JBJS | Intra-Articular Penetration of the Knee Joint by a Fragment of Cortical Bone during Intramedullary Nailing of the Femur. A Report of Two Cases*

The Journal of Bone & Joint Surgery, Volume 78, Issue 7

Articles | July 01, 1996

Intra-Articular Penetration of the Knee Joint by a Fragment of Cortical Bone during Intramedullary Nailing of the Femur. A Report of Two Cases*

DARREN L. JOHNSON, M.D.†; DONALD A. WISS, M.D.‡, LOS ANGELES, CALIFORNIA

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Investigation performed at the Division of Hand Surgery, Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento

The Journal of Bone & Joint Surgery. 1996; 78:1092-5

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Introduction

Introduction | Case Reports | Discussion | References

The preferred treatment for comminuted fractures of the femur extending from the lesser trochanter to the adductor tubercle is fixation with an intramedullary locking nail^{5-7,11,12,15,24-31}. The reported intraoperative complications of nailing have included an eccentric entry portal, problems with reaming, binding of the nail, iatrogenic comminution of the fracture, distraction of the fragments, extrusion of the nail into the soft tissues, injury of the femoral or popliteal artery, traction palsy of the sciatic or pudendal nerve, and penetration of the knee joint by the nail^{1-4,7-9,11-13,16-23}. We report the cases of two patients in whom a fragment of cortical bone became trapped in the open tip of an intramedullary nail and was driven into the knee joint during nailing of the femur.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†University of Kentucky Sports Medicine, Kentucky Clinic, Room K431, Lexington, Kentucky 40536-0284.

‡University of Southern California, Southern California Orthopaedic Institute, Van Nuys, California 91405.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†University of Kentucky Sports Medicine, Kentucky Clinic, Room K431, Lexington, Kentucky 40536-0284.

‡University of Southern California, Southern California Orthopaedic Institute, Van Nuys, California 91405.

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Figs. 1-A, 1-B, and 1-C: Case 1. Fig. 1-A: Anteroposterior radiograph showing a comminuted fracture of the femur with intra-articular extension.

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Fig. 1-B Anteroposterior and lateral radiographs of the knee after intramedullary nailing with static locking and placement of an additional transcondylar screw. A fragment of cortical bone is seen to be protruding through the intercondylar notch at the tip of the intramedullary nail (arrowheads).

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Fig. 1-C Intraoperative photograph showing the fragment of cortical bone (arrows) within the intercondylar notch before it was removed.

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Figs. 2-A, 2-B, and 2-C: Case 2. Fig. 2-A: Anteroposterior and lateral radiographs showing a transverse fracture of the femoral shaft with type-I comminution²⁶.

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Fig. 2-B: Anteroposterior and lateral radiographs made after intramedullary nailing with static locking, showing a spike of cortical bone (arrowheads) in the tip of the intramedullary nail penetrating the knee joint (arrows).

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Fig. 2-C Intraoperative photograph showing the cortical fragment (arrows) protruding through the intercondylar notch.

Case Reports

Introduction | Case Reports | Discussion | References

CASE 1. A forty-five-year-old man was in a motorcycle accident and sustained a grade-II open, comminuted, supracondylar fracture of the femur¹⁰ and that extended into the intercondylar notch (Fig. 1-A). The fracture was irrigated and debrided, and two percutaneous cancellous-bone lag-screws, 6.5 millimeters in diameter, were inserted to stabilize the articular surface. After seven days of skeletal traction with use of a tibial pin, closed nailing of the femur with static locking was performed⁵. Before the operation, 1.5 centimeters of the distal end of a thirteen-millimeter-diameter intramedullary nail was cut off to ensure placement of two distal locking screws into the condylar fragments¹⁴. The 6.5-millimeter-diameter lag-screw that had been placed proximally at the time of the initial operation was removed before the nailing.

