Clinical, functional and radiological outcome of retrograde femoral nailing in femoral shaft fractures: an observational study

INTRODUCTION

A femur fracture is among the most frequently occurring fractures, and if not managed appropriately, it can result in severe long-term disability or even life-threatening complications.¹ Femoral shaft fractures are common orthopaedic injuries, typically caused by high-energy trauma, including motor vehicle collisions or falls from significant heights.² If not properly managed, these fractures can result in significant morbidity, highlighting the need for effective treatment strategies. Managing femur fractures often involves a multidisciplinary approach that considers underlying medical conditions while ensuring appropriate surgical stabilization, early mobilization, and rehabilitation. This comprehensive care strategy is essential for restoring functional mobility and promoting early independence.^3,4 A delay in appropriate surgical treatment is linked to a higher risk of complications and increased mortality rates.^5,6

Intramedullary nailing (IMN) is now the standard treatment for femoral shaft fractures, boasting high union rates of approximately 97%. This technique offers several advantages, including minimally invasive application, stable fracture fixation, quicker procedural execution, and early patient mobilization, all of which contribute to improved recovery outcomes.^7,8

However, factors such as nail design, the presence of grooves, the number and positioning of locking screws, the distance from the fracture site, and bone quality can significantly impact the implant’s resistance to various mechanical forces.^9,10 Despite the benefits of intramedullary nailing (IMN), several challenges remain, including the risk of soft tissue damage, increased fluoroscopy exposure, extended operative duration, and difficulties in distal locking screw placement.^11,12

Given the complexity of femoral shaft fractures and the need for optimal fixation methods, retrograde intramedullary nailing (RIMN) has emerged as a valuable alternative to antegrade nailing, particularly in cases where proximal femoral access is challenging or contraindicated. This technique offers several advantages, including preservation of the hip abductors, reduced risk of iatrogenic injury to the femoral head, and improved suitability for patients with multiple injuries or ipsilateral hip and knee pathologies.

However, its clinical efficacy must be evaluated in terms of functional recovery, complication rates, and radiological outcomes to determine its role in contemporary fracture management. Hence this study aimed to assess the clinical, functional, and radiological outcomes of retrograde femoral nailing in the treatment of femoral shaft fractures.

METHODS

This prospective observational study was conducted over a period of one year at the Asian Orthopaedic Institute, SIMS Hospitals. The study included patients diagnosed with femoral shaft fractures, selected using consecutive sampling, resulting in a total sample size of 38. Patients aged above 18 years, of either sex, with clinically and radiologically confirmed femoral shaft fractures were included. Open fractures classified as type I, II, IIIA, and IIIB according to the Gustilo-Anderson classification, patients fit for surgery, and those willing to participate were eligible for inclusion. Patients were excluded if they were below 18 years of age, unwilling to participate, unfit for surgery or anaesthesia, or had type IIIC compound femoral fractures.

All patients underwent surgery using the retrograde technique, with procedures performed by a single senior orthopaedic trauma surgeon. A Smith and Nephew retrograde nail was used in all cases, following the manufacturer's operative technique and using appropriate instruments. Postoperatively, patients were followed up at 2 weeks, 6 weeks, 3 months, and 6 months. At each follow-up, clinical and radiological assessments were conducted. Radiological evaluation involved anteroposterior and lateral X-rays of the operated limb, while clinical assessments included evaluation of pain, range of motion, time to weight-bearing, and return to work. Pain was measured using the visual analogue scale (VAS), and functional outcomes were assessed subjectively using the lower extremity functional scale (LEFS).

Data were entered in Microsoft Excel and analysed using SPSS version 21.0. Descriptive statistics, including frequency and proportion for categorical variables and mean with standard deviation for quantitative variables, were used. Repeated Measures ANOVA was used to assess overall changes in outcome measures (such as VAS and LEFS scores) across multiple time points. Additionally, paired t-tests were performed for specific time-point comparisons. A p value of less than 0.005 was considered statistically significant.

