COMMINUTIVE JOINT FRACTURE OF THE LOWER FEMUR (C3): RETROGRADE NAILING IN 19 CASES

Abstract

Purpose of the study: Treatment of supra- and inter-condylar fractures of the femur remains a difficult challenge, irrespective of the method used, because of the high risk of infection, disassembly, nonunion, joint stiffness, osteoarthritis, and multiple operations. Use of a supracondylar retrograde nail, accepted for C1 and C2 fractures, can be used for some C3 fractures depending on the stability of the epidphyseal assembly.

Material and methods: This series included 19 C3 fractures (AO classification) operated on in 1993–2000. Mean patient age was 54 years (range 30–81), 11 females and 8 males. This consecutive series of patients had: high energy trauma (n=14), low-energy trauma (n=5), multiple fractures (n=16), open fractures (n=10). Osteo-synthesis was performed on an ordinary table in the dorsal supine position with arthrotomy and epiphyseal screw and pin fixation followed by static supracondylar retrograde nailing (Smith and Nephez GHS), completed in two cases with an autologous corticocancellous graft. Kinetec was used for mobilization and weigh bearing delayed until bone healing.

Results: Twelve secondary operations were performed: cover with muscle flap (n=1), early revision for rotation misalignement (n=1), autologous graft (n=4), surgical arthrolysis (n=6), revision for nonunion (n=4). There were no infections. Among the four cases of nonunion, three involved epiphyseal screw failure, two cases having involved grafts. All four cases were treated by decortication, graft and plate fixation; healing was achieved. Mean time to bone healing per primam was 23 weeks on average. The 19 patients were examined at mean 44 months follow-up (range 16–78 months). Pain was noted: absent (n=8), mild (n=3), moderate (n=6), severe (n=2). Gait was noted: normal (n=7), slight limp (n=9), important limp (n=3). Mean flexion was 114° (range 85–150°). Five cass had permanent flexion < 10°. Radiologically, misalignment of +5° in the frontal plan was observed in six cases.

Discussion: Retrograde nailing of C3 fractures is difficult, but possible and requires first epiphyseal fixation then diaphyseal solidarization. The assembly is reliable, allowing immediate mobilization. Weight bearing must however be delayed to bone healing. Complementary surgery to graft bone stock or for relative arthrolysis has to be integrated into the operative plane for more than half of these difficult cases.