Soft tissue anatomy around the hip and its implications for choice of entry point in antegrade femoral nailing

Abstract

Antegrade intramedullary nailing is an accepted method of treatment for femoral shaft fractures. Entrance of the nail through the trochanteric fossa is currently recommended by some surgeons. This approach results in some cases, however, in loss of abduction strength and persistent pain. Nail insertion at the tip of the greater trochanter may be more favorable. In this study the anatomical relationships of the trochanteric fossa and of the tip of the greater trochanter were explored. Dissection was carried out in 10 fresh human cadaver femurs. The risks and safety of the two entry points with respect to the adjacent soft tissues were assessed. Abductor muscles and tendons, branches of the medial circumflex femoral artery and the hip joint capsule were at risk during nail insertion through the trochanteric fossa. These structures were not endangered during insertion through the trochanteric tip. The reported clinical morbidity after nailing through the trochanteric fossa may result from direct soft tissue injury and may be reduced by choosing the route through the greater trochanter.

An appraisal of the short lateral rotators of the hip joint

“…The terminology in the literature regarding this attachment site is variable, being described as: “digital fossa” (Gray et al, ), “pit” (Lumley et al, ) and “depression” (Tortora and Derrickson, ) on the posterior aspect of the medial surface of the greater trochanter (Papadakis et al, ; Ito et al, ). In many reports, OE is described as inserting into the “piriform fossa” (Moein et al, ; Solomon et al, ) while, in a study of eight cadavers, Robinson et al () identified the OE insertion as the “trochanteric fossa”. Although, the discrepancy in the terminology has been discussed by Papadakis et al () in an attempt to improve the accuracy and reliability of the intramedullary nailing surgical procedure, it persists.…”

Does using different entrance points for intramedullary nails affect clinical outcomes for femoral shaft fractures? A retrospective clinical comparative study

“…Stannard et al [3] reported intraoperative parameters including fluoroscopy time and duration of surgery to be better in the GTE group with no differences in functional outcomes. Although some cadaveric studies have claimed that the GT entrance may decrease morbidity due to a reduction in soft tissue injury, [5] other clinical studies have shown that functional outcomes, particularly in regard to the gluteus medius, abductor muscles, and tensor fasciae to be similar between different entrance points [3]. However, only a handful of studies have directly compared the effects of the entrance point among supra-isthmal, isthmal, and infra-isthmal femoral shaft fractures [9].…”

“…However, the duration of postoperative stay in the hospital was longer in the TFE group, likely due to the higher number of open reductions performed in this group. Although several authors have recommended the use of a more lateralized entrance for treatment of femoral shaft fractures, [1,5,12], further studies have revealed that despite developments in the design of GTE nails, more iatrogenic fractures with associated varus malalignment can be anticipated [13]. However, previous studies had not classified these fractures according to the level at which they occurred, which means it is not obvious whether these iatrogenic fractures would be evenly distributed across all fractures or would be isolated to a particular group.…”

“…Abductor muscles and tendons, branches of the medial circumflex femoral artery, and the hip joint capsule are at risk during antegrade nailing of shaft fractures. Moein et al [5] investigated the risks and safety of the two entry points with respect to the adjacent soft tissues on cadaveric femurs, and found that GTE was a safer option. This suggests that clinical morbidity may result from direct soft tissue injury after nailing through the trochanteric fossa, which may be reduced by choosing the route through the greater trochanter.…”