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Zhang MR, Zhao K, Chen HY, Guo JL. Intramedullary nailing for floating knee injury complicated by pulmonary fat embolism: A case report and literature review. Trauma Case Rep 2024; 52:101040. [PMID: 38784218 PMCID: PMC11109876 DOI: 10.1016/j.tcr.2024.101040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 05/25/2024] Open
Abstract
A 28-year-old man involved in a serious motorcycle accident was admitted to our hospital with comminuted fractures of the ipsilateral femoral shaft and tibial shaft, as well as multiple fractures of the right lower limb, including the proximal fibula, medial malleolus, and the third and fourth distal metatarsals. In addition, the patient suffered a skin contusion and laceration of the right foot. On the first day of admission, this patient suddenly developed tachycardia, pyrexia, and tachypnoea, and was immediately transferred to the ICU for further treatment due to a CT-diagnosed pulmonary fat embolism (FE). As a symptomatic treatment, he received a prophylactic dose of low-molecular-weight heparin for 10 days, after which his condition improved. A Doppler ultrasound of the lower leg and a follow-up chest CT angiography were performed, which excluded any remaining thrombus and verified that the pulmonary FE had improved without deterioration. Closed-reduction and retrograde intramedullary nailing were performed for the femoral shaft fractures, while antegrade intramedullary nailing was performed for the tibial shaft fractures under general anaesthesia. In the three-year follow-up, the patient had recovered with good function of the right limb, without any respiratory discomfort. Both the femoral and tibial shaft fractures finally resolved without any further treatment. Ipsilateral femoral and tibial shaft fractures should undergo surgical stabilisation as early as possible to avoid pulmonary FEs. It is still controversial whether intramedullary nailing is suitable for floating knee injuries complicated by pulmonary FEs. However, if patients with pulmonary FEs require intramedullary nailing, we suggest that surgery should be performed after at least one week of anticoagulant use, when patient vital signs are stable and there is no sign of dyspnoea. In addition, patients should try to avoid reaming during the operation to prevent and decrease "second hit" for the lung.
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Affiliation(s)
- Mei-Ren Zhang
- Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Traditional Chinese Medicine, Orthopedics Trauma Zhuhai branch, Jingle road number 53, Xiangzhou District, Zhu Hai City 519015, Guangdong Province, China
| | - Kui Zhao
- Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Traditional Chinese Medicine, Orthopedics Trauma Zhuhai branch, Jingle road number 53, Xiangzhou District, Zhu Hai City 519015, Guangdong Province, China
| | - Hai-Yun Chen
- Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Traditional Chinese Medicine, Orthopedics Trauma Zhuhai branch, Jingle road number 53, Xiangzhou District, Zhu Hai City 519015, Guangdong Province, China
| | - Jiang-Long Guo
- Guangzhou University of Chinese Medicine Second Affiliated Hospital, Guangdong Provincial Hospital of Traditional Chinese Medicine, Orthopedics Trauma Zhuhai branch, Jingle road number 53, Xiangzhou District, Zhu Hai City 519015, Guangdong Province, China
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Bozgeyik B, Büyükbebeci O, Güner S, Mert A. COMPARATIVE ANALYSIS OF OPEN AND CLOSED FLOATING KNEE INJURIES. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e262810. [PMID: 37547232 PMCID: PMC10399990 DOI: 10.1590/1413-785220233104e262810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 11/22/2022] [Indexed: 08/08/2023]
Abstract
Objective To compare the functional outcomes between floating knee injuries with open femur and tibia fractures and closed floating knee injuries. Methods Floating knee injuries (followed up and treated in our clinic) were retrospectively analyzed. Patients were divided into two groups: floating knee injuries with open femur and tibia fractures (Group 1) and floating knee injuries with closed femur and tibia fractures (Group 2). Patients were compared according to their demographic characteristics and clinical and functional outcomes. Results Of 52 study patients, 28 had Group 1 injuries and 24, Group 2 injuries. We found a statistically significant difference in length of hospital stay between the two groups (p = 0.01) and a statistically significant difference in Karlström-Olerud functional scores between the groups (p = 0.02). We found osteomyelitis in five (17%) patients in Group 1 and in one (4%) patient in Group 2. Conclusion Patients with floating knee injuries and open fractures showed poorer outcomes than those with closed fractures. Those with open floating knee injuries show complications more often and longer hospital stays. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.
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Affiliation(s)
- Bahri Bozgeyik
- Kadirli State Hospital, Department of Orthopedic Surgery, Osmaniye, Türkiye
| | - Orhan Büyükbebeci
- Gaziantep University Hospital, Department of Orthopedic Surgery, Gaziantep, Türkiye
| | - Savaş Güner
- Gaziantep University Hospital, Department of Orthopedic Surgery, Gaziantep, Türkiye
| | - Ahmet Mert
- Ömer Halis Demir Unıversity Hospital, Department of Orthopedic Surgery, Niğde, Türkiye
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Kenmegne GR, Zou C, Lin Y, Yin Y, Huang S, Fang Y. The current issues and challenges in the management of floating knee injury: a retrospective study. Front Surg 2023; 10:1164032. [PMID: 37206352 PMCID: PMC10189139 DOI: 10.3389/fsurg.2023.1164032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Purpose The management of floating knee injuries is still controversial and challenging for trauma specialists. This study aims to evaluate the incidence of the floating knee in lower limb trauma, analyzing the challenges in its management, and factors affecting clinical outcomes. Methods In this mono-center retrospective study, 36 consecutive patients were included. All individuals were diagnosed with an ipsilateral fracture of the femur and tibia, managed surgically according to their fracture pattern (Fraser classification), and the severity of the injury. The timing for each operation was determined based on the general condition of the patient and the local physiological condition of soft tissues. The patients' clinical outcomes were finally evaluated based on their Karlstrom and Olerud scores and were categorized as excellent, good, acceptable, fair, or poor. Results In this study, the mean follow-up period was 51.39 ± 16.02 months (11-130 months). Incidence of the floating knee was 2.32% in all lower limb traumas. From this number, 16 patients suffered from floating knee injury in the left lower extremity, and 18 in the right lower limb, while in 2 patients the condition was bilateral. The most common injury mechanism was road traffic accidents, accounting for 28 (77.78%) cases. The outcome was as follows; Excellent to good results in 22 (61.11%) cases, acceptable results in 2 (5.56%) cases, and fair to poor results in 12 (33.33%) cases according to the Karlström-Olerud scoring system. The most frequent early complications were wound infection and deep venous thrombosis in 5 (13.88%) of the cases. The most common late complication was common peroneal nerve palsy recorded in 2 (5.56%) cases. Conclusion The presence of important concomitant injuries to the floating knee together with poor soft tissue conditions constituted important factors influencing possible management options and may have led to poorer clinical outcomes.
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Engorn JR, Vivace BJ, Seligson D, Parkulo T, Arrington DD, Rashid SF, Roberts C, Zamora R. Intramedullary nailing of concurrent ipsilateral fractures of the tibia and femur: primary synchronous nailing versus staged osteosynthesis with temporizing external fixation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03340-w. [PMID: 35932307 DOI: 10.1007/s00590-022-03340-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The optimal timing to definitive osteosynthesis in the polytraumatized patient remains an unanswered question. Early total care, damage control orthopaedics, and early appropriate care have been described to manage the fractures in these patients, but there is a paucity of literature specific to ipsilateral tibial and femoral fractures. We sought the perioperative outcomes of primary simultaneous intramedullary nailing (IMN) versus temporizing external fixation (EF) of both fractures. METHODS A chart review of all patients who sustained fractures of the ipsilateral femur and tibia that were definitively treated with (IMN) from January 2010 to December 2020 was performed. Patients who underwent initial EF and those that were primarily treated with IMNs were examined. RESULTS IMNs and EF were the initial treatment in 23 and 16 patients, respectively. The mean (range) injury severity score (ISS) was 23.3 (33) in the EF group vs. 18.5 (34) in the IMN group, (p = 0.0686). The EF group had a higher total transfused units of packed red blood cells 7.4 vs. 2.8, the mean initial operative time was 236 vs. 282.6 (min), (p = 0.7399), a longer mean total operative time 601.78 vs. 236 (min), and longer mean length of stay 15.6 vs. 11 (days), (p < 0.5). Rates of complications were not significantly different between groups. CONCLUSION Primary IMN is as safe as provisional EF in the adequately resuscitated patient with ipsilateral femoral and tibial fractures. This implies the fixation of both fractures into a single surgery without increasing perioperative complications, and decreasing total hospital stay in patients with sufficient preoperative resuscitation.
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Affiliation(s)
- Jeffrey R Engorn
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Bradley J Vivace
- Department of Orthopaedic Surgery, University of Missouri, University of Missouri School of Medicine, Columbia, USA
| | - David Seligson
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Travis Parkulo
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | | | - Salwa F Rashid
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Craig Roberts
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA
| | - Rodolfo Zamora
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40292, USA.
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Ethiraj P, Shringeri AS, Prasad P A, Shanthappa AH, Nagarajan V. Early Total Care Versus Damage Control Orthopedics in Floating Knee Injury: Analysis of Radiological and Functional Outcomes. Cureus 2022; 14:e25615. [PMID: 35784973 PMCID: PMC9249040 DOI: 10.7759/cureus.25615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Floating knee injury (FKI) occurs as a result of a high-velocity impact. We assessed the radiological and functional outcomes of FKIs treated by various fixation methods, by damage control orthopedics (DCO) or early total care (ETC). Materials and methods We investigated 46 patients with FKI who were operated on between January 2013 and January 2018 at the RL Jalappa Hospital and Research Center, Kolar, India. Functional assessments were evaluated using Karlström and Olerud’s criteria (KOC). Based on their treatments, the patients were divided into the damage control orthopedics group (n = 21) and the ETC group (n = 25). Statistical analyses were used to obtain and compare summary data. Results The data of 46 patients were collected. Fractures were classified using the modified Fraser’s classification. Five patients were not included in the final analysis because of death due to complications in the immediate postoperative period. In patients managed by DCO, after radiological union, the functional outcome was excellent in three cases, good in eight, fair in seven, and poor in two. The average time required for radiological union of the femur was 10.75 ± 1.482 months (P = 0.001); for tibia union, it was 10.25 ± 1.682 months (P = 0.011). The average range of knee flexion was 85°± 16.059° (P = 0.001), which was statistically significant. In patients managed by ETC, there were six cases with an excellent functional outcome, 13 with a good outcome, and two with a fair outcome. The average time required for radiological union of the femur was 9.29 ± 1.765 months (P = 0.006); for the tibia, it was 9.05 ± 1.161 months (P = 0.012). The average range of knee flexion was 100° ± 10.954° (P = 0.001), which was statistically significant. Fat embolism was noted in eight cases; four of these patients died due to multiorgan dysfunction. This was the major life-threatening complication in the early definitive fixation group. In the DCO group, only three cases had fat embolism, with one death due to multiorgan dysfunction. Early postoperative infection was a concern in the ETC group, evident in six cases. Conclusion The classification system for FKI needs further research, which must include multiple parameters. Fracture classification and patient selection are crucial considerations in deciding the best treatment for a particular fracture.
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Selvam S, Ganesh J. Bilateral floating knee: A rare case report. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2022. [DOI: 10.4103/jotr.jotr_50_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Hosny GA, Ahmed ASAA, Tabl EA. Neglected infected floating knee injury: evaluation of closed reduction techniques. Eur J Trauma Emerg Surg 2021; 48:2331-2339. [PMID: 34215902 DOI: 10.1007/s00068-021-01745-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/29/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Floating knee injury is uncommon yet challenging problem. The situation is more complicated by presence of infection, open comminuted fractures, and late presentation. The aim of this study was to evaluate the closed reduction techniques by circular external fixation in a single stage to treat patients having infected neglected floating knee injuries. METHODS This retrospective study included 19 patients with a mean age of 34.4 years. The average duration from trauma to surgery was 51.1 days. All patients had at least one infected open fracture. According to Fraser's classification, ten injuries were type I, one case was type IIa, four were type IIb, and four were type IIc. Patients were treated by closed reduction techniques using the Ilizarov principles. Orthoplastic procedures were done in four cases in the same surgical setting. RESULTS Closed reduction and union were achieved in all cases with control of infection in 17 cases. The follow-up period averaged 41 months. The mean knee flexion was 97.4°. The complications included 5° extension lag (two cases), malunion (three cases), refracture (two cases), and DVT (four cases). The bone results were excellent (12 cases), good (5 cases), and poor (2 cases). The functional results were excellent (two cases), good (seven cases), acceptable (seven cases), and poor (three cases). CONCLUSIONS Closed reduction techniques using a circular frame provided a valid treatment option for infected neglected floating knee injuries in one stage without bone grafting. However, the high rate of complications and the diminished knee range of motion should be considered.
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Affiliation(s)
- Gamal Ahmed Hosny
- Department of Orthopaedic Surgery, Faculty of Medicine, Benha University, Farid Nada Street, Kalyubia, Benha, 13518, Egypt
| | - Abdel-Salam Abdel-Aleem Ahmed
- Department of Orthopaedic Surgery, Faculty of Medicine, Benha University, Farid Nada Street, Kalyubia, Benha, 13518, Egypt.
| | - Eslam Abdelshafi Tabl
- Department of Orthopaedic Surgery, Faculty of Medicine, Benha University, Farid Nada Street, Kalyubia, Benha, 13518, Egypt
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Acute Femoral Nailing and Ipsilateral Knee-Spanning External Fixation: Improved Early Stability for Floating Knee Injuries Involving the Tibial Plateau. J Orthop Trauma 2021; 35:e258-e262. [PMID: 32898080 DOI: 10.1097/bot.0000000000001944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 02/02/2023]
Abstract
Ipsilateral femoral shaft and tibial plateau fractures, termed a "floating knee," are rare and challenging injuries. There is limited literature guiding the operative technique and the outcomes associated with these injuries. The author's preferred technique is early intramedullary of the femoral shaft fracture with knee-spanning external fixation of any length unstable plateau fractures in the same operative setting. Early fixation of the femur fracture allows for improved hemodynamic and inflammatory stability. External fixation of the tibial plateau restores length and alignment and allows for soft tissue rest until definitive fixation. The purpose of this study is to describe this operative technique and determine the infection rate and complications requiring return to the operating room in patients with femoral shaft fractures and length unstable plateau fractures.
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Comparison of functional outcomes among subtypes of Fraser's type Ⅱ floating knee. Chin J Traumatol 2021; 24:25-29. [PMID: 33339679 PMCID: PMC7878454 DOI: 10.1016/j.cjtee.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The poor prognosis in patients with floating knee injuries is mainly contributed to articular involvement (Fraser's type Ⅱ). This study aims to evaluate and compare the functional outcomes among different Fraser's type Ⅱ floating knee injuries after surgical management. METHODS Twenty-seven patients with Fraser's type Ⅱ floating knee injuries (54 fractures) between September 2014 and December 2015 were enrolled prospectively in this study and were distributed according to Fraser's floating knee classification into three different groups as type ⅡA (ipsilateral femoral shaft and tibial intra-articular involvement, n = 11), type ⅡB (ipsilateral tibial shaft and femoral intra-articular involvement, n = 9) and type ⅡC (both femoral and tibial intra-articular involvement, n = 7). The differences among the groups were evaluated and compared. The functional outcomes of these injuries at one year were analyzed using Knee Injury and Osteoarthritis Outcome Score (KOOS) which covers 5 subscales of pain, other symptoms, activities of daily living, sports and recreation, and quality of life. The result was also compared with standardized age-sex matched healthy population using paired samples t-test. RESULTS All the patients were male, and the injury mechanism was solely roadside accident. The mean age was 29.8 years and injury severity score 17.9 (comparable in all the three groups). Most injuries were observed on the right side (20 cases, 74.1%). Based on paired samples t-test, the KOOS score of patients with Fraser's type ⅡA was found to be better than that of type ⅡB and type ⅡC. Compared with the reference age-sex matched control group, patients with Fraser's type ⅡB and ⅡC fractures had significantly lower mean score in all KOOS subscales (all p < 0.01). However, Fraser's type ⅡA only revealed significant difference regarding the subscales of activities of daily living (p < 0.0001), sports and recreation (p < 0.0001), and quality of life (p < 0.0001). CONCLUSION The results of this study show that patients with Fraser's type ⅡA fractures had a better functional outcome as compared to those with type ⅡB and ⅡC fractures. This might be due to the open intra-articular involvement of the distal femur of the latter two fracture types.
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Suriyakumar S, Saluja SS, Ramanujam M, Mancheri MN, Jambu N. Management of Grade 3C Compound Injury of Lower Limb with Floating Knee - Salvage versus Amputation (Case Series). J Orthop Case Rep 2021; 11:119-127. [PMID: 34141685 PMCID: PMC8180318 DOI: 10.13107/jocr.2021.v11.i02.2052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Severe open injuries of limbs, especially of the femur and tibia when associated with vascular injuries, present major challenges in management. The decision to amputate or salvage can often be a difficult one even for experienced surgeons. Mangled lower extremity results due to high-energy trauma, especially due to motor vehicle accidents, and is defined as injury to three of the four systems in the extremity that is soft tissues, bone, vascular, and nerve. Open fractures are classified by Gustilo and Anderson’s classification in which type 3B is an injury where soft-tissue loss and primary closure of the wound are not possible and type 3C is any open fracture with vascular compromise. Case Report: We report a series of six ipsilateral fractures of the femur and the tibia treated at the Department of Orthopaedics, Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, over a 3-year period (2014–2017). The mean age of our patients was 30 years old, and there were five men and one woman. The right side lower limb was frequently involved (five cases), and the main etiology was road traffic accidents (six cases). Articular involvement was found in six cases. Skin wounds were noticed in all cases (type III C of the Gustilo classification). Urgent wound care, fluid replacement, and antibiotic therapy were undertaken for open fractures. According to modified Fraser classification, all six cases was classified under type II-C. Mangled extremity severity score for five cases was 7 and for one case it was 8. Ganga Hospital Open Injury Severity Score was also used which was found to be in borderline range of 16 score for three cases, 15 score for two cases, and 14 score for one case. All six cases were managed with serial wound debridement + Ilizarov fixator + soft-tissue repair with involvement of orthopedic, vascular, and plastic surgery team. Limb salvage was done for all six cases after considering all the factors. Postoperatively, rehabilitative care and physiotherapy in the form of non-weight-bearing mobilization with walker support was given to all patients. The patients were followed up for the period of 2 years and doing symptomatically better. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision-making in these situations. Conclusion: With great effort and good team work (like vascular and orthopedic surgeons), badly comminuted compound injuries (Type III C injury) can be managed well with Ilizarov fixation. Even though the decision of amputation versus salvage was based on more scientific/scoring system, patient’s option should be taken, especially in borderline cases considering the present medicolegal scenario.
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Affiliation(s)
- Sundar Suriyakumar
- Department of Orthopaedic surgery, Sri Ramachandra Institute of Higher Education and Research Centre, Chennai, Tamil Nadu, India
| | - Sharandeep Singh Saluja
- Department of Orthopaedic surgery, Sri Ramachandra Institute of Higher Education and Research Centre, Chennai, Tamil Nadu, India
| | - Muthumanickam Ramanujam
- Department of Orthopaedic surgery, Sri Ramachandra Institute of Higher Education and Research Centre, Chennai, Tamil Nadu, India
| | - Muhammed Niyas Mancheri
- Department of Orthopaedic surgery, Sri Ramachandra Institute of Higher Education and Research Centre, Chennai, Tamil Nadu, India
| | - N Jambu
- Department of Orthopaedic surgery, Sri Ramachandra Institute of Higher Education and Research Centre, Chennai, Tamil Nadu, India
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Abstract
The "floating knee" is defined as fractures of the ipsilateral femur and tibia, which consists of a spectrum of injury, and may be in isolation or part of multiple system trauma for a given patient. A floating knee may compromise limb viability due to severe soft-tissue and vascular injury. Expeditious fracture reduction and patient resuscitation are crucial, while type and timing of provisional and definitive management is guided by the extent of injury to the involved extremity and associated systemic injuries. Numerous surgical techniques are available to treat the floating knee, including external fixation and internal fixation with plates or intramedullary nails. Fracture complexity and severity of soft-tissue injury present challenges, with articular injuries potentially more debilitating in the long term. Complications such as infection, deep vein thrombosis, knee stiffness, nonunion, malunion, and posttraumatic arthrosis after these injuries should be considered.
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Nwosu C, Salawu O, Mejabi J, Fadimu A. Management of floating knees in adults: Experience from tertiary hospital. SAHEL MEDICAL JOURNAL 2020. [DOI: 10.4103/smj.smj_25_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Saini G, Sen RK, Kalia A, Kadam S. Implant-associated Hoffa's Fracture in a Floating Knee: A Case Report and Review of Literature. J Orthop Case Rep 2019; 9:79-83. [PMID: 31559235 PMCID: PMC6742877 DOI: 10.13107/jocr.2250-0685.1432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Complex floating knee in the presence of a previous implant creates an unusual fracture pattern which is a rare entity and poses a unique challenge in management and subsequent rehabilitation. Case Report: A 56-year-old psychiatric patient who jumped from height had a polytrauma and a floating knee injury. Following the primary care and damage control surgery with knee-spanning fixator at some other centers, he was shifted to us on ventilator care and was directly admitted to intensive care unit for further management. On presentation, it was a floating knee injury with gross comminution of both femur and tibia with associated Hoffa with bent implant in situ. It was managed by plating of both lower end femur and tibia and at the end of 6 months, showed a satisfactory outcome. Conclusion: Floating knee injuries further complicated by the presence of the previous implant in a polytrauma situation poses a unique challenge which requires meticulous surgical planning and prolonged rehabilitation to achieve satisfactory outcome.
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Affiliation(s)
- Gaurav Saini
- Department of Orthopaedics, Max Super Speciality Hospital, Mohali, Punjab, India
| | - R K Sen
- Department of Orthopaedics, Max Super Speciality Hospital, Mohali, Punjab, India
| | - Anoop Kalia
- Department of Orthopaedics, Max Super Speciality Hospital, Mohali, Punjab, India
| | - Sagar Kadam
- Department of Orthopaedics, Max Super Speciality Hospital, Mohali, Punjab, India
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Yadav V, Suri HS, Vijayvargiya M, Agashe V, Shetty V. "Floating knee," an Uncommon Injury: Analysis of 12 Cases. Rev Bras Ortop 2019; 54:53-59. [PMID: 31363243 PMCID: PMC6424807 DOI: 10.1016/j.rboe.2017.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/05/2017] [Indexed: 11/17/2022] Open
Abstract
Objective Floating knee injuries are complex injuries and are usually caused by high-velocity trauma. These injuries are often associated with life treating injuries, which should take precedent over extremity injuries. The authors reviewed the outcomes of floating knee injuries managed in this institute from 2003 to 2015. Method A retrospective study was conducted of all patients with floating knee injuries from2003 to 2015. Twelve patients were included in the study. Data related to fracture type, associated injuries, treatment modalities, and complications were noted. Functional assessment was performed using the modified Karlstrom and Olerud criteria after complete bony union. Result The mechanism of injury was motor vehicle accident in all patients. The mean follow up was four years. The mean age of patients was 34.75 year. The mean union time was 6.5 months in femurs and 6.7 month in tibias. The complications were knee stiffness, delayed union, and infection. According to modified Karlstrom criteria, there were three - excellent, five - good, three - fair, and one poor result. Conclusion Floating knee injuries are severe injuries and are usually associated with multi-organ injuries. Early detection and appropriate management of associated injuries, early fixation of fractures, and postoperative rehabilitation are needed for good outcome. Complications are frequent, in the form of delayed union, knee stiffness, and infection.
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Affiliation(s)
- Vishal Yadav
- Departmento de Ortopedia, P.D. Hinduja National Hospital, Mumbai, Maharashtra, India
| | - Harpreet Singh Suri
- Departmento de Ortopedia, P.D. Hinduja National Hospital, Mumbai, Maharashtra, India
| | - Mayank Vijayvargiya
- Departmento de Ortopedia, P.D. Hinduja National Hospital, Mumbai, Maharashtra, India
| | - Vikas Agashe
- Departmento de Ortopedia, P.D. Hinduja National Hospital, Mumbai, Maharashtra, India
| | - Vivek Shetty
- Departmento de Ortopedia, P.D. Hinduja National Hospital, Mumbai, Maharashtra, India
- Address for correspondence Vivek Shetty Department of Orthopedics, P.D. Hinduja National HospitalMumbaiIndia
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Functional outcomes and quality of life in adult ipsilateral femur and tibia fractures. J Orthop Translat 2019; 16:53-61. [PMID: 30723681 PMCID: PMC6350037 DOI: 10.1016/j.jot.2018.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/20/2018] [Accepted: 08/07/2018] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of our study is to evaluate the functional outcomes and quality of life in adult ipsilateral femur and tibia fractures. Methods 26 patients (21 male, 5 female; mean age 30 years, range: 18 to 66) treated for adult ipsilateral femur and tibia fractures were evaluated retrospectively. For femur fractures, intramedullary nails were used in 15 patients (12 antegrade, 3 retrograde), plate in 11 patients (10 locked-plate, and 1 blade-plate with a 95 degree angle). For tibia fractures, locked-plate were used in 13 patients, intramedullary nails in 9 patients, external fixator in 3 patients and multiple screws in 1 patient. According to Blake and McBryde classification, 17 fractures were type I, 9 fractures were type II (7 type 2A and 2 type 2B). The functional outcomes were evaluated by Karlström and Olerud criteria, and quality of life was evaluated by Short Form-36. The mean follow-up duration was 4.4 years (range: 1.1 to 7.3 years). Results The functional outcomes were excellent in 6 patients, good in 8 patients, acceptable in 6 patients and poor in 6 patients. The mean values of quality of life scales were; physical function: 64.8, physical role limitation: 60.5, pain: 68.2, general health: 63.3, vitality: 58.4, social function: 68.2, emotional role limitation: 62.7, and mental health: 65.8. Conclusion Adult ipsilateral femur and tibia fractures are severe injuries and adversely affect the quality of life and functional outcomes. The quality of life scales should be used along with functional outcome scores in evaluating these injuries. The translational potential of this article Adult ipsilateral femur and tibia fractures cause severe morbidity. Functional outcomes and quality of life scales should be used together to evaluate these fractures. Karlström and Olerud criteria for functional outcomes and Short Form-36 scales for quality of life are suitable methods to evalute these fractures.
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Abstract
BACKGROUND The term "floating" is used in orthopedic literature to describe certain patterns of skeletal injuries that share one common character which is disruption and discontinuity of bones above and below a joint. The first time used in orthopedic literature being in late 1970 to describe a type of elbow injury. Later the word was used increasingly and applied to a variety of injuries affecting the knee, shoulder, hip, forearm, hand, and ankle. Currently, there are about 12 different skeletal injuries described as floating. OBJECTIVES The aim of this article was to define the term "floating" used in traumatic orthopedics and to discuss its history, mechanism of injury in each region, treatment and outcomes based on the currently available literature. As there were many separate articles describing different sites of floating injuries, this review aimed to summarize all floating injuries into 1 article.
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Affiliation(s)
| | | | - Ying Qin
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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17
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Kulkarni MS, Aroor MN, Vijayan S, Shetty S, Tripathy SK, Rao SK. Variables affecting functional outcome in floating knee injuries. Injury 2018; 49:1594-1601. [PMID: 29885963 DOI: 10.1016/j.injury.2018.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/19/2018] [Accepted: 05/22/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The surgical outcome of floating knee injuries is difficult to predict. The high-velocity nature of the injury, complex fracture pattern and associated soft tissue/visceral injuries may have some impact on the functional outcome. The present study evaluates the variables affecting the clinical and radiological outcomes of floating knee injuries. MATERIALS AND METHODS The clinical, radiological and functional outcome (Karlstrom and Olegrud criteria) of 89 patients with 90 floating knee injuries were evaluated at the end of one year who were managed in our level 1 trauma center between January 2013 and December 2016. The details of the injury, fracture pattern, management and complications were collected retrospectively from their records. RESULTS There were 81 (91.1%) males and 8 (8.9%) females with mean age of 34.34 ± 12.28 years. The mean time for tibia and femur union was 9.52 (±6.6) and 10.5 (±7.37) months. There was significant delay (p < 0.005) in time taken for union in segmental femur fractures (14.3 ± 9.6 months) compared to nonsegmental femur fractures (8.68 ± 5.18 months). Such significant difference in time taken for union was not seen in tibial segmental (10.6 ± 4.62 months) and nonsegmental fractures (9.05 ± 7.27 months). As per the Karlstrom and Olegrud criteria, there were 22 (24.4%) excellent, 26 (28.9%) good, 24 (26.7%) fair and 11 (12.2%) poor outcome. There were 15 patients with malunited tibia, 6 with malunited femur, 10 with limb length discrepancy and 39 with knee stiffness. 28 (33.3%) patients underwent major additional procedures such as bone grafting, re-fixation or bone transport or tendon transfer. It was observed that open tibia fracture, segmental fracture, intra-articular fracture, additional surgical procedures, initial external-fixator (ex-fix) application were significantly associated with development of knee stiffness, limb shortening, malalignment and unsatisfactory (Karlstrom and Olegrud fair to poor) functional outcome. CONCLUSION Open tibial fractures, segmental fractures, intraarticular involvement, additional surgical procedures and initial external fixator application are the poor prognostic indicators of floating knee injuries.