RESULTS

Table 1 summarizes the demographic and clinical characteristics of the study participants. The majority of patients (36.8%) were aged between 61 and 80 years, followed by 31.6% in the 41–60 years age group, 21.1% in the 20–40 years group, and 10.5% were above 80 years. Female patients (55%) slightly outnumbered male patients (45%). Regarding the side of injury, fractures were distributed almost equally between the left (50%) and right (47%) femur, with one patient (3%) having bilateral fractures. Slip and fall was the most common mode of injury (53%), followed closely by road traffic accidents (47%). According to the AO fracture classification, 44.7% of patients had Type A1 fractures, 28.9% had Type A2, and 26.3% had Type A3 fractures.

In Table 2, the mean operative time among the study participants was 120.26 minutes with a standard deviation of 59.97 minutes, indicating variability in surgical duration. Similarly, the mean duration of hospital stay was 9.16 days with a standard deviation of 7.91 days.

In Figure 1, the data illustrates the time of union among participants with a mean Time of Union of 14.53 weeks ±4.4. The majority of participants reaching union at various time intervals where, 20 participants achieved union within 12 weeks, 9 participants within 16 weeks, 6 participants within 20 weeks, and 2 participants within 24 weeks.

In Figure 2, the mean lower extremity functional scale (LEFS) scores at different time intervals indicate a progressive improvement in functional outcomes among the study participants. At 2 weeks, the mean LEFS was 23.76 (SD ±4.14), which increased to 37.42 (SD ±7.17) at 6 weeks. By 3 months, the mean score further improved to 51.11 (SD ±8.41), and at 6 months, it reached 63.29 (SD ±8.80).

Table 3 compares the mean LEFS scores at different intervals using a paired t-test. At 2 weeks, the mean LEFS score was 23.76±4.14, which significantly increased to 37.42±7.16 at 6 weeks (t=19.987, p=0.000). Further improvement was observed at 3 months, with a mean score of 51.11±8.41 (t=21.171, p=0.000), and at 6 months, the mean score reached 63.29±8.80. The p values for all comparisons were less than 0.05, indicating statistically significant improvements in the LEFS scores at each interval.

In Figure 3, the mean visual analog scale (VAS) scores at different time intervals demonstrate a gradual reduction in pain among the study participants. At 2 weeks, the mean VAS score was 4.95 (SD±1.04), which decreased to 2.68 (SD±0.99) at 6 weeks. By 3 months, the mean score further declined to 0.84 (SD±0.82), and at 6 months, it reached 0.34 (SD±0.48). This steady decrease in pain levels over time suggests significant pain relief and recovery following retrograde femoral nailing.

Table 4 compares the mean VAS scores at different intervals using a paired t-test. At 2 weeks, the mean VAS score was 4.95±1.038, which significantly decreased to 2.68 ± 0.989 at 6 weeks (t = 19.282, p=0.000). The VAS score further decreased to 0.84 ± 0.823 at 3 months (t=4.482, p=0.000), and continued to decline to 0.34±0.481 at 6 months. The p values for all comparisons were less than 0.05, indicating statistically significant reductions in VAS scores at each interval.

In Table 5, the mean range of motion (ROM) scores at different time intervals indicate a progressive improvement in joint mobility among the study participants. At 6 weeks, the mean ROM was 77.37° (SD±18.26), which increased to 98.82° (SD±17.95) at 3 months. By 6 months, the ROM further improved to 112.63° (SD±16.43). This upward trend suggests a steady recovery in knee mobility following retrograde femoral nailing, with significant gains over time.

Table 6 presents the changes in LEFS, VAS, and ROM among study participants over the study period. The LEFS (lower extremity functional scale) showed a significant change, with a p value of <0.001, indicating a highly significant improvement in lower extremity function over time. The VAS (Visual Analogue Scale for pain) also demonstrated a significant reduction in pain levels, with a p value of <0.001, confirming that the observed changes were statistically significant. Similarly, the ROM (Range of Motion) exhibited notable improvement, with a p value of <0.001, highlighting a significant increase in joint mobility over the study period. In Figure 4a, the pre-operative CT scan reveals a comminuted proximal humerus fracture. Figure 4b shows the immediate postoperative radiograph with anatomical reduction and stable fixation with Smith and Nephew retrograde nail. Figures 4c, 4d, and 4e demonstrate serial follow-up images at 6 weeks, 3 months, and 6 months, respectively. At 6 weeks, early callus formation was noted; by 3 months, bridging callus indicated progressive healing; and by 6 months, complete union with restored cortical continuity was observed, with no evidence of implant-related complications.

