Introduction. Femoral periprosthetic fractures above TKA are commonly treated with retrograde intramedullary nailing (IMN). This study determined if TKA design and liner type affect the minimum knee flexion required for retrograde nailing through a TKA. Methods. Twelve cadaveric specimens were prepared for six single radius (SR) TKAs and six asymmetric medial pivot (MP) TKAs. Trials with 9mm polyethylene liners were tested with cruciate retaining (CR), cruciate substituting (CS) and posterior stabilizing (PS) types. The knee was extended to identify the minimum knee flexion required to allow safe passage of the opening reamer while maintaining an optimal fluoroscopic starting point for retrograde nailing. Furthermore, the angle of axis deviation between the reamer and the femoral shaft was calculated from fluoroscopic images. Results. In all specimens, the reamer entry point was posterior to Blumensaat's line. In the SR TKA, the average flexion required was 70, 71 and 82 degrees for CR, CS and PS respectively. The required flexion in PS was significantly greater than the other designs (p=0.03). In the MP TKA, the average flexion required was 74, 84 and 123 degrees for CR, CS and PS respectively. The required flexion was significantly greater in CS and PS designs (p<0.0001). Femoral component size did not affect the minimum flexion required. Furthermore, the entry reamer required 9.2 (SR) and 12.5 (MP) degrees of posterior axis deviation from the femur. Conclusions. Our study illustrates four novel factors to consider when performing retrograde nailing through TKA. First, significant knee flexion is required to obtain an ideal radiographic starting point when retaining the liner. Second, PS implants require more flexion with both TKA designs. Third, femoral component size does not affect the flexion required. Fourth, there is a consistent posterior axis deviation of the entry reamer from the femoral shaft, explaining the commonly created extension deformity

This study aimed to evaluate the clinical outcomes of paediatric patients who underwent a retrograde drilling treatment for their osteochondritis dissecans (OCD) of the talus. The secondary purpose was to identify factors that are predictive of a failure of the treatment. A retrospective study was done. All patients treated for talar OCD between 2014 and 2017 were reviewed to extract clinical and demographic information (age, sex, BMI, OCD size and stability, number of drilling, etc). Inclusion criteria were: (1) talar OCD treated with retrograde drilling, (2) less than 18 years, (3) at least one available follow up (4) stable lesion. Exclusion criteria was another type of treatment for a the talar OCD. Additionally, all pre-operative and post-operative medical imaging was reviewed. Outcome was classified based on the last follow-up appointment in two ways, first a score was attributed following the Berndt and Harty treatment outcome grading and second according to the necessity of a second surgery which was the failure group. Chi-square and Mann-Whitney tests were used to compared the success and failure group. Seventeen patients (16 girls and 1 boy, average age: 14.8±2.1 years) were included in our study group. The mean follow up duration was 11.5 (±12) months. Among this population, 4/17 (24%) had a failure of the treatment because they required a second surgery. The treatment result grading according to Berndt and Harty outcome scale identified good results in 8/17 (47%) patients, fair results in 4/17(24%) patients and poor results in 5/17 (29%) patients. The comparisons for various patient variables taken from the medical charts between patients who had a success of the treatment and those who failed did not find any significant differences. At a mean follow-up duration of 11.5 months, 76% of patients in this study had a successful outcome after talar OCD retrograde drilling. No statistically significant difference was identified between the success and failure group. Talar OCD in a paediatric population is uncommon, and this study reviewed the outcome of retrograde drilling with the largest sample size of the literature. Retrograde drilling achieved a successful outcome in 76% of the cases and represents a good option for the treatment of stable talar OCD

