Comparing Entry Points for Antegrade Nailing of Femoral Shaft Fractures

The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. The purpose of this systematic review was to determine whether there is a difference in operative parameters, healing, and functional outcome when comparing the greater trochanter (GT) and piriformis fossa (PF) entry points. A systematic search of multiple databases and 3 major orthopedic meetings (American Academy of Orthopaedic Surgeons, Canadian Orthopaedic Association, and Orthopaedic Trauma Association) was conducted. Four studies (570 patients) met the inclusion criteria. Mean patient age was 34.5 years, and 60.4% were male. The GT entry point was associated with significantly shorter operative (mean difference [MD], -20.05 minutes [95% confidence interval (CI), -23.09 to -17.02]; P<.00001) and fluoroscopy times (MD, -24.55 seconds [95% CI, -43.23 to -5.86]; P=.01). There was no significant difference in nonunion (risk ratio [RR], 0.74 [95% CI, 0.35 to 1.58]; P=.44) and delayed union rates (RR, 0.94 [95% CI, 0.41 to 2.14]; P=.88) between the 2 entry points. Heterogeneity in outcome measures reported prevented pooled analysis of functional outcomes. This review supports the use of the GT entry point during antegrade nailing of femoral shaft fractures over the PF entry point, with regard to shorter operative and fluoroscopy times. Healing and complication rates were not related to the entry point. Further study is required to determine the effect of each entry point on the surrounding soft tissue structures and ultimately its impact on postoperative function.