Case Reports

Antegrade Femoral Nail Distal Interlocking Screw Causing Rupture of the Medial Patellofemoral Ligament and Patellar Instability

Publish date: July 11, 2018

Gregory L. Cvetanovich, MD

Gift Ukwuani, MD

Benjamin Kuhns, MD

Alexander E. Weber, MD

Edward Beck, MPH

Shane J. Nho, MD, MS

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Anterograde intramedullary nailing is the gold standard for fixation of diaphyseal femur fractures.
Damage to the MPFL can be caused by the distal interlocking screw of an anterograde intramedullary nail.
The trajectory of the distal interlocking screw from posterolateral to anteromedial, and a prominent screw tip, likely contributed to the injury to the MPFL observed in this case.
Surgeons treating these conditions should pursue advanced imaging if patients present with effusion and patellar instability after femoral intramedullary nail placement.
Distal interlocking screw removal and arthroscopic MPFL reconstruction can result in successful return of function and normal activities.

References

Brumback RJ, Virkus WW. Intramedullary nailing of the femur: reamed versus nonreamed. J Am Acad Orthop Surg. 2000;8(2):83-90.
Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15(3):161-169.
Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009;17(5):296-305.
Lindsey JD, Krieg JC. Femoral malrotation following intramedullary nail fixation. J Am Acad Orthop Surg. 2011;19(1):17-26.
Busam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg. 2006;14(2):113-120.
Morshed S, Humphrey M, Corrales LA, Millett M, Hoffinger SA. Retention of flexible intramedullary nails following treatment of pediatric femur fractures. Arch Orthop Trauma Surg. 2007;127(7):509-514.
Boerger TO, Patel G, Murphy JP. Is routine removal of intramedullary nails justified. Injury. 1999;30(2):79-81.
Kellan J. Fracture healing: Does hardware removal enhance patient outcomes. Chin J Orthop Trauma (Chin). 2010;12:374-378.
Schöttle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med. 2007;35(5):801-804. doi:10.1177/0363546506296415.
Stephen JM, Lumpaopong P, Deehan DJ, Kader D, Amis AA. The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and nonanatomic attachments. Am J Sports Med. 2012;40(8):1871-1879. doi:10.1177/0363546512449998.
Hüfner T, Citak M, Suero EM, et al. Femoral malrotation after unreamed intramedullary nailing: an evaluation of influencing operative factors. J Orthop Trauma. 2011;25(4):224-227. doi:10.1097/BOT.0b013e3181e47e3b.
Ayalon OB, Patel NM, Yoon RS, Donegan DJ, Koerner JD, Liporace FA. Comparing femoral version after intramedullary nailing performed by trauma-trained and non-trauma trained surgeons: is there a difference? Injury. 2014;45(7):1091-1094. doi:10.1016/j.injury.2014.01.024.
Patel NM, Yoon RS, Cantlon MB, Koerner JD, Donegan DJ, Liporace FA. Intramedullary nailing of diaphyseal femur fractures secondary to gunshot wounds: predictors of postoperative malrotation. J Orthop Trauma. 2014;28(12):711-714. doi:10.1097/BOT.0000000000000124.
Ziegler CG, Fulkerson JP, Edgar C. Radiographic reference points are inaccurate with and without a true lateral radiograph: the importance of anatomy in medial patellofemoral ligament reconstruction. Am J Sports Med. 2016;44(1):133-142.
Fulkerson JP, Edgar C. Medial quadriceps tendon-femoral ligament: surgical anatomy and reconstruction technique to prevent patella instability. Arthrosc Tech. 2013;2(2):e125-e128. doi:10.1016/j.eats.2013.01.002.
Tanaka MJ, Voss A, Fulkerson JP. The anatomic midpoint of the attachment of the medial patellofemoral complex. J Bone Joint Surg Am. 2016;98(14):1199-1205. doi:10.2106/JBJS.15.01182.
Mochizuki T, Nimura A, Tateishi T, Yamaguchi K, Muneta T, Akita K. Anatomic study of the attachment of the medial patellofemoral ligament and its characteristic relationships to the vastus intermedius. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):305-310. doi:10.1007/s00167-012-1993-7.

References

Brumback RJ, Virkus WW. Intramedullary nailing of the femur: reamed versus nonreamed. J Am Acad Orthop Surg. 2000;8(2):83-90.
Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15(3):161-169.
Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009;17(5):296-305.
Lindsey JD, Krieg JC. Femoral malrotation following intramedullary nail fixation. J Am Acad Orthop Surg. 2011;19(1):17-26.
Busam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg. 2006;14(2):113-120.
Morshed S, Humphrey M, Corrales LA, Millett M, Hoffinger SA. Retention of flexible intramedullary nails following treatment of pediatric femur fractures. Arch Orthop Trauma Surg. 2007;127(7):509-514.
Boerger TO, Patel G, Murphy JP. Is routine removal of intramedullary nails justified. Injury. 1999;30(2):79-81.
Kellan J. Fracture healing: Does hardware removal enhance patient outcomes. Chin J Orthop Trauma (Chin). 2010;12:374-378.
Schöttle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med. 2007;35(5):801-804. doi:10.1177/0363546506296415.
Stephen JM, Lumpaopong P, Deehan DJ, Kader D, Amis AA. The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and nonanatomic attachments. Am J Sports Med. 2012;40(8):1871-1879. doi:10.1177/0363546512449998.
Hüfner T, Citak M, Suero EM, et al. Femoral malrotation after unreamed intramedullary nailing: an evaluation of influencing operative factors. J Orthop Trauma. 2011;25(4):224-227. doi:10.1097/BOT.0b013e3181e47e3b.
Ayalon OB, Patel NM, Yoon RS, Donegan DJ, Koerner JD, Liporace FA. Comparing femoral version after intramedullary nailing performed by trauma-trained and non-trauma trained surgeons: is there a difference? Injury. 2014;45(7):1091-1094. doi:10.1016/j.injury.2014.01.024.
Patel NM, Yoon RS, Cantlon MB, Koerner JD, Donegan DJ, Liporace FA. Intramedullary nailing of diaphyseal femur fractures secondary to gunshot wounds: predictors of postoperative malrotation. J Orthop Trauma. 2014;28(12):711-714. doi:10.1097/BOT.0000000000000124.
Ziegler CG, Fulkerson JP, Edgar C. Radiographic reference points are inaccurate with and without a true lateral radiograph: the importance of anatomy in medial patellofemoral ligament reconstruction. Am J Sports Med. 2016;44(1):133-142.
Fulkerson JP, Edgar C. Medial quadriceps tendon-femoral ligament: surgical anatomy and reconstruction technique to prevent patella instability. Arthrosc Tech. 2013;2(2):e125-e128. doi:10.1016/j.eats.2013.01.002.
Tanaka MJ, Voss A, Fulkerson JP. The anatomic midpoint of the attachment of the medial patellofemoral complex. J Bone Joint Surg Am. 2016;98(14):1199-1205. doi:10.2106/JBJS.15.01182.
Mochizuki T, Nimura A, Tateishi T, Yamaguchi K, Muneta T, Akita K. Anatomic study of the attachment of the medial patellofemoral ligament and its characteristic relationships to the vastus intermedius. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):305-310. doi:10.1007/s00167-012-1993-7.

Antegrade Femoral Nail Distal Interlocking Screw Causing Rupture of the Medial Patellofemoral Ligament and Patellar Instability

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