The use of retrograde femoral intramedullary nails in children for deformity correction is controversial. It is unknown if the injury to the central part of the growth plate results in premature bony union, leading to limb deformities or discrepancies. The aim of this study was to assess physeal healing and bone growth after insertion of a retrograde femoral nail thorough the centre of the physis in a skeletally immature experimental porcine model. Eleven immature pigs were included in the study. One leg was randomised for operation with a retrograde femoral nail (diameter 10.7 mm), whilst the non-operated contralateral remained as control. All nails were inserted centrally in coronal and sagittal plane under fluoroscopic guidance, and the nails spanned the physis. The nails were removed at 8 weeks. Both femora in all animals underwent MRI at baseline (pre-operatively), 8 weeks (after nail removal) and 16 weeks (before euthanasia). Femoral bone length was measured at 5 sites (anterior, posterior, central, lateral and medial) using 3d T1-weighted MRI. Growth was calculated after 8 weeks (growth with nail) and 16 weeks (growth without nail). Physeal cross-sectional area and percentage violated by the nail was determined on MRI. Operated side was compared to non-operated. Corresponding 95% confidence intervals were calculated. No differences in axial growth were observed between operated and non-operated sides. Mean growth difference was 0,61 mm [−0,78;2,01] whilst the nail was inserted into the bone and 0,72 mm [−1,04;1,65] after nail removal. No signs of angular bone deformities were found when comparing operated side to non-operated side. No premature bony healing at the physis occurred. Histology confirmed fibrous healing. Mean physeal violation was 5.72% [5.51; 5.93] by the femoral nail. The insertion of a retrograde femoral nail through the centre of an open physis might be a safe procedure with no subsequent growth arrest. However, experiments assessing the long term physeal healing and growth are needed

Background. The approach to Intramedullary (IM) fixation of long bone fractures remains a controversial issue. Early reports demonstrated less favourable results of retrograde nailing as compared with antegrade options due to higher non-union rates. The aim of this audit was to evaluate the outcomes of practice within the Trauma and Orthopaedic department with relation to IM nail fixation of diaphyseal femur fractures. Methodology. The Trauma database between February 2010 and September 2013 was used to identify all femur IM nailing procedures. Picture Archiving and Communication System (PACS) software was used to classify the fractures according to the Muller AO classification. All 3–2 (Diaphyseal femur fractures) were included in the audit. PACS imaging together with outpatient documentation was evaluated for radiological and clinical outcome. Results. A total sample size of 23 patients was identified (13 antegrade vs. 10 retrograde approach fixations). Mean patient age was 67 years and male to female ratios were similar (11M vs. 12F). Antegrade nailing was performed in a younger population as compared to retrograde nailing (mean age 60 vs. 73 respectively). Mean time to union was somewhat more protracted in the retrograde group (7 vs. 5 months), although all fractures united. The most common complication with relation to antegrade nailing was due to distal locking screws backing out. I case of infection was reported in the retrograde nail group, which was treated successfully with antibiotic therapy. There were 2 cases of nonunion observed in the antegrade group. Conclusions. The results of our practice were comparable to those published in recent literature. Overall, union rates for the two groups of fixation were similar. Each fixation technique is associated with its own specific set of complications. As a general rule antegrade nailing was reserved for a younger population so as to prevent trauma to the native knee joint

Retrograde nailing of femoral shaft fractures has been a routine trauma practice option for approximately five years and may be technically advantaged in many situations. Earlier review of our antegrade experience revealed that 30% of standard nails are recognized to frequently cause pain (30%) and/or heterotopic ossification at the hip; knee pain of unclear etiology was found frequently as well (13%). This review of our preliminary experience with retrograde nails found a 30% frequency of nonspecific knee pain complaints at a mean of thirty-four months. No ectopic ossification was seen and no nails had been removed. The purpose of this study was to review the experience of patients who have undergone retrograde femoral nailing with regard to possible knee pain complaints. Chart and imaging records were reviewed retrospectively. Patients were contacted and interviewed by telephone to determine late pain complaints. From January 2000 through February 2002, eighteen patients were treated for twenty-two femoral shaft fractures. The group included ten males and and eight females of mean age 54.5 years (range, nineteen to ninety years). Treatment was with Synthes retrograde femoral nails, reamed and statically locked, inserted under fluoroscopic control on a radiolucent table using a Tenet™ leg holder. At thirty-four months, all fractures had healed primarily with no appreciable malalignment, no infections and no nonunions. No intraarticular free bodies or ectopic ossification were seen. Eleven patients were asymptomatic with regard to the index injured extremity. Five had mild to moderate pain, generally localized anteriorly, without associated articular symptoms and not requiring any analgesia. Two had severe symptoms of diffuse knee pain with radiographic degenerative changes noted, but these were cases with associated complex tibial plateau fractures to account for it. Even eliminating these two patients, fully five of sixteen patients (30%) without associated periarticular trauma at the knee had mild to moderate nondisabling anterior knee pain complaints after retrograde femoral nailing. The frequency of anterior knee pain complaints after retrograde femoral nailing is significant. Previous authors have found knee pain complaints in 27–29% of cases. We found no evidence of articular derangement in our patients undergoing retrograde femoral nailing in the absence of associated periarticular trauma at the knee, we confirm a 30% frequency of nonspecific knee pain complaints persisting at almost three years after injury. Patients should be made aware that, at intermediate-term follow-up, mild to moderate knee pain may be a result of this fracture treatment

