title: Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures.
abstract: OBJECTIVE
  The purpose of this study was to compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa with nails specifically designed for each starting point.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Four level 1 trauma centers.
  
  
  METHODS
  One-hundred and eight patients treated by 1 of 4 surgeons for a femoral shaft or subtrochanteric fracture with antegrade nailing between January 2001 and April 2003 were included. Four patients who expired early in the postoperative period and 13 with insufficient follow-up were excluded from analysis.
  
  
  METHODS
  Patients were treated with either nailing through a greater trochanter starting point with the Trigen TAN nail (GT group) (n = 38) or through a piriformis fossa starting point with the Trigen FAN nail (PF group) (n = 53).
  
  
  METHODS
  Operative time, fluoroscopy time, fracture alignment, fracture healing, complications, and functional outcome based on the lower-extremity measure (LEM).
  
  
  RESULTS
  Thirty-seven of the 38 fractures from the GT group and 52 of the 53 fractures from the PF group healed after the index procedure. One patient from the GT group had external rotation malalignment of 12 degrees. There were no other malalignments or iatrogenic fracture comminution. There were 2 infectious complications, 1 from each group. The average operative time was 75 minutes for piriformis insertion using the FAN nail and 62 minutes for trochanteric insertion using the TAN nail (P = 0.08). The average fluoroscopy time was 61% greater for the PF group (153 seconds) than for the GT group (95 seconds) (P < 0.05). These differences were magnified in patients who were obese (body mass index > 30) where the operative time was 30% greater (P < 0.05) and the fluoroscopy time was 73% higher in the PF group (P < 0.02). Patients from both groups had a similar initial decline and subsequent improvement in function over time (P > 0.05).
  
  
  CONCLUSIONS
  A femoral nail specially designed for trochanteric insertion resulted in equally high union rates, equally low complication rates, and functional results similar to conventional antegrade femoral nailing through the piriformis fossa. The greater trochanter entry portal coupled with an appropriately designed nail represents a rational alternative for antegrade femoral nailing with the benefit of decreased fluoroscopy time and decreased operative time in patients who are obese.
authors.affiliation: Washington University School of Medicine at Barnes-Jewish Hospital, Department of Orthopaedic Surgery, St Louis, MO 63110, USA. ricciw@wustl.edu
authors.forename: William M
authors.initials: WM
authors.lastname: Ricci
authors.forename: John
authors.initials: J
authors.lastname: Schwappach
authors.forename: Michael
authors.initials: M
authors.lastname: Tucker
authors.forename: Kevin
authors.initials: K
authors.lastname: Coupe
authors.forename: Angel
authors.initials: A
authors.lastname: Brandt
authors.forename: Roy
authors.initials: R
authors.lastname: Sanders
authors.forename: Ross
authors.initials: R
authors.lastname: Leighton
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001858:Bone Nails; D015331:Cohort Studies; D018483:Diaphyses / Q000293:injuries* / Q000601:surgery; D005260:Female; D005264:Femoral Fractures / Q000601:surgery*; D005269:Femur / Q000601:surgery*; D005471:Fluoroscopy; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome