Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis

Circular external fixation as definitive treatment for open or comminuted femoral fractures: Radiologic and functional outcomes

INTRODUCTION

Ring external fixation can be a definitive treatment of high energy femoral fractures. A retrospective analysis of outcomes is presented.

MATERIALS AND METHODS

23 patients with open or comminuted femoral fractures treated with circular external fixators were included. Mean age was 33 (range, 13-81) years. Lesions were classified according to AO/ASIF. 12 fractures were open. Mean follow up period has been 26.3, (range 20-144) months. The results were assessed according to the modified criteria of Association for the Study and Application of the Method of Ilizarov. Knee functional results were assessed with Hospital for Special Surgery knee scoring system.

RESULTS

22 fractures united primarily, one showed nonunion. Knee stiffness developed in two patients. No patient had deep pin tract infection. Bone results were quoted as excellent, good, fair and poor in 19, 1, 1 and 2. The functional results were excellent, good, and fair in 16, 6, and 1, on the basis of ASAMI criteria. Mean HSS knee score has been 90.1 (range 60-100).

CONCLUSION

Circular external fixation can achieve reliable rates of union and good to excellent functional outcome in open or comminuted femoral fractures. A strict rehabilitation protocol was effective in preserving knee joint function.

Leeds-Genoa Non-Union Index: a clinical tool for asessing the need for early intervention after long bone fracture fixation

AIM OF THE STUDY

The aim of this case-control study was to develop a clinical decision rule to support assessment of the risk of long-bone non-union and plan for appropriate early intervention.

METHODS

Two hundred patients (100 cases and 100 controls) were recruited. Risk factors identified to contribute to the development of non-union were recorded and analysed with a multivariable logistic regression model. Tabulation of the outcome (non-union/union) against each risk factor in turn (univariable analysis) was carried out. Odds ratios and confidence intervals were derived using Wald's method. A receiver-operator curve was calculated and the area under the curve was computed. Having established the eight most important risk factors, a non-union risk index was developed as the count of the risk factors present in each patient.

RESULTS

The five risk factors for non-union with greater effect size were post-surgical fracture gap > 4 mm (odds ratio (OR) = 11.97 95% CI (4.27, 33.53)), infection superficial/deep (OR 10.16 (2.44, 42.36)), not optimum mechanical stability (OR 10.06 (3.75, 26.97)), displacement > 75% of shaft width (OR 6.81 (2.21, 20.95)), and site of fracture-tibia (OR 4.33 (1.32, 14.14)). The ROC curve for the non-union index was 0.924, sensitivity 91%, specificity 77%.

CONCLUSIONS

The non-union index derived from counting risk factors predicts union for 0-4 risk factors and non-union for 5-8 risk factors. It can be readily applied and can guide clinicians about the risk of development of long-bone non-union. It can become a powerful aid for assessing fracture fixation outcome and to support early intervention.

Functional outcome of open distal femoral fractures managed with lateral locking plates

PURPOSE

This prospective study evaluated the functional outcome and union rates of open distal femoral fractures managed with anatomic lateral locking plates.

METHODS

Thirty-four patients with open distal femur fractures with mean age of 40.8 years (range 20-65 years) were included in the study. Patients with Gustilo-Anderson grade IIIC fractures and those managed with non-locking modalities were excluded. In total, 70.6% (n = 24) of the fractures were Type IIIA and 55.9% (n = 19) were AO/OTA Type C3 fractures. In 23.5% (n = 8) patients, knee spanning external fixator was applied initially before definitive fixation. Patients were followed up for a mean period of 11.6 months (range 8-22.5 months). Functional outcome was evaluated using Sanders Score.

RESULTS

In the primary plating group, 69.2% (n = 18) fractures united at an average of 27 weeks (range 21-40 weeks), while eight patients had non-union and required bone grafting. All eight patients with external fixator underwent lateral locked plating with bone grafting and united at an average time of 39.6 weeks (range 31-50 weeks). There were two cases each of infection and screw failure. The final mean Sanders Score was 30.1 (range19-40) with 73.5% (n = 25) patients having good to excellent functional outcomes.

