Fig. 20.1
Operative treatment of a distal femur fracture (AO/OTA Type 33.C.1) with lag screws and an anatomical plate (Lambotte 1913)
However, bone surgery before antibiosis, blood transfusion, and operative fluoroscopy was a hazardous undertaking. As late as 1939, Campbell’s, the standard American Text, recommended screw fixation of the femoral condyles with cast treatment for “T” fractures (Fig. 20.2). Soon, cast treatment was improved with the introduction of hinged casts (the cast brace) for ambulatory management of supracondylar fractures [2].
Fig. 20.2
(a, b) Open reduction and lag screw fixation of a distal femur fracture AO/OTA Type 33.C.1 with lag screws. The supracondylar fracture was treated in a cast (Campbell 1939)
In the 1940s fixed angle blade plates used originally for proximal femoral osteotomies were adapted to the distal femur. As early as 1943, Dr. Hugh Thompson of New York treated a supracondylar fracture of the femur with a Moore-Blount blade-plate [3, 4]. This technique evolved into blade-plate fixation of supracondylar fractures as recommended by the Swiss Fracture Study Group (A0/ASIF.) The angle blade had to be placed precisely in the distal femur. In this technique guiding Kirschner wires are placed to locate the correct entrance point for the blade. The postoperative program allowed early motion to maintain cartilage health and to avoid the knee joint stiffness which was inevitable with cast immobilization. Interestingly, the results are generally reported as good when cases where the method could be followed acceptably are included. In Schatzker’s series only half of the cases were considered to have been treated “in accordance with the principles.” [5, 6]. The development of the compression hip screw led to the use of a reversed compression hip screw as an alternative for the stabilization of supracondylar fractures [7].
20.2 The Development of the Retrograde Supracondylar Nail
In 1987 Dr. Stuart Green from Los Angeles, California and Dr. David Seligson of Louisville, Kentucky began a dialogue about an intramedullary supracondylar nail for the treatment of low energy split condylar fractures of the distal femur in the elderly. They wanted a nail that was easy to insert percutaneously with a nail mounted guide for finding the locking holes for screws. They discussed ideas from Rush [8], Huckstep, Modny and Bambara [9], Zickel et al. [10] and Klemm and Schellmann [11]. The first illustrations from Stuart Green were for a portion of straight nail from the Huckstep nail manufactured by the Downs Company in London. At the time Downs’s equipment was not readily available in the United States and innovative new design prototypes were not forthcoming. Richards’ medical (today Smith and Nephew) worked with Seligson in Louisville to produce a nail and nail guide expressly for supracondylar nailing [12].
The first nailings were done in the summer of 1988 and reported to the Kuentscher society at its annual meeting [13]. Seligson invited Green to submit a preliminary paper for publication in Techniques in Orthopedics. The first versions of the Intramedullary Supracondylar nail were 10 and 12 mm in diameter with lengths of 150 and 200 mm. The holes were spaced at intervals the length of the nail. The nail had an 8° bend at the distal end, and the last two holes were placed closer together in the distal segment. The nail had holes for 6.5 mm locking screws. The nail fit to a guide with a side arm to locate the locking holes.
The original clinical cases in Louisville and Los Angeles were performed in elderly patients will low energy fractures and these went well. Postoperatively the regimen was non-weight bearing with active assisted limited flexion (45 at first) of the knee until the leg and the patient began to get better (usually at 6 weeks.) Straight leg raising exercises were prohibited. The patients were placed in a knee immobilizer and subsequently fitted with a long leg brace or a hinged knee brace. The collaboration of Green, Seligson, and Henry in the development of this implant led to the eponym – the ‘GSH’ nail. The early results were reported at the AAOS Annual Meeting in New Orleans in February, 1990 [14].
Independently, Kuis and de Ridder in the Netherlands adapted a short ‘reversed’ Gamma nail for the nailing of supracondylar fractures from the knee. The nail of Kuis and de Ridder was straight and a bit thicker than the GSH nail. Kuis and de Ridder report their first series of 11 patients from eight Dutch Hospitals in 1992 [15]. In Budapest, Sárváry fabricated a nail for retrograde insertion and interlocking and by 1992 documented a similar series of 11 cases (Fig. 20.3a–f).
