In patients treated in the LD position, side supports were used to bring the pelvic ring of the patient into a perpendicular position to the table. Nail insertion was identical to that described for the patients in the SCLE position. The distal holes were locked after the exact circular shape of the hole was obtained on the lateral view with the C-arm. Rotation and length were determined as described for the patients in the SCLE position.
During the early postoperative period, all patients performed regular hip and knee ROM and isometric exercises. Patients were mobilized with weightbearing permitted as tolerated after 3 weeks.
Patients and Methods
We retrospectively reviewed data from all 116 patients treated with AO/ASIF Type 32  femoral shaft fractures with intramedullary nailing from November 2004 and July 2009. All operations were performed by three surgeons (AF, AO, MB) who were experienced with at least 5 years as trauma department specialists and with an equivalent degree of experience in both techniques. We first performed a series of LD position cases. After gaining experience with the SCLE position, it was used routinely. Data from 53 patients were not analyzed because the patients were in the standard supine position (n = 11) for surgery, had coexisting proximal or distal metaphyseal femoral fractures (n = 15), had coexisting ipsilateral or contralateral tibia or femoral fractures (n = 7), had multiple trauma (n = 9), had a pathologic fracture (n = 1), had a problem with the uninjured extremity that could affect rotational measurements (n = 4), and could not be reached for followup (n = 6). Among the remaining 63 patients, 30 were treated with the SCLE approach (mean age, 38 years; 30% female) and 33 with the LD approach (mean age, 37 years; 36% female). There were no differences in selection of patients. All patients were operated on with these techniques for the same indication. The indication for the SCLE approach was AO/ASIF Type 32 femoral shaft fractures. The contraindications were: (1) contralateral leg fractured; (2) contralateral hip or knee contracture; and (3) contralateral compartment syndrome or neurovascular injury. The indication for the LD approach was AO/ASIF Type 32 femoral shaft fractures. The contraindications were: (1) contralateral hip or leg fracture; (2) coexisting pelvic fracture; and (3) coexisting abdominal injury that required laparotomy. Minimum followup was 20 months (mean, 46 months; range, 20-72 months). The patients were informed about the surgical procedure and their informed consent was obtained before surgery. Our retrospective data were reviewed and approved by the institutional review board.
We observed no differences in demographic characteristics and fracture patterns between the two groups (Table 1).
All patients were followed monthly from discharge to bony union and then every 3 months until the second year. On followup, we routinely examined ROM, muscle strength, extremity length, and rotation. Additionally, plain radiographs were collected. All patient data including surgical and fluoroscopy times (from C-arm monitor) and complications were recorded routinely. Major complications were defined as deep infection, compartment syndrome, and neurovascular injury. A minor complication was defined as a superficial infection. Infections were diagnosed with microbiologic and hematologic tests, compartment syndrome with physical examination, and, if needed, using an intracompartmental pressure measuring device. Neurovascular complications were assessed with electroneuromyography and Doppler sonography.
We reviewed the patient charts and recorded demographic information, fracture pattern, intramedullary nail diameter, fluoroscopy and surgery times, complications, and whether open reduction was performed. Measurements of limb length, alignment, and rotation were performed independently by three surgeons (CI, RA, MA) who were not treating surgeons. Mean values were calculated. Limb lengths were measured from the hip to ankle with orthoroentgenograms which means an AP view of both lower extremities from hip to ankle, and the limb length differences compared with the contralateral side were noted (Fig. 6). Final extremity length was classified as one of five subgroups; equal limb, shortening 10 mm or less, shortening greater than 10 mm, lengthening 10 mm or less, or lengthening greater than10 mm. The number of patients in each group was determined . A longer length than the uninjured leg was considered a positive value and a shorter length than the uninjured leg was considered a negative value. Coronal-sagittal plane alignments were evaluated with standard radiographs. According to the criteria of Thoresen et al. , greater than 5° varus-valgus angulation for the AP plane and greater than 10° antecurvatum-recurvatum angulation for the sagittal plane denote fair and poor values. We considered the fair and poor values of these criteria as unsatisfactory. Rotational alignment of the uninjured and injured lower extremities was evaluated clinically by measuring the internal and external rotation using a goniometer while the hip was at 90° flexion with the patient supine and 0° hip flexion with the patient prone; the mean values in each position were calculated . The shift in ROM toward internal or external rotation determined the clinical rotational deformity. Internal and external rotational deficits were classified as greater or less than 15° . Because a difference of as much as 15° may occur normally , we considered a difference in torsion angle greater than 15° as rotational malalignment . External rotation was noted as a positive value and internal rotation as a negative value. The repeatability of the measurements of limb length, alignment, and rotation for the three observers was determined with Cronbach’s alpha (alpha = 0.837).