CONCLUSIONS

Lateral locking plates offer excellent stability to allow fracture union in open distal femoral fractures. A proactive approach to identify and manage potential healing difficulties is advisable to promote bone healing.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Treatment of atrophic nonunion via autogenous ilium grafting assisted by vertical fixation of double plates: A case series of patients

OBJECTIVE

To investigate the efficacy of the treatment of atrophic nonunion using structural autogenous ilium bone grafting in combination with vertical fixation of double plates.

METHODS

This retrospective study analysed the clinical data from consecutive patients with atrophic nonunion who underwent autogenous ilium grafting in combination with double-plate vertical fixation. The injury type and the bone affected by nonunion, the duration of nonunion and the outcomes following surgery were recorded for all patients.

RESULTS

The study enrolled 43 patients with atrophic nonunion of the upper and lower limbs: 17 patients with tibial nonunion, 21 with femoral nonunion, four with humeral nonunion and one with radial shaft nonunion. The mean duration of postoperative follow-up was 14.5 months (range, 8-28 months). A total of 43 of 43 patients (100%) achieved a healed nonunion fracture without the occurrence of complications such as infection, fracture of internal fixation or pain in the harvesting site. Comprehensive postoperative assessments of bone healing and function were observed to be good and/or excellent in all 43 patients.

CONCLUSION

Structural autogenous ilium grafting used in combination with double-plate vertical fixation can provide a stable structural environment for near optimal bone healing in patients with atrophic nonunion.

Paradigm shift in geriatric fracture treatment

The number of geriatric patients is increasing. These patients exhibit specific characteristics, which influence the type of fracture care. Many patients have comorbidities, which make them more vulnerable to surgical procedures. The soft tissue envelope around the fracture often is compromised due to pre-existing diseases such as diabetes, chronic venous insufficiency or peripheral vascular disease. Bone mineral density has decreased, which enhances the risk of implant loosening. The goals of treatment differ from those, which are valid for younger adults. Primary goal is preserving independency of the elderly patient in his activities of daily life. Advantages and drawbacks of surgical procedures have to be balanced with those of conservative treatment. Fractures of the lower extremities will more often need surgical treatment than fractures of the upper extremities. Patient´s autonomy is best obtained by creating high stability in the fracture plane, which enables motion and weight-bearing. Second priority is prevention of general and local post-operative complications by the use of less invasive surgical procedures. Restoring anatomy and optimal function are less important goals. The implants, which are used, are inserted through small incisions, placed deep under the skin and use long anatomic or osseous corridors. Intramedullary devices have important advantages. This paradigm shift takes the special challenges and requirements of geriatric patients into account.

The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study

INTRODUCTION

Femoral shaft fractures with third fragments have a high non-union rate, which may reach 14%. This study aims to assess the impact of the radiological features of the third fragment, evaluated on post-operative X-rays, on the outcome of femoral shaft fractures type 32-B managed with intramedullary nailing, in order to obtain an algorithm which could predict the fracture healing time.

MATERIALS AND METHODS

We have retrospectively evaluated a series of 52 patients. On post-operative X-rays, four radiological parameters were evaluated: the third fragment angle, the fracture gap, the third fragment size, and the mean third fragment displacement. All the patients underwent a radiologic follow-up at one, two, three, six, nine and 12 months post-operatively, to assess the bone healing. The patients were then divided into three groups, according to the fracture healing time: within six months (group A), between six and 12 months (group B), or fracture non-union after 12 months (group C).

