Introduction: Little attention is paid to insertion site morbidity associat
ed with antegrade femoral nailing. However, residual peritrochanteric pain
after nailing is not uncommon. Additionally, the end branches of the medial
femoral circumflex artery (m.f.c.a.) supplying the femoral head are in clo
se proximity to the insertion site of the nail, and the occurrence of avasc
ular necrosis of the femoral epiphysis after nailing in adolescents is rath
er frequent.
Objective: The aim of this study was to assess iatrogenic soft tissue injur
ies at the site of nail insertion.
Materials and Methods: Nailing with a reamed AO universal femoral nail was
performed on sixteen adult cadavers followed by dissection of the proximal
part of the femur to assess possible damage to the soft tissues. Three entr
y portals were defined. (A) entry portal lateral to the junction of the nec
k and the greater trochanter; (B) entry portal at the base of the greater t
rochanter anterior to a line along the longitudinal axis of the femoral nec
k; and (C) entry portal at the base of the greater trochanter posterior to
a line along the axis of the femoral neck (at the piriformis fossa).
Results: In Group A, partial avulsion of the piriformis and the obturator i
nternus tendon were present in four and in one of five specimens, respectiv
ely. Group B showed injuries to the piriformis tendon in two and to the glu
teus minimus tendon in one of four cases. In Group C, partial avulsion of t
he piriformis, obturator internus, and obturator externus tendon were encou
ntered in five, six, and two of seven specimens, respectively. Anterior bra
nches of the ramus profundus of the m.f.c.a. within the synovial fold were
damaged in all of these cases.
Conclusion: To select the best nail entry portal, the ease of nail insertio
n must be weighed against the resulting soft tissue damage at the site of i
nsertion. The nail entry portal at the piriformis fossa, although geometric
ally ideal and most recommended, causes the most significant damage to musc
le and tendons as well as to the blood supply to the femoral head. Therefor
e, even if reported only once, the occurrence of avascular necrosis of the
femoral head after nailing in adults is a possible complication of this nai
l entry portal. The authors therefore prefer to avoid this entry portal in
every case. The nail entry portal anterior to the longitudinal axis of the
femoral neck, as in group B, although better with respect to the soft tissu
e damage, has the worst geometric and biomechanical disadvantages. The resu
lts of the current study favor the nail entry portal lateral at the greater
trochanter as in Group A, which is equal to the entry portal B with respec
t to the soft tissue damage but allows introduction of the nail into the me
dullar cavity without difficulties.