Nailing precision: a systematic review and meta-analysis of randomized controlled trials comparing piriformis and trochanteric entry points for femoral antegrade nailing

Daniel Acevedo; Andy Suarez; Taylor Checkley; Iman Fakhoury; Mariafe Reyes; David Constantinescu; Giselle M Hernandez

doi:10.1007/s00402-024-05359-6

Nailing precision: a systematic review and meta-analysis of randomized controlled trials comparing piriformis and trochanteric entry points for femoral antegrade nailing

Arch Orthop Trauma Surg. 2024 May 14. doi: 10.1007/s00402-024-05359-6. Online ahead of print.

Authors

Daniel Acevedo¹, Andy Suarez², Taylor Checkley², Iman Fakhoury², Mariafe Reyes², David Constantinescu³, Giselle M Hernandez³

Affiliations

¹ Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD), Fort Lauderdale, FL, USA. Acevedodaniel5100@gmail.com.
² Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD), Fort Lauderdale, FL, USA.
³ Department of Orthopedic Surgery, University of Miami Hospital, Miami, FL, USA.

PMID: 38744693
DOI: 10.1007/s00402-024-05359-6

Abstract

Introduction: Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs.

Materials and methods: A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion.

Results: Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26 min (95% CI - 28.60 to - 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33 s, 95% CI - 84.441 to - 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found.

Conclusion: The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics.

Keywords: Femoral antegrade nailing; Femur fractures; Intramedullary nail; Trochanteric fracturs.