Open reduction and internal fixation of proximal humerus fractures with angular stable plates is, beside antegrade nailing of the humerus, a standard procedure. A retrograde nail has been developed to avoid penetrating the rotator cuff and to avoid opening the fracture side during osteosynthesis. The aim of our biomechanical study was to evaluate if retrograde nailing of proximal humerus fractures is as stable as locking plate osteosynthesis. The biomechanical properties of 2 implants were tested in 11 human fresh frozen cadaveric humeri pairs. The Retron Nail® and the Philos® plate were implanted after osteotomy. All specimens were suspected to axial and torque load for 1000 cycles in a servo pneumatic testing apparatus. The Philos® plate had greater torsion stiffness than the Retron® nail, but we found no significance. The Retron® nail had greater axial stiffness but our findings were not statistically significant. Our study showed, that there are no significant differences between a retrograde nail and locking plate osteosynthesis for proximal humerus fractures concerning axial and torsion deformities. Therefore the retrograde nail is a suitable alternative for fixation of proximal humerus fracture

Introduction Retrograde nailing of femoral shaft fractures, through the knee joint, have been increasing. The indications for retrograde nailing are presently still evolving. This paper aims to discuss the indications for retrograde nailing. Methods We had conducted a prospective trial of nailing of femoral shaft fractures, using the retrograde approach. Nails were placed and reamed, with both distal and proximal locking done. Attention was given to the appropriate entry point. A literature review is also presented. Results The set-up was easy. Operative time was a median of 70 minutes and average blood loss 200 mls. Time to union was 15 weeks with minimal complications, but dynamisation rates were high. No knee problems were found at a follow-up period of 47 months. Conclusions The indications for retrograde nailing are ipsilateral femoral and acetabular fractures, ipsilateral patellar and femoral shaft fractures, ipsilateral tibial amd femoral shaft fractures, multiple trauma, femoral fracture with previous ipsilateral hip fusion, bilateral femoral shaft fractures, the obese or pregnant patient with a unilateral/bilateral femoral shaft fractures and perhaps the elderly with a unilateral femoral shaft fracture. We feel that the retrograde nailing is a useful technique for the orthopaedic surgeon to have in his/her armamentarium. Due to the longer union time and possible knee damage, indications should be respected

