Retrograde Nail for Open Femoral Shaft Fractures – is it Safe?

Introduction: Open femoral shaft fractures are serious injuries often caused by high energy blunt trauma or firearm injuries. While external fixation was the mainstay for the initial treatment for many years, antegrade, reamed, intramedullary nailing (IMN) has become the treatment of choice even for high grade open fractures. The use of retrograde nail in those cases is commonly contraindicated due to fear of knee sepsis, wound infection and non-union. The purpose of this study is to compare the outcomes between those two methods of nailing and proof the safety of using retrograde nailing in open femoral shaft fractures.

Methods: A retrospective review of all (71) open femoral shaft fractures treated between 2006 and 2016 at our level III trauma center was performed. Injury pattern and outcomes were reviewed for all cases of retrograde and antegrade nailing. The available information was obtained from patients’ charts as well as a quality of life questionnaire by the means of the SF-12 survey.

Results: Among 71 cases of open femoral shaft fractures, 17 were treated with antegrade nail (AN) and 30 with retrograde nail (RN). Gustilo and AO classification was almost similar in both groups. Injury Severity Score (ISS) was 11 for AN and 14.2 for RN. Complications in the AN group included nonunion (3 patients), mal-union (1), infection (3) and overall 73% required revision surgery. Among the patients who were treated with RN: nonunion (2), infection (1) and overall 36% required revision surgery (P value 0.0281). Mean PSV and MSV SF-12 scores were 38.461 and 43.86 for AN, 35.498 and 44.749 for RN, respectively.

Conclusion: High grade open femoral shaft fracture is a serious injury often associated with complications and revision surgery. However, retrograde nailing, as proved in our series is an acceptable alternative and was actually associated with lower overall complication rate.