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Affiliation(s)
- Mahesh Suresh Kulkarni
- Department of Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka, 576104, India
| | - Monappa Naik Aroor
- Department of Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka, 576104, India.
| | - Sandeep Vijayan
- Department of Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka, 576104, India
| | - Saurabh Shetty
- Department of Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka, 576104, India
| | - Sujit Kumar Tripathy
- Department of Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka, 576104, India
| | - Sharath K Rao
- Department of Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Udupi, Karnataka, 576104, India
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18
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Abstract
BACKGROUND Floating knee is a condition resulting from high energy trauma usually associated with minor to life threatening injuries making it challanging to treat There are no studies available in literature describing cross leg sitting and squatting after surgical management of floating knee. This study analyzes prognostic factors, plan of management, functional outcomes (special attention to squatting and cross legged sitting), complications. MATERIALS AND METHODS 52 patients with floating knee injuries treated over a period of 3 years were included in this study. The study followed an algorithmic approach for the management. Femur fractures were fixed before fixing the tibia according to fracture type that was classified by Fraser classification after the stabilization of patient. The mean followup duration was 21 ± 6 months. The outcome was assessed using Karlstrom criteria after bony union. RESULTS The study consists of majority (46) of male. Thirty three patients had some types of significantly associated injury. The mean postoperative range of motion of the knee was observed to be 97° ± 27°. Twenty one patients showed excellent results, whereas 17, 8, and 6 patients had good, fair, and poor results, respectively, as per Karlstrom criteria. Knee pain, stiffness, infection, nerve palsy, delayed union, and nonunion were some of the complications observed. Cross legged sitting was possible in 40 patients and squatting in 31. CONCLUSION The prognosis of floating knee injury is dependent on factors such as type of fracture, soft tissue condition, and management. Excellent outcomes following these injuries can be achieved with individualized plan of management by multidisciplinary team.
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Affiliation(s)
| | - Nadeem A Lil
- Orthopaedic Department, V. S. General Hospital, Ahmedabad, Gujarat, India,Address for correspondence: Dr. Nadeem A Lil, Orthopaedic Department, V. S. General Hospital, Ellis Bridge, Ahmedabad - 380 006, Gujarat, India. E-mail:
| | - Pankaj R Patel
- Orthopaedic Department, V. S. General Hospital, Ahmedabad, Gujarat, India
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Andrade-Silva FB, Carvalho A, Mansano C, Giese A, de Camargo Leonhardt M, Barbosa D, Kojima KE, Silva JS. Functional results and isokinetic muscle strength in patients with Fraser type I floating knee treated with internal fixation. Injury 2017; 48 Suppl 4:S2-S5. [PMID: 29145963 DOI: 10.1016/s0020-1383(17)30767-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION According to Fraser's description, ipsilateral femoral and tibial diaphyseal fractures are characterised as type I floating knee and have a better prognosis than fractures with joint involvement (type II). There are few reports of functional and muscle strength in these patients. The objective of this study was to evaluate the functional and isokinetic muscle strength of patients with type I floating knee undergoing femoral and tibial internal fixation. METHODS Patients with type I floating knee undergoing concomitant femoral and tibial internal fixation were invited for clinical evaluation. The parameters evaluated included the following: Karlstrom and Olerud score; Lysholm score; isokinetic thigh and hip muscle evaluation; knee range of motion; pain level; investigation of associated knee injuries by clinical evaluation and MRI; and types of complications. RESULTS Twenty-one patients were included in the study; 11 of these were clinically evaluated, with a mean follow-up of 23.9 months. Six patients had an acceptable result according to the Karlstrom criteria, whereas eight patients had a poor result based on the Lysholm scale. The peak torque deficit was 61% for knee extensors, 37% for flexors and -9% for hip abductors. The mean pain level was 5.9. Three patients had a partial anterior cruciate ligament (ACL) injury; one patient had a posterior cruciate ligament (PCL) injury; and three patients had a meniscal injury. There were four cases of tibial or femoral nonunion at one year and two cases of chronic osteomyelitis. CONCLUSION Patients with type I floating knee had unsatisfactory functional results, significant knee extensor and flexor muscle strength deficits and a significant rate of complications at the two-year follow-up.
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Affiliation(s)
| | - Adriana Carvalho
- Department of Orthopedics and Traumatology, University of Sao Paulo, Brazil
| | - Caio Mansano
- Department of Orthopedics and Traumatology, University of Sao Paulo, Brazil
| | - Aline Giese
- Department of Orthopedics and Traumatology, University of Sao Paulo, Brazil
| | | | - Dennis Barbosa
- Department of Orthopedics and Traumatology, University of Sao Paulo, Brazil
| | - Kodi Edson Kojima
- Department of Orthopedics and Traumatology, University of Sao Paulo, Brazil
| | - Jorge Santos Silva
- Department of Orthopedics and Traumatology, University of Sao Paulo, Brazil
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20
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Song W, Zhou D, He Y. Biomechanical characteristics of fixation methods for floating pubic symphysis. J Orthop Surg Res 2017; 12:38. [PMID: 28270223 PMCID: PMC5341422 DOI: 10.1186/s13018-017-0541-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 02/23/2017] [Indexed: 01/13/2023] Open
Abstract
Background Floating pubic symphysis (FPS) is a relatively rare injury caused by high-energy mechanisms. There are several fixation methods used to treat FPS, including external fixation, subcutaneous fixation, internal fixation, and percutaneous cannulated screw fixation. To choose the appropriate fixation, it is necessary to study the biomechanical performance of these different methods. The goal of this study was to compare the biomechanical characteristics of six methods by finite element analysis. Methods A three-dimensional finite element model of FPS was simulated. Six methods were used in the FPS model, including external fixation (Ext), subcutaneous rod fixation (Sub-rod), subcutaneous plate fixation (Sub-plate), superior pectineal plate fixation (Int-sup), infrapectineal plate fixation (Int-ifa), and cannulated screw fixation (Int-scr). Compressive and rotational loads were then applied in all models. Biomechanical characteristics that were recorded and analyzed included construct stiffness, micromotion of the fracture gaps, von Mises stress, and stress distribution. Results The construct stiffness of the anterior pelvic ring was decreased dramatically when FPS occurred. Compressive stiffness was restored by the three internal fixation and Sub-rod methods. Unfortunately, rotational stiffness was not restored satisfactorily by the six methods. For micromotion of the fracture gaps, the displacement was reduced significantly by the Int-sup and Int-ifa methods under compression. The internal fixation methods and Sub-plate method performed well under rotation. The maximum von Mises stress of the implants was not large. For the plate-screw system, the maximum von Mises stress occurred over the region of the fracture and plate-screw joints. The maximum von Mises stress appeared on the rod-screw and screw-bone interfaces for the rod-screw system. Conclusions The present study showed the biomechanical advantages of internal fixation methods for FPS from a finite element view. Superior stabilization of the anterior pelvic ring and fracture gaps was obtained by internal fixation. Subcutaneous fixation had satisfactory outcomes as well. Sub-rod fixation offered good anti-compression, while the Sub-plate fixation provided favorable anti-rotational capacity.