P value 0.000 ˂0.05 was taken as statistically significant

0.00 ˂0.05 was taken as statistically significant

DISCUSSION

In the present study, the number of female participants was higher than males, whereas Khanzada et al reported more males. In the current study, the average age of fracture occurrence was 42.3±0.9 years, in contrast to 29.4 years as reported by Ostrum et al. Most participants had left-sided injuries, while study conducted by Khanzada et al observed more right-sided cases. Slip and fall was the most common mode of injury in this study, whereas their findings showed a different trend. However, the majority of patients had A1 type fractures in both studies, showing a similar pattern.^13,14

The average time for union was 14.5 weeks, with only one case of non-union, compared to 20.3±2.13 weeks reported by Anaberu et al, and 24.2 weeks in a study by Salphale et al.^15,16 A meta-analysis by Dokostakis et al, reported a shorter union time in a group of 553 femoral fractures treated with a retrograde nail. Additionally, no complications were observed in this study, which is consistent with the findings of Cannada et al.

A study by Kim et al reported a union time of 17.4 weeks.^17-19 The mean knee range of motion was 112±16℃, consistent with the findings of Kim et al, who reported a mean knee ROM of 116℃, and Anaberu et al, who reported a mean knee ROM of greater than 111 degrees.^15,19 At 2 weeks, the mean lower extremity functional scale (LEFS) score was 23.76±4.14, and at 6 weeks, the mean score increased to 37.42±7.17.

The difference was statistically significant (˂0.005), indicating a higher LEFS at 6 weeks compared to 2 weeks. At 3 months, the mean LEFS score was 51.11±8.41, and at 6 months, it further increased to 63.29±8.80. The difference was statistically significant (˂0.005), showing a higher LEFS at 3 months compared to 6 months. Thus, there was a significant improvement in the LEFS from 2 weeks to 6 months, reflecting a good functional outcome. Additionally, the mean visual analogue scale (VAS) scores were recorded at 2 weeks, 6 weeks, 3 months, and 6 months. At 2 weeks, the VAS was 4.95±1.04, at 6 weeks it decreased to 2.68±0.99, at 3 months it was 0.84±0.82, and at 6 months it further decreased to 0.34±0.48. At 2 weeks, the mean VAS score was 4.95±1.04, and at 6 weeks, it was 2.68±0.99. The difference was statistically significant (˂0.005), showing a lower VAS score at 6 weeks compared to 2 weeks. At 3 months, the mean VAS score was 0.84±0.82, and at 6 months, it was 0.34±0.48.

The difference was statistically significant (˂0.005), indicating a lower VAS score at 6 months compared to 3 months. In the current study, the mean LEFS score steadily increased from the 2nd week to 6 months, demonstrating a continuous improvement in functional outcomes. Similarly, the mean VAS score showed a gradual decline over the same period, indicating a reduction in pain. Additionally, the mean knee range of motion improved progressively from the 3rd week to 6 months, reflecting enhanced joint mobility over time.

In this study, the time of union was not associated with any demographic characteristics, which is consistent with the findings of Shah et al.²⁰ The mean operative time was 120 minutes and average hospital stay was 9 days. The absence of complications in this study could be attributed to several factors, including meticulous surgical technique, proper patient selection, and adherence to postoperative protocols.

CONCLUSION

Retrograde intramedullary nailing (RIMN) is a safe and effective option for femoral shaft fractures, especially when proximal access is challenging. It offers advantages such as preserved hip abductor function, easier positioning, reduced operative time, and minimal blood loss. This study showed significant functional improvements, with higher LEFS scores, lower VAS scores, and better knee mobility over six months. Union times were consistent with literature, with no major complications. Demographic factors had no significant effect on healing, supporting RIMN as a reliable method for early mobilization and favorable outcomes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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