Longstanding un-united scaphoid fractures or scapholunate insufficiency can progress to degenerative wrist osteoarthritis (termed scaphoid non-union advanced collapse (SNAC) or scapho-lunate advanced collapse (SLAC) respectively). Scaphoid excision and partial wrist fusion is a well-established procedure for the surgical treatment of this condition. In this study we present a novel technique and mid-term results, where fusion is reserved for the luno-capitate and triquetro-hamate joints, commonly referred to as bicolumnar fusion. The purpose of this study was to report functional and radiological outcomes in a series of patients who underwent this surgical technique. This was a prospective study of 23 consecutive patients (25 wrists) who underwent a bicolumnar carpal fusion from January 2014 to January 2017 due to a stage 2 or 3 SNAC/SLAC wrist, with a minimum follow-up of one year. In all cases two retrograde cannulated headless compression screws were used for inter-carpal fixation. The clinical assessment consisted of range of motion, grip and pinch strength that were compared with the unaffected contralateral side where possible. Patient-reported outcome measures, including the DASH and PRWE scores were analysed. The radiographic assessment parameters consisted of fusion state and the appearance of the radio-lunate joint space. We also examined the relationship between the capito-lunate fusion angle and wrist range of motion, comparing wrists fused with a capito-lunate angle greater than 20° of extension with wrists fused in a neutral position. The average follow-up was 2.9 years. The mean wrist extension was 41°, flexion 36° and radial-ulnar deviation arc was 43° (70%, 52% and 63% of contralateral side respectively). Grip strength was 40 kg and pinch strength was 8.9 kg, both 93% of contralateral side. Residual pain for activities of daily living was 1.4 (VAS). The mean DASH and PRWE scores were 19±16 and 29±18 respectively. There were three cases of non-union (fusion rate of 88%). Two wrists were converted to total wrist arthroplasty and one partial fusion was revised and healed successfully. Patients with an extended capito-lunate fusion angle trended toward more wrist extension but this did not reach statistical significance (P= 0.07). Wrist flexion did not differ between groups. Radio-lunate joint space narrowing progressed in 2 patients but did not affect their functional outcome. After bicolumnar carpal fusion using retrograde headless screws, patients in this series maintained a functional flexion-extension arc of motion, with grip-pinch strength that was close to normal. These functional outcomes and fusion rates were comparable with standard 4-corner fusion technique. A capito-lunate fusion angle greater than 20° may provide more wrist extension but further investigation is required to establish this effect. This technique has the advantage that compression screws are placed in a retrograde fashion, which does not violate the proximal articular surface of the lunate, preserving the residual load-bearing articulation. Moreover, the hardware is completely contained, with no revision surgery for hardware removal required in this series

In this retrospective radiographic review, we compared the adequacy of reduction of 18 femoral fractures treated by retrograde and 35 fractures treated by pro-grade nailing. The groups were similar with regard to age, gender and side of the fracture. In the prograde group, there were eight fractures of type A5, 25 of type A3 and two of type C2. In the retrograde group there were two type-A2 fractures, 14 type-A3 and two type-C2. On the Winquist classification there were eight group-0, two group-1, two group-3 and 23 group-4 fractures in the prograde group, and two group-0, one group-3 and 15 group-4 fractures in the retrograde group. We measured the lateral femoral angle (LFA) from the anatomical axis to assess alignment postoperatively. We considered an LFA value of 83( normal and LFA values between 78( and 88( acceptable. The LFA was greater than 88( in 3% of the prograde group and in 6% of the retrograde group. In the prograde and retrograde groups, 86% and 83% of the nails respectively were in the acceptable range. In both groups, the LFA was less than 78( in 11%. There was shift of more than 1 cm in 17% of the prograde and in 44% of the retrograde groups. Recurvatum of more than 5( was seen in 31%( of prograde and 22% of retrograde nailings. In the retrograde group, 67% of nails were distal to the femoral notch on the lateral radiograph and were deemed to be proud. We concluded that prograde and retrograde nailing of distal third femur fractures gave comparable results in terms of alignment, but that recurvatum could be problematic with prograde nailing and that shift and proud nails were a concern with retrograde nailing. The clinical significance of these results has still to be determined