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Affiliation(s)
- Wenhao Song
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Ji'nan, Shandong, People's Republic of China
| | - Dongsheng Zhou
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Ji'nan, Shandong, People's Republic of China.
| | - Yu He
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Ji'nan, Shandong, People's Republic of China.
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Muñoz Vives J, Bel JC, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis T. The floating knee: a review on ipsilateral femoral and tibial fractures. EFORT Open Rev 2016; 1:375-382. [PMID: 28461916 PMCID: PMC5367526 DOI: 10.1302/2058-5241.1.000042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In 1975, Blake and McBryde established the concept of 'floating knee' to describe ipsilateral fractures of the femur and tibia.1 This combination is much more than a bone lesion; the mechanism is usually a high-energy trauma in a patient with multiple injuries and a myriad of other lesions.After initial evaluation patients should be categorised, and only stable patients should undergo immediate reduction and internal fixation with the rest receiving external fixation.Definitive internal fixation of both bones yields the best results in almost all series.Nailing of both bones is the optimal fixation when both fractures (femoral and tibial) are extra-articular.Plates are the 'standard of care' in cases with articular fractures.A combination of implants are required by 40% of floating knees.Associated ligamentous and meniscal lesions are common, but may be irrelevant in the case of an intra-articular fracture which gives the worst prognosis for this type of lesion. Cite this article: Muñoz Vives K, Bel J-C, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis, T. The floating knee. EFORT Open Rev 2016;1:375-382. DOI: 10.1302/2058-5241.1.000042.
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Bertrand ML, Andrés-Cano P. Management of the Floating Knee in Polytrauma Patients. Open Orthop J 2015; 9:347-55. [PMID: 26312119 PMCID: PMC4541470 DOI: 10.2174/1874325001509010347] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/26/2015] [Accepted: 05/18/2015] [Indexed: 12/24/2022] Open
Abstract
Ipsilateral fracture of the femur and tibia, or floating knee, is a rare injury that is found almost exclusively in polytrauma or high-energy trauma patients. It presents a combination of diaphyseal, metaphyseal and intra-articular fractures of the femur and tibia, with a high incidence of neurovascular, ligamentous and soft-tissue injuries. The functional outcome and, in some cases, the life, of such polytrauma patients depends largely on a correct therapeutic approach being taken. In general, the treatment decided upon will depend on the individual characteristics present, regarding aspects such as the patient’s general condition, the fracture line and the state of the soft tissues. The treatment provided may be the same as when single fractures are presented, but it is often necessary to consider whether certain techniques or surgical approaches may interfere with other lines of treatment. It is essential at all times to take into consideration the associated injuries and complications before deciding upon a treatment strategy. Ligamentous injuries play an important role in these injuries, much more so than when fractures occur singly. Therefore, these injuries require management by an experienced multidisciplinary team.
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Affiliation(s)
- M L Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol. University of Malaga, Spain
| | - P Andrés-Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol. University of Malaga, Spain
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Feron JM, Bonnevialle P, Pietu G, Jacquot1 F. Traumatic Floating Knee: A Review of a Multi-Centric Series of 172 Cases in Adult. Open Orthop J 2015; Suppl 1 M11:356-60. [PMID: 26312122 PMCID: PMC4541414 DOI: 10.2174/1874325001509010356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/26/2015] [Accepted: 05/18/2015] [Indexed: 11/22/2022] Open
Abstract
The traumatic floating knee in adults (FK) is a combined injury of the lower limb defined by ipsilateral fractures of the tibia and femur. The first publications emphasized the severity of injuries, the bad results after conservative treatment, the most severe functional outcome in case of articular fracture and the frequency of associated cruciate ligament injuries. The surgical management of FK has been highly modified according the improvement of the fracture fixation devices and the operative techniques. This retrospective multicentric observational study included 172 adults with a FK injury admitted in emergency in 5 different level I or II trauma centers. All the patients data were collected on an anonymized database. Results were evaluated by the overall clinical Karlström's score at latest follow-up. Fracture union was assessed on X-rays when at least 3 out of 4 cortices were in continuity in two different radiological planes. A statistical analysis was performed by a logistic regression method. Despite some limitations, this study confirms the general and local severity of this high-energy trauma, mainly occurring in young people around the third decade. A special effort should lead to a better initial diagnosis of associated ligamentous injury: a tear of PCL can be suspected on a lateral-ray view and a testing of the knee should be systematically performed after fixation of the fracture under anesthesia. Secondary MRI assessment is sometimes difficult to interpret because of hardware artifacts. The timing of fracture fixation is discussed on a case by case basis. However, a first femoral fixation is recommended except in cases of tibia fracture with major soft tissue lesion or leg ischemia requiring the tibia fixation first. Also a tibia stabilized facilitates the reduction and fixation of a complex distal femur fracture. The dual nailing remains so far for us the best treatment in Fraser I FK. Further prospective studies are needed to validate treatment algorithms, best fixation techniques in order to decrease the rate of complication and improve the functional outcome of floating knee injuries.
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Affiliation(s)
- J-M Feron
- Orthopaedic and Trauma Department, HUEP Saint Antoine, UPMC-Sorbonne Universités, Paris, France
| | - P Bonnevialle
- Orthopaedic and Trauma Department, CHU Toulouse. Université Paul Sabatier, Toulouse, France
| | - G Pietu
- Orthopaedic and Trauma Department, CHU Nantes, Université de Nantes, France
| | - F Jacquot1
- Orthopaedic and Trauma Department, HUEP Saint Antoine, UPMC-Sorbonne Universités, Paris, France
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Liu Y, Zhang J, Zhang S, Li R, Yue X. Concomitant ligamentous and meniscal injuries in floating knee. Int J Clin Exp Med 2015; 8:1168-1172. [PMID: 25785109 PMCID: PMC4358564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 01/05/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND To identify and characterize the concomitant ligamentous and meniscal injuries in floating knee. METHODS A total of 37 cases of floating knee were enrolled. Arthroscopic or open surgical examination of the knee, Lachman test, posterior drawer's test, and varus and valgus stress tests under anesthesia were carried out to determine the incidence of knee injury. RESULTS Through arthroscopic and open surgical examinations, a medial meniscal tear was detected in 14 (37.8%) cases and a lateral meniscal tear in 11 (29.7%). Twenty-one (56.8%) patients had anterior cruciate ligament (ACL) injury including complete injury in 6 and incomplete injury in 15 cases. Three (8.1%) patients had posterior cruciate ligament (PCL) tear, including complete injury in 1 and incomplete injury in 2. Varus and valgus stress tests revealed that 10 (27.0%) and 7 (18.9%) patients had medial and lateral collateral ligament (MCL and LCL) laxity, respectively. Lachman test showed positive in 8 (21.6%) cases. Posterior drawer test showed positive in 3 (8.1%) cases. Twenty-six (70.3%) patients had knee ligamentous injuries. ACL injury was the most common ligamentous injury. ACL injury in 15 (71.4%) cases was associated with meniscal injury, including medial meniscal injury in 9 (42.9%) and lateral meniscal injury in 6 (28.6%). CONCLUSION Physicians should pay attention to the concomitant ligamentous and meniscal injuries in floating knee. Careful clinical examination with aid of arthroscopic examination is helpful for the early diagnosis and treatment of these injuries.
