International Orthopaedics

, Volume 42, Issue 6, pp 1379–1385 | Cite as

Heterotopic ossification around the knee after tibial nailing and ipsilateral antegrade and retrograde femoral nailing in the treatment of floating knee injuries

  • William T. Kent
  • Trevor J. Shelton
  • Jonathan Eastman
Original Paper



Floating knee injuries are relatively uncommon injuries. We report the prevalence, location, and severity of heterotopic ossification (HO) around the knee in patients treated with antegrade tibial intramedullary nailing and ipsilateral antegrade versus retrograde femoral intramedullary nailing as well as how the severity of HO around the knee affects knee range of motion (ROM).


From 2004 to 2014, 26 floating knee injuries were included. Radiographs were reviewed to determine presence, location, and severity of HO. Post-operative knee ROM was determined.


A significantly higher prevalence of HO around the knee was detected in the retrograde group (90%) compared to the antegrade group (43%) (p = 0.028). There was a trend for more HO into the patellar tendon occurring in 29% of patients in the antegrade group and 74% in the retrograde group (p = 0.069). The severity of HO was higher for the retrograde group 1.6 ± 1.0 compared to the antegrade group 0.4 ± 0.5 (p = 0.004). There was poor correlation between HO severity and knee ROM.


Treatment of floating knee injuries with a retrograde femoral nail was demonstrated to result in a greater likelihood of developing HO and a greater severity of HO around the knee than if treated with an antegrade femoral nail. However, this increased severity of HO is unlikely to affect ROM.

Level of evidence: III.


Heterotopic ossification Floating knee injury Retrograde nail Antegrade nail 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Patient consent

Obtaining the informed consent from involved patients was waived by the Institutional Review Board.

Ethical approval

All procedures involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments. The study was approved by the Institutional Review Board.

The study was approved by our ethical committee.