The categorical variables of patient demographics and fracture characteristics such as sex, side, cause of injury, diaphyseal segment, AO fracture type, and Gustilo type were compared between groups using chi-square and Fisher’s exact tests, and the mean age and implant diameter were compared using Student’s t-test. We determined differences in surgery time between the SCLE and LD groups using the Mann-Whitney U test, fluoroscopy time using Student’s t-test, and open reduction rate, rotational deformities, and limb length differences using the chi-square test. There were no missing data for any patients included in the study. Statistical analysis was performed using SPSS Version 15.0 (SPSS, Inc, Chicago, IL, USA).
The mean surgery time was shorter (p = 0.001) in the SCLE group (98 minutes) than in the LD group (108 minutes). The mean fluoroscopy time was shorter (p = 0.003) in the SCLE group (3.4 minutes) than in the LD group (3.8 minutes) (Table 2).
The mean difference in limb length was +0.4 mm (range, −14 to +17 mm) in the SCLE group and −1.6 mm (range, −12 to +14 mm) in the LD group. When the number of patients in the subgroups were compared between groups, there were more patients (p < 0.001) in the shortening 10 mm or less subgroup in the LD group (Table 3). There were no differences among subgroups.
We detected no coronal-sagittal plane malalignment in either group. Mean rotational differences between injured and uninjured extremities were +1.2° (range, −17° to +19°) in the SCLE group and −2.6° (range, −24° to +22°) in the LD group. When the two groups were compared for malrotation, there were more patients (p < 0.001) who had greater than 15° internal rotation in the LD group (six patients [18%]). Five of six patients were those with AO/ASIF Type C fractures (Fig. 7). There were no differences for other values between groups (Table 3).
Three of 30 patients (10%) in the SCLE group and 12 of 33 patients (36%) in the LD group needed open reduction through a minimal incision for passage of the reduction guide wire to the distal fragment during surgery. The open reduction rate was lower (p = 0.001) in the SCLE group when compared with the LD group.
At the last followup, all fractures had healed. None of the patients underwent revision surgery as a result of limb length discrepancy or rotational deformity (Fig. 8). Two patients in the SCLE group and four in the LD group developed superficial infections, which all resolved with oral antibiotics. One patient in the LD group experienced a deep infection after a Grade 2 open fracture, treated with sequential débridement and antibiotics. No patient had compartment syndrome or peroneal nerve injury of the uninjured leg.
Manual traction for femoral intramedullary nailing can be performed with the patient in either the standard supine or LD position [8, 15, 20, 21]. In the standard supine position, some surgeons elevate the injured extremity with a bump; some surgeons also use a fracture table for controlled adduction to obtain a proper entry point for the nail [8, 13, 15, 17, 20]. Although this position permits full adduction and facilitates nail entry, taking true orthogonal views with the C-arm becomes difficult as a result of oblique placement of the extremity. In the LD position, the fractured extremity is directed anterior and downward on the contralateral extremity to obtain hip adduction so that the patient’s pelvis is rotating on the table from the absolute lateral position . In both positions, because the fractured extremity needs to be positioned in full adduction during surgery, the extremity is not able to be positioned parallel to the floor owing to overlapping of the extremities while it contacts with the OR table. Therefore achieving and maintaining anatomic reduction is difficult as a result of placement of the femur off the table during manual traction. It mostly depends on the position of the patient on the OR table. This also complicates taking true AP and lateral fluoroscopic views of the fracture and results in much more radiation exposure. We, therefore, developed a technique of positioning the patient supine with the contralateral leg elevated.