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Affiliation(s)
- Ya Liu
- Department of Orthopedics and Traumatic Surgery, Jinan Military General Hospital Jinan 250031, China
| | - Jun Zhang
- Department of Orthopedics and Traumatic Surgery, Jinan Military General Hospital Jinan 250031, China
| | - Shu Zhang
- Department of Orthopedics and Traumatic Surgery, Jinan Military General Hospital Jinan 250031, China
| | - Rui Li
- Department of Orthopedics and Traumatic Surgery, Jinan Military General Hospital Jinan 250031, China
| | - Xianhu Yue
- Department of Orthopedics and Traumatic Surgery, Jinan Military General Hospital Jinan 250031, China
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Dahmani O, Elrhazi A, Elidrissi M, Shimi M, Elibrahimi A, Elmrini A. The intramedullary nailing using a single knee incision for treatment of extraarticular floating knee (nine cases). J Emerg Trauma Shock 2014; 7:322-6. [PMID: 25400397 PMCID: PMC4231272 DOI: 10.4103/0974-2700.142774] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/06/2013] [Indexed: 11/05/2022] Open
Abstract
Context: Floating knee injuries are uncommon and complex injuries. Management of this injury has been variously described in the literature. Aims: We present the outcome of the intramedullary nailing using a single knee incision for treatment of extraarticular floating knee. Materials and Methods: We report a retrospective series of nine patients with extraarticular floating knee. Results: There were seven men and two women with an average age of 35 years. At least one of the fractures was open in three cases. The average Injury Severity Score was 17. According to Fraser's classification, 100% of the cases are type I. All our patients were treated by the intramedullary nailing using a single knee incision. The mean operating time was 146 min. The mean follow-up is 19 months. According to the Karlström criteria, the end results were excellent in two cases, good in four, acceptable in two, and poor in one. Bone union was achieved in eight cases with an average period of 93 days. Conclusions: The intramedullary nailing using a single knee incision has shown in this series better results.
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Affiliation(s)
- Omar Dahmani
- Department of Orthopaedics (B4), University Hospital Hassan II, Fez, Morocco
| | - Amine Elrhazi
- Department of Orthopaedics (B4), University Hospital Hassan II, Fez, Morocco
| | - Mohamed Elidrissi
- Department of Orthopaedics (B4), University Hospital Hassan II, Fez, Morocco
| | - Mohamed Shimi
- Department of Orthopaedics (B4), University Hospital Hassan II, Fez, Morocco
| | | | - Abdelmajid Elmrini
- Department of Orthopaedics (B4), University Hospital Hassan II, Fez, Morocco
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Chen W, Tang DZ, Guo ZM, Shi B, Lin B, Ding ZQ, Lian KJ. Use a simple lower limb outrigger frame in intramedullary nailing fixation of a floating knee. Orthop Traumatol Surg Res 2014; 100:561-4. [PMID: 25082776 DOI: 10.1016/j.otsr.2014.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 05/14/2014] [Accepted: 05/26/2014] [Indexed: 02/02/2023]
Abstract
Closed intramedullary nailing is a classical therapeutic approach for floating knee injuries. An appropriate positioning is critical for a successful surgery. However, there is a lack of an ideal auxiliary device to facilitate the implantation of intramedullary nail. The authors developed a simple lower limb outrigger frame (SLLOF), which is made of nylon, to facilitate the nail implementation process. The SLLOF could be radiolucent and autoclavable. A total of 31 patients with floating knee injury underwent the closed intramedullary nailing assisted by SLLOF. The average operative duration was 91.0 min, and all tibial and femur fractures reached bony union. The SLLOF could assist well insertion of intramedullary nail for the treatment of floating knee injuries, with the advantages of simple operation, less manpower, easy imaging access but less radiation exposure, and more cost-effectiveness.
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Affiliation(s)
- W Chen
- Department of Orthopaedic Surgery, the Affiliated Dongnan Hospital of Xiamen University, 269 Huazhong Road, 363000 Zhangzhou, Fujian, PR China; Orthopaedic Trauma Center of the 175th Hospital of PLA, 363000 Zhangzhou, Fujian, PR China
| | - D-Z Tang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, 200032 Shanghai, PR China
| | - Z-M Guo
- Department of Orthopaedic Surgery, the Affiliated Dongnan Hospital of Xiamen University, 269 Huazhong Road, 363000 Zhangzhou, Fujian, PR China; Orthopaedic Trauma Center of the 175th Hospital of PLA, 363000 Zhangzhou, Fujian, PR China.
| | - B Shi
- Zhengzhou University School of Medicine, 450001 Zhengzhou, Henan, PR China
| | - B Lin
- Department of Orthopaedic Surgery, the Affiliated Dongnan Hospital of Xiamen University, 269 Huazhong Road, 363000 Zhangzhou, Fujian, PR China; Orthopaedic Trauma Center of the 175th Hospital of PLA, 363000 Zhangzhou, Fujian, PR China
| | - Z-Q Ding
- Department of Orthopaedic Surgery, the Affiliated Dongnan Hospital of Xiamen University, 269 Huazhong Road, 363000 Zhangzhou, Fujian, PR China; Orthopaedic Trauma Center of the 175th Hospital of PLA, 363000 Zhangzhou, Fujian, PR China
| | - K-J Lian
- Department of Orthopaedic Surgery, the Affiliated Dongnan Hospital of Xiamen University, 269 Huazhong Road, 363000 Zhangzhou, Fujian, PR China; Orthopaedic Trauma Center of the 175th Hospital of PLA, 363000 Zhangzhou, Fujian, PR China
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Floating knee injuries: Results of treatment and outcomes. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2013; 18:1087-91. [PMID: 24523801 PMCID: PMC3908531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/07/2013] [Accepted: 07/04/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Floating knee, referred to as ipsilateral fractures of the femur and tibia, is usually associated with several complications and mortality. This study was designed to present our experience with treatment of this injury throughout; age, sex, mechanism of injury, associated injuries, method and results of treatment, and complications of floating knee are discussed. MATERIALS AND METHODS This retrospective study was performed between January 2006 and December 2011. All patients with floating knee injuries who were admitted to the referral educational hospitals were included. The information about the 238 cases of floating knee injuries were gathered through the 254,620 trauma files and after excluding 18 patients who died within 6 months, the remaining files were studied and the target information was recorded. RESULTS The most frequent age group was 20-29 years (44.5%). The floating knee injuries were more common in males (85.5%). Type (D) according to "the classification of Letts and Vincent" was observed in 38.9% cases. The most frequent mechanism of injury was car to motorcycles accidents (48.2%). The most common associated injury was pelvic fractures (86.8%). Open reduction and internal fixation was the common type of treatment (70%). The most common early and late complications were knee hemarthrosis in 31 cases (14%) and knee osteoarthritis in 30 cases (13.6%), respectively. Death during the 5 years follow up was due to circulatory disruption, followed by deep vein thrombosis (61%). There was a significant relation between the age and outcomes as it worsens with age (P-value < 0.05). CONCLUSION This study revealed that the complication rate associated with floating knee injuries remained high, regardless of the used treatment regimen and surgeons should focus on reducing complications while treating it.