  1. 1.
    Elmrini A, Elibrahimi A, Agoumi O, Boutayeb F, Mahfoud M, Elbardouni A, Elyaacoubi M (2006) Ipsilateral fractures of tibia and femur or floating knee. Int Orthop 30(5):325–328. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Nouraei MH, Hosseini A, Zarezadeh A, Zahiri M (2013) Floating knee injuries: results of treatment and outcomes. J Res Med Sci 18(12):1087–1091PubMedPubMedCentralGoogle Scholar
  3. 3.
    Fraser RD, Hunter GA, Waddell JP (1978) Ipsilateral fracture of the femur and tibia. J Bone Joint Surg Br 60-B(4):510–515CrossRefPubMedGoogle Scholar
  4. 4.
    Omer GE Jr, Moll JH, Bacon WL (1968) Combinded fractures of the femur and tibia in a single extremity. Analytical study of cases at Brooke General Hospital from 1961-to1967. J Trauma 8(6):1026–1041CrossRefPubMedGoogle Scholar
  5. 5.
    Paul GR, Sawka MW, Whitelaw GP (1990) Fractures of the ipsilateral femur and tibia: emphasis on intra-articular and soft tissue injury. J Orthop Trauma 4(3):309–314CrossRefPubMedGoogle Scholar
  6. 6.
    Kaplan FS, Glaser DL, Hebela N, Shore EM (2004) Heterotopic ossification. J Am Acad Orthop Surg 12(2):116–125CrossRefPubMedGoogle Scholar
  7. 7.
    Mitchell EJ, Canter J, Norris P, Jenkins J, Morris J (2010) The genetics of heterotopic ossification: insight into the bone remodeling pathway. J Orthop Trauma 24(9):530–533. CrossRefPubMedGoogle Scholar
  8. 8.
    Nauth A, Giles E, Potter BK, Nesti LJ, O’Brien FP, Bosse MJ, Anglen JO, Mehta S, Ahn J, Miclau T, Schemitsch EH (2012) Heterotopic ossification in orthopaedic trauma. J Orthop Trauma 26(12):684–688. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Shehab D, Elgazzar AH, Collier BD (2002) Heterotopic ossification. J Nucl Med 43(3):346–353PubMedGoogle Scholar
  10. 10.
    Cipriano CA, Pill SG, Keenan MA (2009) Heterotopic ossification following traumatic brain injury and spinal cord injury. J Am Acad Orthop Surg 17(11):689–697CrossRefPubMedGoogle Scholar
  11. 11.
    Forsberg JA, Pepek JM, Wagner S, Wilson K, Flint J, Andersen RC, Tadaki D, Gage FA, Stojadinovic A, Elster EA (2009) Heterotopic ossification in high-energy wartime extremity injuries: prevalence and risk factors. J Bone Joint Surg Am 91(5):1084–1091. CrossRefPubMedGoogle Scholar
  12. 12.
    Garland DE (1988) Clinical observations on fractures and heterotopic ossification in the spinal cord and traumatic brain injured populations. Clin Orthop Relat Res 233:86–101Google Scholar
  13. 13.
    Wittenberg RH, Peschke U, Botel U (1992) Heterotopic ossification after spinal cord injury. Epidemiology and risk factors. J Bone Joint Surg Br 74(2):215–218CrossRefPubMedGoogle Scholar
  14. 14.
    Mills WJ, Tejwani N (2003) Heterotopic ossification after knee dislocation: the predictive value of the injury severity score. J Orthop Trauma 17(5):338–345CrossRefPubMedGoogle Scholar
  15. 15.
    Stannard JP, Wilson TC, Sheils TM, McGwin G Jr, Volgas DA, Alonso JE (2002) Heterotopic ossification associated with knee dislocation. Arthroscopy 18(8):835–839CrossRefPubMedGoogle Scholar
  16. 16.
    Horne LT, Blue BA (1999) Intraarticular heterotopic ossification in the knee following intramedullary nailing of the fractured femur using a retrograde method. J Orthop Trauma 13(5):385–388CrossRefPubMedGoogle Scholar
  17. 17.
    Howell RD, Park JH, Egol KA (2011) Late symptomatic heterotopic ossification of the patellar tendon after medial parapatellar intramedullary nailing of the tibia. Orthopedics 34(3):226. CrossRefPubMedGoogle Scholar
  18. 18.
    Takemoto RC, Epstein D, McLaurin TM (2011) Intra- and periarticular heterotopic ossification in the knee after a low-velocity gunshot wound treated with retrograde intramedullary nailing of the femur. J Orthop Trauma 25(7):e77–e82. CrossRefPubMedGoogle Scholar
  19. 19.
    Lundy DW, Johnson KD (2001) “Floating knee” injuries: ipsilateral fractures of the femur and tibia. J Am Acad Orthop Surg 9(4):238–245CrossRefPubMedGoogle Scholar
  20. 20.
    Simonsen LL, Sonne-Holm S, Krasheninnikoff M, Engberg AW (2007) Symptomatic heterotopic ossification after very severe traumatic brain injury in 114 patients: incidence and risk factors. Injury 38(10):1146–1150. CrossRefPubMedGoogle Scholar
  21. 21.
    Gosselin RA, Belzer JP, Contreras DM (1993) Heterotopic ossification of the patellar tendon following intramedullary nailing of the tibia: report on two cases. J Trauma 34(1):161–163CrossRefPubMedGoogle Scholar
  22. 22.
    Tornetta P 3rd, Tiburzi D (2000) Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial. J Bone Joint Surg Br 82(5):652–654CrossRefPubMedGoogle Scholar
  23. 23.
    Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R (2001) Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 15(3):161–169CrossRefPubMedGoogle Scholar
  24. 24.
    Kuhn KM, Ali A, Boudreau JA, Cannada LK, Watson JT (2013) Antegrade versus retrograde intramedullary nailing of proximal third femur fractures. J Surg Orthop Adv 22(4):263–269CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.Department of OrthopaedicsUC San DiegoSan DiegoUSA
  2. 2.Department of Orthopaedics, UC DavisUniversity of California, DavisSacramentoUSA

Personalised recommendations