We recognize limitations of our study. First, we had a relatively small number of patients although sufficient to describe the technique and report operating and fluoroscopy times. Second, we compared only two positions excluding the standard supine position. While we began to use the original SCLE position we continued using LD position. Therefore we used the SCLE and the LD positions for comparison. Third, we did not evaluate the durations of each surgical and fluoroscopic step (such as patient preparation, nail entry, reduction, locking). Because the SCLE position facilitated the various steps of the operation, we considered it important to record the total surgical and fluoroscopic times. Fourth, we have no randomization. However, the indications for both positions were similar.
Wolinsky et al. reported mean operative times of 107 ± 36 minutes for femoral interlocking nailing with the patient in the supine position without a fracture table . We found the operative time for patients in the SCLE position (mean duration, 98 minutes) was shorter than that of the patients in the LD position (mean duration, 108 minutes). Surgery time is affected by several steps, like preoperative preparation, nail entry, reduction, nail placement, and locking. Although nail entry and locking steps are performed in the same manner, we suggest that time spent for reduction may be different between two positions. Although this result is statistically meaningful, it has no practical importance. However, this is a new technique with better logic. We believe that it can be improved with time.
In the supine position with 30° hip elevation, because of the angle between the fractured femur and the table, the AP view must be obtained by rotating the C-arm. In the SCLE position, the C-arm is easily placed around the OR table and the true AP view can easily be obtained. As a result of these factors, fluoroscopy time for patients in the SCLE position (mean duration, 3.4 minutes) in our study was less than for patients in the LD position (mean duration, 3.8 minutes). Less fluoroscopy time was probably the result of the easier reduction and nail placement that the SCLE position afforded, although this difference would have no practical importance for individual patients.
Limb length discrepancy after intramedullary nailing of femoral shaft fractures is not uncommon [20, 22]. We measured the limb length discrepancy with standing orthoroentgenograms and less than 10 mm shortening was observed more often in the LD group than the SCLE group. Although this amount of limb length discrepancy is not clinically important, it serves as an indication of the greater difficulty in maintaining anatomic reduction with the patient in the LD position.
Liu et al.  reported some disadvantages of the LD position. They emphasized that it is difficult to take the true AP view with fluoroscopy and varus or valgus deformity may occur in fractures adjacent to the distal part of the femur. In addition, they reported it is difficult to perform reduction of comminuted (Winquist-Hansen Type 3 or 4 ) fractures in this position. We did not detect any varus or valgus malalignment in six patients with AO/ASIF Type C fractures when they were in the SCLE position during the operation.
In patients with comminuted fractures, rotational deformities and limb length discrepancies are more common [4, 7]. Reducing comminuted fractures is especially difficult with the patient in the LD position. However, in the SCLE position, the fractured extremity is supported by the OR table, making control of the fractured fragments much easier. More of our patients in the LD position than the SCLE position had greater than 15° internal rotation. For patients in the LD position, five of the six who had greater than 15° rotational deformity were those with AO/ASIF Type C fractures. In the treatment of AO/ASIF Type C fractures, the SCLE position may be the preferred position.
Several techniques have been described for reduction of femur fractures during closed intramedullary femoral nailing . In all these techniques, two reduction maneuvers are needed for passing the guide wire and nail placement. Between these stages the first reduction is usually lost because of the intermittent and decreased powered manual traction by the assistant. In the SCLE position, with the support provided by the table, less effort is needed to maintain the reduction. In our study, the SCLE position also resulted in fewer patients needing a limited open reduction procedure when compared with patients in the LD position. We recognize that our open reduction rate is high in both groups. This problem is most likely attributable to our relative inexperience with closed nailing and our lack of modern equipment. We suspect that with the correction of these issues, our need for open reduction will decrease substantially. However, this situation in no way detracts from our overall findings. We believe the SCLE technique is a reasonable choice of treatment, as it facilitates obtaining orthogonal views of the femur thereby shortening surgery and fluoroscopy times for femoral intramedullary nailing.
We thank Cetin Isik MD, Ramazan Akmese MD, and Murat Altay MD for making the measurements of limb length, alignment, and rotation.
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