Introduction: Distal femoral shaft and supracondylar fractures are now more common. Non-operative treatment of these challenging fractures is difficult and fraught with complications. Retrograde and supracondylar nails have emerged as a good alternative to stabilize these fractures. This study evaluates the outcome of retrograde femoral nails done over a span of 5 years at a University Hospital. Materials and Methods: In this retrospective study, review of case notes and radiographs of 56 patients was done. All patients, who underwent retrograde and supracondylar femoral nailing between 1999 and 2003 were included. Various factors including patient demographics, mechanism of injury and fracture type were studied. Time to union, intra and post -operative complications and need for re-operation were also recorded. Results: 41 retrograde and 15 supracondylar femoral nails were done in the study period. There were 16 males and 40 females. Most of the patients had sustained their fractures due to fall. 3 out of the 56 patients presented with open fractures. 53 patients had insertion of reamed nails and 52 of them had both ends locked. The average time of operation was 2 hours 10 minutes and the average blood loss was 500 ml. Most patients were mobilized early with partial weight bearing. There were 3 superficial wound infections, which resolved with appropriate antibiotics. There were no cases of nerve damage or septic arthritis. 2 patients died with bronchopneumonia in the post- operative period. 55 out of 56 fractures united at an average of 16 weeks. 1 patient required re-operation for non-union, 9 months after the index operation. Conclusion: We conclude from this study that there is a high union rate of distal femoral fractures treated with supracondylar and retrograde nails with very low complication rate. It allows early mobilization, particularly in elderly patients and seems to produce very good functional outcome with low re-operation rate

Purpose: Operative treatment of diaphyseal humeral fractures is indicated for transverse displaced fractures, pathological or impending fractures, non unions, fractures with radial nerve palsy and oblique fractures after conservative treatment failure. Different techniques are available but many surgeons have recently expressed a preference for retrograde nailing. We present our results with new generation retrograde self-locking nail. Methodology: From 1998 to 2004, we treated 112 patients with the cannulated retrograde EXP nail (LIMA LTO). All patient have been operated in the prone position on a conventional orthopaedic table. Proximal locking, in this device, is obtained by the angled protrusion of a wire from the nail proximal extremity. Experimental tests in the lab have confirmed the excellent torsion stability of this mechanism. Distally, the EXP nail has two little wings shaped to sit on the medial and lateral columns of the olecranic fossa and to thus provide an effective rotational and traction control. We treated 67 traumatic fracture, 15 pathological fractures, 10 impending fracture and 20 a non-unions. 10 patients in this series were obese. Results: Average surgical time was 40 minutes (min 30 – max 110). Average radiation exposure was 1 minute and 15 seconds (20 seconds for proximal locking). Union was obtained in all the 67 primary fractures and stability was secured for all the impending and pathological cases. All but 1 non-union healed after an average of 2.6 months. In 2 patients of the primary fractures and in 3 patients of the non-union group we had a delayed union. The 3 non-union patients healed after 5, 7 and 9 months respectively. Overall 9 of the 10 obese patients healed. No patients suffered shoulder pain. In 8 cases a reduction of less than 10 degrees of elbow extension was detected. Forty-five nails have been removed so far after an average of 11 months after nailing. No major problems in nail removal have been encountered. Conclusions: Retrograde nailing of the humerus presents significant advantages over other techniques and is meeting more and more consensus. The nail employed in this series provides satisfactory stability, it is cannulated and requires minimal radiation exposure

Introduction: Nailing of the femoral shaft fractures has almost exclusively been done through the antegrade approach. This involves the use of a traction table and location of the entry point piriform fossa can be difficult especially in the obese or well-built patient. The set-up and operative time and blood loss can be considerable. We conducted a prospective study of nailing of femoral fractures, using the retrograde approach (through the knee joint) to measure the operating time, blood loss and knee function. A purpose built retrograde system was used (ART Nail ® ACE Medical Company-El Segundo, California). Materials & Methods: Seventeen patients who had a femoral shaft fracture, either as an isolated injury, or with associated with other injuries were nailed using the Art Nail, using the retrograde approach. The patients were placed on a radiolucent table, with a bolster place under the knee joint. A stienmann pin was inserted into the ipsilateral tibia 1” inferior and posterior to the tibial tubercle. This was used to apply traction manually by an assistant. The surgical approach was to split the patella tendon and the knee joint was entered. Using a light source, the nail entry point at the intercondylar notch, 7mm anterior to the PCL, is located. The rest of the operative procedure was done according to the operative manual. Blood loss was estimated by the anaesthesiologist. A drain was inserted into the knee joint after a through wash-out and continuos passive motion was started when the drain was removed on the 2nd postoperative day. Results: Fourteen had a single fracture while 3 had other associated fractures. The age range of was 28 to 67 years. Operative time was 60–100 minutes with blood loss ranging from 50–600 mls,with the median at 200mls. Post-operative drainage was 10–335 mls with median at 100mls. One patient developed distal deep vein thrombosis. Two patients were lost to follow-up. Union occurred at 12–20 weeks in fourteen patients, Two patients had to undergo dynamisation of the nail, one of which required a bone grafting to achieve union at 24 weeks. Two patients had a 1cm shortening of the limb and there were no malrotations. Two patients had < 5 degree medial–lateral angulation, on X-ray. At six months follow-up, fourteen patients had full range of motion at the knee joint, while one patient who had chondrocalcinosis had range of motion from 0 to 90 degrees. . The follow-up period is from 10–26 months. No patient complained of pain or instability of the knee joint. Conclusion: The retrograde approach is a safe and quick method of nailing femoral shaft fractures with no medium term effects on the knee joint

