Description: OTA 2002 - Session 2 Session II - Post-Traumatic Reconstruction Fri., 10/11/02 Post Traumatic Reconstruction, Paper #10, 3:06 PM *Arthroscopically Assisted Removal of Retrograde Femoral Nails: Description
of Technique and Intraarticular Findings at Long-Term Follow-Up Christopher T. Born, MD, FACS (a-Smith + Nephew, Synthes,
USA, Howmedica; b-Zimmer; e-Stryker Howmedica Osteonics); Paul J. King,
MD; Lisa Khoury, MD; William G. DeLong, Jr., MD, FACS (a-Smith + Nephew,
Synthes, USA, Howmedica); University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania, USA (-AO North America Grant) Purpose: Numerous studies have supported the use of retrograde
nailing for the management of femur fractures. Many of the patients who
had a femur fracture treated with retrograde nailing develop some degree
of postoperative knee pain. Concern has been expressed regarding the potential
for injury of the patellofemoral articulation as well as for the development
of intraarticular metallosis. To date, there is little information about
the long-term postoperative intraarticular milieu after retrograde nailing,
especially in the patient with a painful knee. The purpose of this paper
is to report the intraoperative findings, indications for, and the clinical
results of knee arthroscopy at the time of retrograde femoral nail removal.
We also describe the principles of the arthroscopically assisted technique
that we have developed. Methods: Over a 9-year period, 16 patients underwent arthroscopically
assisted removal of retrograde femoral nails. These included 11 because
the nail was considered a possible source of knee pain, 3 for chronic infection,
and 1 each as a preoperative measure before additional surgery and for peace
of mind. The mean time to removal was 20.5 months after insertion. The outpatient
technique utilizes two standard arthroscopic portals in addition to a limited
infrapatellar tendon-splitting incision. Location of the buried distal nail
end is by orthogonal intraoperative fluoroscopy. Operative findings were
reviewed retrospectively for the first 6 years and prospectively for the
last 3 years. Results: Fifteen of sixteen nails (94%) were successfully removed
with use of this technique. One patient required a formal arthrotomy after
the arthroscopy in order to remove intraarticular lag screws. In all cases
(100%), the distal end of the nail and the entry portal were covered by
fibrous reparative tissue. No patient was found to have any changes at the patellofemoral
articulation that could be attributed directly to the nail. There was no
evidence of intraarticular metallosis in any case. Fourteen of 16 patients
(88%) were found to have some identifiable intraarticular pathologic condition
that was treated at the time of arthroscopy, and some patients had more
than one lesion. They included eight patients with osteochondral injuries,
seven with significant adhesions, and two with loose bodies. The injuries
were appropriately managed at the time of arthroscopy. Three patients had
infections that were cultured and debrided. Five meniscal tears were found
(four were debrided and one was repaired), and two ACL tears were diagnosed
and debrided. There was one complication (6%) in the form of a postoperative
hemarthrosis that resolved uneventfully with aspiration. In the two patients
with non-painful knees who were having the nails removed either for "peace
of mind" or as a precursor to a second procedure, no significant pathologic
condition was found at arthroscopy. Discussion and Conclusions: This technique allows for the evaluation
and treatment of potentially painful intraarticular pathologic conditions
after femur fracture and subsequent retrograde nailing. In our series, 88%
of patients were found to have some identifiable pathologic condition most
likely related to the index injury and not to the nail or its insertion.
Despite early concerns to the contrary, the clinical impression of most
orthopaedic traumatologists that the patellofemoral joint is spared after
proper recessing of the nail appears to be borne out by this study. The
presence of intraarticular metallosis has not been substantiated. This technique
is safe, avoids the morbidity associated with open arthrotomy, allows for
nail removal on an outpatient basis, and promotes accelerated rehabilitation.
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