Fig. 20.3
(a, b) Intra- and supracondylar multifragmentary femur fracture. Anteroposterior and lateral view (c, d) Minimal invasive fixation with condylar lag screws and retrograde supracondylar nail. Anteroposterior and lateral view. (e, f) Bony healing after 6 months. Anteroposterior and lateral view (Dr. Andras Sárváry, personal communication 1992)
The results with these early cases were surprisingly good. They were so go that Dr. David Seligson’s young associate Dr. Steven Henry used the supracondylar nail in young patients as well and in patients with high energy injuries (Fig. 20.4a–f). Innacone and Born began using the nail in Camden, New Jersey and in 1991 reported their cases combined with Henry’s at the Orthopedic Trauma Association Annual meeting in Seattle [16, 17]. Mechanical comparison between the intramedullary supracondylar nail and the much stiffer reversed compression screw showed greater resistance to lateral bending, compression, and torque with the compression screw, but the nail had adequate resistance to varus loading [18].
Fig. 20.4
A 34-year old motorcycle driver suffered a AO/OTA 33.C3 fracture of the right distal femur. (a, b) Preoperative anteroposterior and lateral views. (c, d) The intraarticular fracture was open reduced and fixed with several lag screws through an anterolateral approach, the supracondylar fracture stabilized with a retrograde femoral nail with four locking bolts. Postoperative anteroposterior and lateral view. (e, f) Anteroposterior and lateral view 1 year after surgery
20.3 The Original Technique
Green and Seligson devised a simple technique for nailing as a counterpoise to the elaborate method of blade plate fixation. Elderly patients with poor bone would benefit, they reasoned, from an intuitive, short duration operation with minimum local and systemic tissue cost. When the soft tissues are not substantial and bone is paper thin, Kirschner guide wires easily dislodge. Creating an entrance hole with drills and a router is pointless when the blade itself can manually be pushed through the cortex. Therefore the operation was performed on a radiolucent table with the patient is the supine position. A rolled up drape is placed as a bump under the distal femur to put the knee in flexion, restore the antecurvation of the distal femur shaft and relax the gastrocnemii. A good closed reduction is critical. Small incisions for bone holding clamps are sometimes helpful. After the fracture is reduced closed an entrance hole is made through a stab wound located by fluoroscopy. The entrance point is reamed to not more than 13 mm to avoid separating the condyles and the nail pushed not hammered into the distal femur with the bend facing either anteriorly or posteriorly depending on the reduction of the fracture. A locking screw guide assists in finding the holes for 6.5 mm coarse-threaded screws [19].
The details of postoperative care are important to the success of this method. Case series where although the nailing is well done, but the postoperative program is poorly controlled do not do justice to the technique. In the original concept supracondylar retrograde nailing was introduced for the treatment of unstable fractures in elderly patients with osteoporotic bone and limited activity demand. After nailing, the leg is placed in a knee immobilizer. The construct is not stable enough for weight bearing. A therapist, nurse or family member comes by once or twice daily and lifts the leg out of the immobilizer and takes the knee through a short arc of motion (45°). The patient is encouraged to do supine knee setting in the immobilizer. As the leg control returns the patient is advanced to short arc active assisted range of motion of the knee. It takes about 10 days to 2 weeks for swelling to subside sufficiently to fit the leg with a hinged knee brace. At this time the patient can be brought to a standing position in a walker and allowed to bear a little weight on the limb in the brace. It takes about a month before the patient begins to walk again. Usually the elderly patient leads the way by showing the doctors how much more the leg can do as fracture consolidation begins. More is not better and overzealous physiotherapy directed at increased range of motion should not be allowed. Exercises such as abduction and adduction of the leg (‘snow queens’), are pointless, put marked stress on the osteosynthesis, and should be prohibited. Younger patients with better bone and simpler fracture patterns can be progressed sooner. In all cases, sutures are left in place until the wound is convincingly healed. This often takes 3–4 weeks. Most patients are on chemoprophylaxis for thromboembolism for 10 days to 2 weeks following surgery. There is no clear guideline for the duration of therapy. The literature and the litigation over this issue is extensive. The bottom line is that a small number of patients (less than 5 %) embolize no matter the duration or type of prophylaxis. Chemoprophylaxis can create wound problems that usually resolve slowly in time.