RESULTS

In 28 patients, out of 52 (53.85%), the fracture healing was observed at 6-month follow-up; in 18 patients, out of 52 (34.62%), the fracture healed within 12 months after trauma; and in six patients, out of 52 (11.54%), no fracture healing was observed at 12-month follow-up. The mean third fragment size was significantly different in each group (p < 0.05), while the mean third fragment displacement was significantly higher in group C, compared with group A (p = 0.0006) and group B (p = 0.0027). In group B, a positive correlation was found between the fracture healing time and the mean third fragment size (R = 0.594, p = 0.036); in group C, the fracture union time was positively related to the third fragment size (R = 0.689, p = 0.013) and the mean third fragment displacement (R = 0.7107, p = 0.006). Regression analysis showed that the third fragment size and the mean third fragment displacement are the most important features which affect the fracture healing time.

CONCLUSIONS

The third fragment size (cutoff 40 mm) is the leading parameter to influence the fracture healing within or in more than six months. The mean third fragment displacement (cutoff 12 mm); on the other hand, impacts on the fracture delayed rather than absent healing.

Outcomes of distal femur fractures treated with the Synthes 4.5 mm VA-LCP Curved Condylar Plate

PURPOSE

Given the recent controversy in the literature and the alarming reports of early mechanical failure associated with the use of the Synthes 4.5 mm VA-LCP Curved Condylar Plate in acute distal femur fractures, the goal of our study was to examine the outcomes and mechanical failure rates of this implant in a larger patient population.

METHODS

Patients 18 years of age and older who underwent plate fixation of their acute distal femoral fracture using the Synthes 4.5 mm VA-LCP Curved Condylar Plate were included in this retrospective study. The study data was collected through a retrospective chart review and review of the existing radiographic studies. Primary outcome measure was mechanical hardware failure while secondary outcome measures included nonunion, malunion, and medical and surgical complications.

RESULTS

A total of 74 patients (77 fractures) were included in this study. The fractures were classified according to the OTA/AO classification as 33-A2 (n = 6), 33-A3 (n = 19), 33-C1 (n = 5), 33-C2 (n = 25), and 33-C3 (n = 22). Thirty-two out of 77 fractures presented as open fractures (41.6%). A mechanical failure was observed in 7 patients (9.1%). Twenty additional patients needed a re-operation of the surgical site including two nonunion repairs, one malunion repair, 15 staged treatments of traumatic segmental bone defects, and two soft tissue debridements.

CONCLUSIONS

In our experience, the Synthes 4.5 mm VA-LCP Curved Condylar Plate is a safe and effective implant with a relatively low mechanical failure rate.

The ideal timing for nail dynamization in femoral shaft delayed union and non-union

INTRODUCTION

Nail dynamization is one of the proposed surgical options to manage femoral shaft non-union. This study aims to assess the efficacy and the ideal timing for dynamization in patients with femoral shaft delayed union or non-union.

MATERIAL AND METHODS

Sixty-eight patients (38 male and 30 female, mean age 36.85 years old, range 22-58) were recruited. The patients were divided into three groups according to the fracture healing time: groupa A, fracture healing occurred within nine months; group B, fracture healing occurred between nine and 12 months; and group C, fracture healing after 12 months or secondary procedure needed for union. Callus-to-diaphysis ratio was calculated on femur X-rays at the time of dynamization.

RESULTS

In 30 patients out of 68, the fracture healing was observed at nine month follow-up; in 26 patients, the fracture healed within 12 months; eight fractures healed in more than 12 months and only four fractures required a secondary procedure for union. Dynamization was successful in 64 patients out of 68 (94.12%). The mean callus-diaphysis ratio was significantly different in group A (p = 0.001) and in group B (p = 0.03), compared with group C. The timing of dynamization resulted significantly different between the three groups. Linear regression analysis revealed that nail dynamization should be performed between three and six months after trauma. The optimal callus-to-diaphysis ratio should be comprised between 1.47 and 1.19, at the time of dynamization.

DISCUSSION

Nail dynamization revealed safe and effective in the treatment of femoral delayed union and non-union. It should be considered as a first-line treatment for femoral non-union or delayed union.