective cohort study.
Note: Star (*)=item present. Maximum 1 star (*) for the selection and outcome components
and 2 stars (**) for the comparability component.
Malunion. Malunion or malalignment
was reported in 2 of the eligible studies.14,17 One study defined malalignment
as greater than 10° of angulation, greater
than 15° of malrotation, and/or a leglength discrepancy greater than 2 cm.14
This study did not report any cases of
malalignment in either group; however, 1
patient in the GT-entry group healed with
12° of external rotation.14 The other study
had a total of 9 fractures that healed with
5° to 8° of malalignment.17 Six patients
in the PF-entry group had a malunion; 4
healed in varus and 2 healed with femoral
recurvatum. Two patients in the GT-entry
group healed in varus, and one healed in
slight procurvatum.17
Functional Outcomes. Due to the
heterogeneity in outcome measures used
among the included studies, data on functional outcomes could not be pooled.
Although each study used a different outcome measure (Harris Hip Score [HHS],19
customized functional outcome questionnaire,18 Lower Extremity Measure
[LEM],14 and Western Ontario and McMaster Universities Osteoarthritis Index
[WOMAC]17), it is important to note that
there were no differences in function and
patient-reported outcomes between patients
who received GT- and PF-entry nailing.
Discussion
Figure 2: Forest plots illustrating results of the pooled analysis for greater trochanter (GT) vs piriformis
fossa entry for operative time (A), fluoroscopy time (B), nonunion rate (C), and delayed union rate (D).
Abbreviations: CI, confidence interval; IV, inverse variance; M-H, Mantel-Haenszel.
analysis of the 3 studies showed no statistically significant difference in the overall
risk of delayed union among patients treat-
6
ed with a GT-entry vs a PF-entry IM nail (3
studies [551 patients]; RR, 0.94 [95% CI,
0.41 to 2.14]; P=.88) (Figure 2).
The current systematic review of comparative studies evaluating the optimal entry point (GT vs PF) for antegrade nailing
of femoral shaft fractures found the following: (1) using the GT entry point leads to
significantly reduced operative times compared with the PF entry point; (2) fluoroscopy time is significantly less when using
the GT entry point compared with the PF
entry point; and (3) nonunion and delayed
union rates are not significantly different
among patients undergoing antegrade nailing via the GT and PF entry points.
The observed MD in operative time
of approximately 20 minutes favoring the
GT entry point is a clinically significant
finding. A decrease in operative time re-
Copyright © SLACK Incorporated
n Feature Article
duces the potential morbidity associated
with a longer anesthetic time and could
potentially reduce intraoperative blood
loss. It also reduces the economic costs
associated with the surgical procedure
(eg, resource use and nursing). The cost of
operating room time in the United States
(as per 2005 data) has been estimated
to range from $22 to $133 per minute.26
These figures do not include surgeon and
anesthetist fees. Thus, the potential cost
savings may be substantial. Furthermore,
evidence from the literature suggests that
the decrease in operative time associated
with use of the GT entry point is even
more pronounced when considering obese
patients.14,19 However, it is important to
note that future conversion to a total hip
arthroplasty (THA) may be more difficult
after use of a GT entry nail. Although no
studies have reported on conversion to
THA after GT-entry IM nailing for femoral fractures, literature pertaining to THA
conversion following cephalomedullary
nailing for hip fractures has found operative times and blood loss to be significantly greater with the GT entry point.27
The current review’s finding that the
time exposed to fluoroscopy is significantly less (approximately 25 seconds) when
using the GT entry point is another clinically relevant finding. Previous work has
found that the average fluoroscopy time
for antegrade femoral nailing can range
from 0.56 minutes (31.2 seconds) to 4.60
minutes (276 seconds).28,29 The current results suggest that there can be a significant
reduction in radiation exposure to both the
surgical team and the patient through the
use of the GT entry point.
The pooled nonunion rate among all
patients in this study was 4.6%, which
may seem higher than the rates reported
in the literature. However, nonunion rates
have been found to range from 0.9% in
simple femoral shaft fractures to 10% in
cases of severe comminution and bone
loss.8,30,31 With pooling of all fracture
types (OTA 32-A/B/C) in the study, the
overall nonunion rate reported here likely
reflects this varying degree of severity in
fractures treated. The finding of no difference in nonunion and delayed union rates
between the GT and PF entry points is an
important finding because it suggests that
the biological healing process is not influenced by entry point.
The heterogeneity in outcome measures used to assess postoperative function in the eligible studies prevented any
pooled analysis. Although no universal
functional outcome measure was used,
each eligible study in this review reported
no significant difference in patient function (as per the outcome measure used in
each study) when comparing the 2 entry
points.14,17-19 However, whether PF-entry
nailing has a detrimental effect on the soft
tissue structures around the hip is an area
of controversy. In fact, Archdeacon et al32
compared hip abductor function in patients who were treated for femoral shaft
fractures with antegrade IM nailing using
the GT or PF entry point. They found the
PF-entry group had significantly less internal hip abduction moment at terminal
stance or push-off compared with the GTentry group.32 In a cadaver study, Dora
et al33 found that the PF entry portal was
associated with significant damage to the
external rotators and medial circumflex
artery when compared with the GT entry portal. Ansari Moein et al34 reported
similar findings in their study of cadavers,
noting that nailing through the GT would
limit any surgical injury to the tendinous
aspect of the hip abductor complex. However, in another cadaver study by McConnell et al,35 the GT entry point was reported to cause an average of 27% damage
to the gluteus medius tendon insertion.
Considering the current authors’ finding
of no significant difference in functional
outcome between the 2 entry points, postoperative function may be independent of
the entry point.
The entry site may be a more critical
element in the management of subtrochanteric fractures, which have demonstrated a propensity toward varus de-
formity with the PF entry point.36,37 The
deforming forces of the hip flexor and
abductor muscles make the subtrochanteric fracture difficult to treat irrespective
of entry point.5 Despite this fact, there has
only been one RCT examining the effect
of entry point on proximal femur fractures
(intertrochanteric and subtrochanteric).20
This study found no difference in operative time, varus malunion rate, blood loss,
and incision length between the GT and
PF entry points using a cephalomedullary
nail.
The strength of the current systematic
review is that it is the first to summarize
and combine the available evidence comparing the GT and PF entry points for antegrade nailing of femoral shaft fractures. In
addition, the authors’ search strategy was
comprehensive and inclusive because they
attempted to identify unpublished data by
searching 3 North American orthopedic
conference proceedings and did not limit
results by language. Furthermore, they
attempted to minimize bias throughout
the study selection, data extraction, and
quality assessment process by performing these in duplicate. However, there are
also a number of limitations to the study.
First, both randomized and nonrandomized studies were pooled together in this
review to increase the sample size and
power for the pooled analysis. Moreover,
due to the variation among the included
studies in outcome measures used, it was
not possible to provide any definitive conclusions on the difference in functional
outcomes between patients who underwent antegrade nailing through the GT vs
the PF entry portal.
Conclusion
The current systematic review demonstrates that use of the GT entry point
during antegrade IM nailing is associated
with decreased operative and fluoroscopy
times, with no difference in nonunion
and delayed union rates when compared
with the PF entry point. Further research
is required to determine the effect of each
7
n Feature Article
entry point on the surrounding soft tissue
structures and functional outcomes.
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