20.4 Extended Indications
When a method is used in new situations it is inevitable that new problems will arise. In supracondylar nailing these difficulties fall into two general categories: complications from the design of the implants and biological complications. Many criticisms were leveled at the supracondylar nail when it was first introduced. Some thought that it would damage the ligaments of the knee. Careful anatomic studies now have shown that the entrance point is anterior to the cruciate ligaments and they are not damaged by the operation. Others opined that there would be a high incident of arthrofibrosis. Indeed many cases show a reduced range of motion from maximal knee flexion, this loss of flexion has not been problematic. One respected and senior trauma surgeon thought that this ‘antigravity’ nail would ‘fall out’; that has not been the case. Finally few cases of septic arthritis of the knee have resulted from the use of the retrograde, transarticular approach to the femur.
As the nail came into more general use particularly in more active and less sedentary patients, complications of the nail design emerged. These included nail breakage particularly through the hole just proximal to the bend in the nail, screw migration, and subsidence of the nail into the knee joint. These problems induced the Richards’ Company to change the form of the implant. The first change in 1992 was to reduce the size of the locking screws to 5 mm with a corresponding decrease of the size of the holes in the nail. This change delayed but did not eliminate the problem of nail breakage. So the screw holes proximal to the bend in the nail were eliminated to produce the so-called ‘five-hole’ nail.
The smaller 5 mm locking screws provide less convincing anchorage particularly in osteoporotic bone of the distal femur. One solution to this problem was the expansion sleeve from Vécsei in Vienna. If ‘Vécsei Bolts’ break, the fragments are hard to remove making the bolts unacceptable for the North American market. Künstcher proposed a cannulated locking bolt for the distal femur. This cannulated bolt was to be introduced through a nail over a guide wire and mated to a threaded nut on the far side. This design was adapted for Seligson by the Richards’ Company with special instruments for insertion through a nail in the distal femur. The bolt is introduced at the far end of the screw and the special washer lies beneath the head of the screw. Since the distal femur is sloped and not flat, these bolts not only are hard to place and countersink but also can be painful and prominent at the knee. The patent for a “Supra Condylus Bone Nail” filed in 1997 by Asche and associates shows a similar locking bolt [20] (Fig. 20.5).
Fig. 20.5
Patent application of a supracondylar nail by G. Asche in 1997
20.5 The Current State of Retrograde Nailing of the Femur
20.5.1 Current Clinical Practice
Since the time of Künstcher and Böhler most femoral fractures have been nailed antegrade from a starting point at the greater trochanter with the patient on a fracture table. In the early decades, the nails were open section relatively stout and unlocked (15–18 mm) [21]. The practice has evolved to the use of closed section nails of small caliber locked both proximally and distally. Some centers are successfully nailing without an extension table. However, nailing from the knee can be easier, and there has not been a problem with infection probably because the entrance hole from the nail is rapidly sealed over by the synovium. Retrograde nailing is a great advantage for certain clinical scenarios:
1.
With massive obesity when the infrapatellar entry is much easier to find than the trochanteric entry point
2.
With spinal injury when positioning on the fracture table would apply dangerous torsional forces to the spine
3.
With tissue injury at the greater trochanter which would impose risks for infection at the entry point for an antegrade nail
4.
When body habitus or associated conditions like lower limb amputations make antegrade nailing inconvenient
5.
With pregnancy when undesired radiation would be delivered to the fetus
20.5.2 Distal Femur Fractures
The current treatment of supracondylar femur fractures aims to provide articular reduction, axial alignment, and stable fixation to allow early motion and weight bearing while utilizing indirect fracture reduction techniques in order to preserve tissue biology. The current treatment options include retrograde femoral nailing, with a variety of interlocking options, distal femoral locking plates, and condylar blade plates. The retrograde nail is considered a standard alternative to plate fixation particularly for type C fractures [22]. The advantages of locking plates and retrograde nails are the ability to insert these devices with minimal soft tissue disruption. The advantage of nailing when it can be done percutaneously is the rapid evolution of callus when the fracture site has not been exposed. This is possible in various situations particularly with low energy injuries. The recent advance in plate fixation is the use of plates with fixed angle screws where the plate can be passed percutaneously through a tunnel across the fracture site and then fixed to bone proximal to the fracture either through a short incision or with a guide fixed to the plate. This technique provides a biological advantage equivalent to closed nailing [23]. Many controversies persist with respect to the best interlocking pattern and number of screws or bolts required to provide adequate fixation.