Introduction: Symptomatic osteochondral lesions of the talus have been managed with a variety of operative techniques involving open or arthroscopic approaches to the ankle joint. The purpose of this study is to report our technique of drilling stable osteochondral lesions of the talus via a percutaneous retrograde approach using computed tomography for guidance. Materials and Methods: Seven adult patients with Berndt and Harty Stage 2 or 2A/5 (subchondral cyst positive) talar osteochondral lesions, confirmed by magnetic resonance imaging, had retrograde drilling with CT guidance performed under local anaesthesia. Follow-up MR imaging was performed to investigate radiological evidence of healing. Results: All retrograde drillings performed were technically successful. Discussion: The concept of retrograde drilling is to preserve intact articular cartilage while encouraging revascularisation of the osteochondral fragment. The use of CT allowed drilling without conventional direct visualisation of the articular surface via arthrotomy or arthroscopy. The procedure can therefore potentially be performed in an outpatient setting. Suggestions are made from review of the literature as to improve further the technique for future studies

Purpose of the study: The relative role for anterograde nailing in relation to retrograde nailing has become a highly debated issue. Bifemoral fractures would appear to be a priority indication for the later method. Material and methods: From January 1997 to December 2003, 19 bifemoral shaft fractures were treated by simultaneous retrograde nailing (group 1, eight cases, five males, three females) or by anterograde nailing in a one-stage procedure (group 2, eleven cases, six males, five females). Patient age was 23 years 7 months on average (range 16.6–40.5 years) in group 1 and 26 years 7 months (range 17.8–42.3 years) in group 2. The ISS was 30.6 (13–50) in group 1 and 16.8 (10–27) in group 2. Results: The time for installation of the two femurs was 30 min (range 20–40 min) in group 1 and 70 min (range 60–80 min) in group 2. The operative time for the two femurs was 144 min (range 110–170) in group 1 and 156 min (range 140–180 min) in group 2. One patient in group 1 died on day 2 postop; none in group 2. First-intention bone healing was achieved at 14 weeks (range 12–16) in all patients in group 1. In group 2, there were two nail replacements and two grafts. Healing time was 24 weeks (range 10–130). Follow-up was 24 months (range 13–54 months). Knee flexion was 138° (range 130–140°) in group 1 (removal of patellar tendon calcification in one patient) and 123° (range 110–150°) in group 2. The difference in length between the two femurs was 6.2 mm (range 0–6 mm) in group 1 and 5.3 mm (range 0–11 mm) in group 2. The functional outcome (Thorensen criteria) was excellent in nine femurs, good in five in group one and excellent in nine, good in nine and fair in four in group 2. Conclusion: Retrograde nailing provides clinical and radiographic results which are comparable to antero-grade nailing. However, the time required and the ease of installation is in favor of retrograde nailing

Purpose: The purpose of this study is to present an alternative method of treatment for periprosthetic fractures of the femur. Materials and methods: 8 patients, 4 of them after total hip arthroplasty and 4 after Austin Moore hemi-arthroplasty had periprosthetic fracture of the femur. By the classification of Beals and Towers, patients with fractures types IIIa, IIIb and IV were included in this study. All were treated by retrograde intramedullary nailing. The surgical procedure was done closed or open by insertion of a retrograde intramedullary nail. Distal interlocking was achieved by two transversal screws. Clinical and radiological follow-up was performed during the first year after operation. Results: One patient died in the postoperative period from cardiac complication and 2 failed to attend to follow-up. In 5 patients, complete healing of the fracture was noticed and return to daily activities. Conclusions: Retrograde intramedullary nailing of the femur may be a good solution of treatment for periprosthetic fractures of the femur

