title: Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and meta-analysis.
abstract: BACKGROUND
  There are several different techniques commonly used to perform intramedullary (IM) nailing of the femur to fix femoral fractures. We sought to identify significant differences in outcomes of studies comparing 1) trochanteric and piriformis entry and 2) antegrade and retrograde entry in IM nailing of the femur.
  
  
  METHODS
  We searched MEDLINE, Cochrane and Embase databases and the Orthopaedic Trauma Association and American Academy of Orthopaedic Surgeons websites for comparative studies published from inception to November 2015. Criteria used to select articles for detailed review included use of antegrade and retrograde entry point or use of trochanteric and piriformis entry point for IM nailing of the femur in adult patients. Functional and technical outcomes were extracted from accepted studies.
  
  
  RESULTS
  We identified 483 potential studies, of which 52 were eligible. Of these, we included 13 publications and 2 abstracts (2 level I, 7 level II and 6 level III studies). Trochanteric entry significantly reduced operative duration by 14 min compared with piriformis entry (p= 0.030). Retrograde nailing had a greater risk of postoperative knee pain than antegrade nailing (p= 0.05). On the other hand, antegrade nailing had significantly more postoperative hip pain (p= 0.003) and heterotopic ossification (p< 0.001) than retrograde nailing. No significant differences in functional outcomes were observed.
  
  
  CONCLUSIONS
  Although some significant differences were found, the varying quality of studies made recommendation difficult. Our meta-analysis did not confirm superiority of either antegrade over retrograde or trochanteric over piriformis entry for IM nailing of the femur.
  
  
  METHODS
  Level III therapeutic.
authors.affiliation: From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar).
authors.forename: Nasir
authors.initials: N
authors.lastname: Hussain
authors.affiliation: From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar).
authors.forename: Farrah Naz
authors.initials: FN
authors.lastname: Hussain
authors.affiliation: From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar).
authors.forename: Corey
authors.initials: C
authors.lastname: Sermer
authors.affiliation: From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar).
authors.forename: Hera
authors.initials: H
authors.lastname: Kamdar
authors.affiliation: From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar).
authors.forename: Emil H
authors.initials: EH
authors.lastname: Schemitsch
authors.affiliation: From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar).
authors.forename: Amir
authors.initials: A
authors.lastname: Sternheim
authors.affiliation: From the Department of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Hussain, Naz Hussain, Schemitsch); the Wayne State University School of Medicine, Detroit, Michigan (Naz Hussain); the Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ont. (Sermer, Sternheim, Kuzyk); and the Dow University of Health Sciences, Karachi, Pakistan (Kamdar).
authors.forename: Paul
authors.initials: P
authors.lastname: Kuzyk
mesh_terms: D005264:Femoral Fractures / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary / Q000379:methods* / Q000592:standards; D006801:Humans; D010043:Outcome and Process Assessment, Health Care