Postoperative radiographs made in the recovery room revealed a fragment of cortical bone protruding through the fracture in the intercondylar notch (Fig. 1-B). Three days later, an arthrotomy with wide exposure of the joint was performed. At the time of the operation, a two-centimeter fragment of cortical bone protruding through the intercondylar notch was removed with use of a small osteotome and rongeur (Fig. 1-C). There was a three-millimeter separation of the condyles in the intercondylar notch. No other intra-articular abnormality was noted, and the reduction of the fracture was not revised. At the three-year follow-up examination, the fracture had united with 10 degrees of apex-posterior angulation, the knee had a range of motion of 5 degrees of hyperextension to 110 degrees of flexion, and the patient had returned to work as a laborer.

CASE 2. An eighteen-year-old woman was in a motorcycle accident and sustained multiple orthopaedic injuries, including a closed fracture of the proximal third of the femur with type-I comminution²⁶ (Fig. 2-A). Treatment at another facility consisted of insertion of an eleven-millimeter-diameter Kuntscher nail through the tip of the greater trochanter with use of a closed technique; the nail was not locked. Postoperatively, the patient was noted to have an external rotational deformity of the lower limb and was referred to our institution for additional treatment. On physical examination, this deformity was found to be 40 degrees. One week after the injury, the Küntscher nail was removed and intraoperative correction of the rotational deformity was performed through the fracture site with use of closed manipulation and insertion of a twelve-millimeter-diameter locking nail over a three-millimeter-diameter guide-wire. The nail was locked proximally and distally. The original trochanteric entry portal of the Küntscher nail was used during the exchange nailing, leading to iatrogenic comminution of the medial cortex of the proximal part of the femur. Radiographs made at the conclusion of the operation revealed a fragment of cortical bone protruding from the intercondylar notch (Fig. 2-B). An arthrotomy of the knee was performed, and a 1.5-centimeter spike of bone was removed with use of a small osteotome (Fig. 2-C). At the one-year follow-up examination, the fracture had healed and the knee had a full range of motion.

Discussion

Introduction | Case Reports | Discussion | References

To our knowledge, we are the first to report a complication of nailing in which a fragment of cortical bone became trapped within the open tip of the intramedullary nail and was driven down the femoral canal through the intercondylar notch and into the knee joint. We speculated that in our first patient (Case 1) the fragment of cortical bone became lodged in the distal part of the femoral canal at the time of the injury. However, it is possible that it was displaced into the canal either by the intramedullary guide-wire or by the reamers. During nailing, the guide-wire may have migrated proximally, allowing a fracture fragment to become trapped in the open tip of the nail. In addition, the removal of 1.5 centimeters of the distal part of the nail before its insertion eliminated the taper on the nail and may have predisposed it to trapping the fragment of bone. This untoward event may have been avoided if the fracture had been stabilized with plates and screws. However, recent reports have shown intramedullary nailing of a fracture of the distal part of the femur to have mechanical and biological advantages compared with plate osteosynthesis^6,14. In our second patient (Case 2), additional comminution of the fracture occurred during exchange nailing. We attributed this to the lateral entry point in the trochanter and to eccentric reaming. The three-millimeter-diameter guide-wire was insufficient to prevent a fracture fragment from becoming stuck in the tip of the nail and subsequently violating the knee joint. The case of this patient emphasizes the importance of establishing an entry point directly in line with the medullary canal in order to minimize the risk of iatrogenic comminution during reaming or nailing¹².

In an effort to minimize the risk of inadvertent penetration of the knee joint by a fragment of bone, we recommend the careful evaluation of preoperative radiographs in order to assess the degree and location of comminuted fracture fragments and non-displaced fracture lines; the use of high-quality biplanar imaging of the fracture site during passage of the guide-wire as well as during reaming and nailing in order to prevent or detect additional comminution of the fracture; and the use of full-length radiographs of the femur, including the hip and the knee joint, made after the conclusion of the operation but while the patient is still under anesthesia¹¹. Making such radiographs after nailing allows assessment of the implant, the alignment of the fracture, and the length of the limb as well as visualization of the femoral neck and the knee joint to rule out an associated fracture. Only after the radiographs have been carefully reviewed to verify that the placement of the nail and the reduction of the fracture are correct can an operation be safely terminated. This practice ensures that any technical complications can be corrected during the same anesthesia session, thereby avoiding a second procedure.

References

Introduction | Case Reports | Discussion | References

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