Aims: To evaluate the results of our preliminary experience with the retrograde nailing for distal femoral fractures. Methods: During the period 1997 Ð 2000, 39 patients with 43 fractures of the distal femur, treated with retrograde intramedullary nail. There were 10 periprosthetic, 2 nonunions after previous failed þxation and 1 pathological fracture. 12 fractures were extra-articular, 18 had intra-articular extension and 2 fractures were open Type II according to Gustillo classiþcation. The mechanism of injury was road trafþc accident in 15 cases, with 9 of those being polytrauma patients, simple fall in and 1 spontaneous fracture. Results: Union was achieved in 11,3 weeks average time. There were 2 mal-unions and 1 nonunion needed reoperation. From the rest of the patients there were 4 with an excellent functional score, 19 good and 2 fair results. There were one superþcial infection, treated conservatively. In one patient the metalwork removal was necessary because he complained of pain from the distal interlocking screws. Conclusions: Retrograde intramedullary nailing, appears to be a reliable technique to treat fractures of the distal femur. It is accompanied by a high union rate and a low infection rate. It offers the advantage of little soft tissue impairment and adequate stability necessary for the fracture healing. Blood loss is usually small and therefore the method is suitable for fracture treatment in elderly and polytrauma patients. The accuracy of the reduction remains a question, because there is no precise method to test it intraoperatively

Purpose: Retrograde nailing is emerging among methods proposed or stabilisation of femoral fractures above total knee arthroplasties (TKA). Material and methods. Between June 1994 and may 2000, 12 fractures above TKA were treated by retrograde nailing. These fractures occurred 43 months (4–51) after implantation of the TKA in three men and women aged 74 years (43–88). The fracture was situated just above the prosthetic trochlea in ten, and distant from the implant in two. The posterior cruciate ligament was preserved in six TKA and six were posterior stabilised prostheses. Indications for arthroplasty were degenerative joint disease in nine and rheumatoid polyarthritis in three. Four patients had proximal implants (one fixation and three prostheses). A percutaneous approach was used except for three cases in order protect the tibial component. Closed reduction was achieved, but required an open reduction for completion in two cases. the nail was advanced just to the trochlea in patients with a preserved posterior cruciate ligament and beyond the posterior stabilisation cage for the posterior stabilised implants. The knee was mobilised immediately after surgery and total weight-bearing was encouraged four to six weeks later. Results: There was one error in the proximal aiming, one metastatic infection from a leg ulcer at three months and one tibial loosening in a polyarthritic woman 66 months after arthroplasty, i.e. 51 months after the fracture. Bone healing was achieved at two to four months. Frontal deviation was less than 5°. Recurvatum was less than 5° in eight cases, between 5° and 10° in two cases and between 10° and 20° in two others. At mean follow-up of 23 months (3–60), maximal moss of mobility was 10°. There was not worsening of pain. Discussion: Retrograde nailing leads to bone healing with satisfactory frontal alignment and minimal loss of mobility. The approach uses the initial incision, facilitating complementary procedures or revision if needed. The main problem is controlling recurvatum, even though at the follow-up reported there was no clinical impact or loosening. The limitations of this method are well defined: free medullary canal, sufficient knee flexion, compatible femoral component. The tibial obstacle in posterior stabilised implants is less well known; It should be protected during the nailing if it is high. The polyethylene insert may have to be removed temporarily in certain cases. Conclusion: The two principal problems with retrograde nailing are recognising implants compatible with this technique and controlling recurvatum. Results are acceptable with a minimally invasive technique

Introduction: The purpose of this retrospective study was to evaluate the results of retrograde pinning, according to Hacketal procedure, for unstable fractures of the humeral neck with particular attention to three and four part fractures. Materials and Methods: Between 7/1990 and 4/2001, we treated 44 patients (26 females and 18 males) ranging in age from 16 to 92 years (mean: 59/5 years). 75% of the cases followed a domestic trauma. Using Neer classification there were 30 two part fractures, 12 three part and 2 four part fractures. After closed reduction was performed under biplane image intensification, a small incision was made to expose the distal humerus by blount dissection. A 5 mm hole was drilled. Three to five prebend Kirschner (25 cases) or Metaizeau pins (19 cases) were introduced retrograde achieving a ‘bouquet’-type fixation within the humeral head. Post operatively, the arm was immobilized in a Mayo-type sling for 2–3 weeks. Then mobilization was started in all directions except rotation, who was cautiously done later. The results were evaluated according to consolidation, pain and range of motion. Complications associated with the treatment were recorded. We considered as excellent results, asymptomatic shoulder with full motion, good results patients with slight pain or reduction of motion and bad results, those with any pain, valuable restriction of motion and functional handicap. Results: The mean follow up was 21/7 months. Two patients died before callus formation. All patients were re-examined or contacted by phone. No patient was lost to follow-up. The mean hospitalization range was 6.4 days. Two patients had loss of fixation. Fractures united with callus formation in 4 to 8 week. Patients regained a full range of motion in 64% of the cases, 88% were free of pain. No avascular necrosis was noted in that series. The functional outcome was excellent in 64% of the cases, good in 21.5% of the cases. Pins removal was almost necessary for proximal pins migration in 45% of the cases and distal migration in 7.5% of the cases. Discussion: The overall finding of good results in this series compares favorably with results of other operative treatment. We believe that our technique offers distinct advantages: few displacement, no osteonecrosis but our follow-up can be considered as insufficient. Migrations of the pins remain a matter of concern. Conclusion: Retrograde pinning by the olcranon fossea is a demanding technique which makes sense biologically from the stand point of respect of vascularity. It is a useful alternative to open reduction and internal fixation. In three or four part fractures, it has to be tested before primary hemiarthroplasty

Purpose To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN). Method We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, two patients died of unrelated causes and four patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post-traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the American Orthopaedic Foot and Ankle (AOFAS) hindfoot score and with three independent observers reviewing radiographs. Results Radiologically 17 ankles fused, three probably fused whilst 16 (33%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Postoperatively the mean AOFAS score was 51, 25 patients were satisfied (of these 50% had radiological non-union) and 19 would undergo the same procedure again. Conclusion Despite a high rate of ankle and subtalar non-union, most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and subtalar joint arthritis, patients should be warned of the potential for non-union and high complication rates

Introduction. The incidence of distal femoral fractures amongst elderly patients is likely to rise due to increased life expectancy. This study reports on the outcome of a series of distal femoral fractures treated by retrograde femoral nailing and then to compare the results for these patients with a series of patients with a proximal femoral fracture. Materials and/Methods. In this longitudinal cohort study, 36 patients with extra-articular distal femoral fractures were treated with a solid retrograde femoral nail. Data was collected prospectively and then compared to proximal femoral fractures (2426) treated by the same surgeon treated over the same time period. Results. Within the distal femoral group 97% of the patients were female, with a mean age of 81 years. The mean length of hospital stay amongst the distal femoral group was slightly higher (19 days) compared to the proximal femoral group (18 days). All the post-operative complications were higher amongst the distal femoral group which included deep vein thrombosis 8% vs 2%, pneumonia 5% vs 3%, superficial wound infection 5% vs 3% and deep wound infection 2% vs 1%. 5% of patients in the proximal femoral group required revision surgery whereas none in the distal femoral group did. The survival analysis curve indicated to an increased trend in mortality amongst the distal femoral group however due to the small sample size this did not reach statistical significance. Conclusions. Our study shows that there is a significant morbidity and mortality amongst patients who have sustained a distal femoral fracture. Given the significant risk that elderly patients have we propose that distal femoral fractures should be treated with prompt surgical fixation with an emphasis on early rehabilitation and safe discharge