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Abstract
OBJECTIVES To 1) review the existing evidence for early mobilization of the critically ill patients in the ICU with polytrauma; 2) provide intensivists with an introduction to the biomechanics, physiology, and nomenclature of injuries; 3) summarize the evidence for early mobilization in each anatomic area; and 4) provide recommendations for the mobilization of these patients. DATA SOURCES A literature search of the MEDLINE and EMBASE databases for articles published in English between 1980 and 2011. STUDY SELECTION Studies pertaining to physical therapy and rehabilitation in trauma patients were selected. Articles were excluded if they dealt with pediatrics, geriatrics, burn injuries, isolated hand injuries, chronic (i.e., not acute) injuries, nontraumatic conditions, and pressure/decubitus ulcers, were in a language other than English, were published only in abstract form, were letters to the editor, were case reports, or were published prior to 1980. DATA EXTRACTION Reviewers extracted data and summarized results according to anatomical areas. DATA SYNTHESIS Of 1,411 titles and abstracts, 103 met inclusion criteria. We found no articles specifically addressing the rehabilitation of polytrauma patients in the ICU setting or patients with polytrauma in general. We summarized the articles addressing the role of mobilization for specific injuries and treatments. We used this evidence, in combination with biologic rationale and physician and surgeon experience and expertise, to summarize the important considerations when providing physical therapy to these patients in the ICU setting. CONCLUSIONS There is a paucity of evidence addressing the role of early mobilization of ICU patients with polytrauma and patients with polytrauma in general. Evidence for the beneficial role of early mobilization of specific injuries exists. Important considerations when applying a strategy of early physical therapy and mobilization to this distinctive patient group are summarized.
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Hegazy AM. Surgical management of ipsilateral fracture of the femur and tibia in adults (the floating knee): postoperative clinical, radiological, and functional outcomes. Clin Orthop Surg 2011; 3:133-9. [PMID: 21629474 PMCID: PMC3095784 DOI: 10.4055/cios.2011.3.2.133] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 08/23/2010] [Indexed: 01/05/2023] Open
Abstract
Background This study evaluated the outcomes of surgical management of ipsilateral femoral and tibial fractures in adults. Methods Fifteen patients (13 men, 2 women; mean age, 34.8 years; range, 18 to 65 years) were enrolled in this study. The fractures types were classified according to the classification by Fraser et al. as follows: type I (5), type IIa (3), IIb (4), IIc (3). Femur fractures were treated using locked intramedullary nails, plate-screws, or dynamic condylar screws, and tibia fractures were treated with an external fixator (in open fractures), or plate-screws, and locked intramedullary nailing. The mean follow-up duration was 2.2 years (range, 1.3 to 4 years). Results The extent of bony union according to the Karlstrom criteria was as follows: excellent, 8; good, 4; acceptable, 2; poor, 1. Conclusions The associated injuries and type of fracture (open, intra-articular, comminution) are prognostic factors in a floating knee. The best management of the associated injuries for good final outcome involves intramedullary nailing of both the fractures and postoperative rehabilitation.
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Affiliation(s)
- Alaa M Hegazy
- Orthopedic Surgery Department, Zagazig University Faculty of Medicine, Zagazig, Egypt.
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Abstract
Floating knee injuries are usually associated with complications and mortality, regardless of the treatment regimen. Orthopedic surgeons typically recommend various treatment regimens, especially aggressive and early stabilization of both femoral and tibial fractures. Some authors have reported that the complication and mortality rates remain high regardless of the treatment regimen used. The purpose of this retrospective study was to review the long-term results of treatments for floating knee injuries performed at our institution, and also to calculate the distribution of fracture types within patient age groups and the association with complications related to floating knee injury. We retrospectively reviewed medical records and radiographs of 419 floating knee injuries treated for postoperative complications from November 1987 to April 2003. Of the 419 patients with floating knee injuries, 104 (24.8%) developed complications. The result showed that the complication rate was associated with fracture type (open fracture [32.2%; P<.001], Fraser type IIc [36.8%; P<.001], tibial plateau [28.6%; P=.037], and distal tibia [28.6%; P=.035]). This study revealed that the complication rate associated with floating knee injuries remained high, regardless of the treatment regimen used. Surgeons should focus on reducing complications while treating floating knee injuries.
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Affiliation(s)
- Feng-Chen Kao
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Rethnam U, Yesupalan RS, Nair R. Impact of associated injuries in the floating knee: a retrospective study. BMC Musculoskelet Disord 2009; 10:7. [PMID: 19144197 PMCID: PMC2630294 DOI: 10.1186/1471-2474-10-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 01/14/2009] [Indexed: 11/30/2022] Open
Abstract
Background Floating knee injuries are usually associated with other significant injuries. Do these injuries have implications on the management of the floating knee and the final outcome of patients? Our study aims to assess the implications of associated injuries in the management and final outcome of floating knee. Methods 29 patients with floating knees were assessed in our institution. A retrospective analysis of medical records and radiographs were done and all associated injuries were identified. The impact of associated injuries on delay in initial surgical management, delay in rehabilitation & final outcome of the floating knee were assessed. Results 38 associated injuries were noted. 7 were associated with ipsilateral knee injuries. Lower limb injuries were most commonly associated with the floating knee. Patients with some associated injuries had a delay in surgical management and others a delay in post-operative rehabilitation. Knee ligament and vascular injuries were associated with poor outcome. Conclusion The associated injuries were quite frequent with the floating knee. Some of the associated injuries caused a delay in surgical management and post-operative rehabilitation. In assessment of the final outcome, patients with associated knee and vascular injuries had a poor prognosis. Majority of the patients with associated injuries had a good or excellent outcome.
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Affiliation(s)
- Ulfin Rethnam
- Department of Orthopaedics, Glan Clwyd Hospital, Bodelwyddan, UK.
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Oñorbe F, Ferrer-Santacreu E, Rodríguez-Merchán E. Rodilla flotante: revisión retrospectiva de 15 casos tratados durante un periodo de 5 años. Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1888-4415(08)74835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Oñorbe F, Ferrer-Santacreu E, Rodríguez-Merchán E. The floating knee: retrospective review of 15 cases treated over a 5-year period. Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1988-8856(08)70110-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Piétu G, Jacquot F, Féron JM. [The floating knee: a retrospective analysis of 172 cases]. ACTA ACUST UNITED AC 2008; 93:627-34. [PMID: 18065874 DOI: 10.1016/s0035-1040(07)92687-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A retrospective multicentric observational study of 172 floating knee injuries is reviewed. According Fraser's classification 71.5% of the cases are type I and the repartition of the type II in the 3 subgroups is as follow: II A 8.2%, II B 11.6%, et II C 8.7%. At least one of the fractures was open in 69.2% of the patients. The average Injury Severity Score (ISS) was 19.5. The polytraumatized patients (ISS over 18) represented 37.7% of the cases. The surgical procedure started within the 6 first hours in 62% of the injured people. The Intramedullary nailing (IM) was the preferred method at the femur site (73%, 126 cases), at the tibia IM was performed in 54.4% of cases and external fixation was used in one every four patients. The mean operating time was 167 minutes (range: 40'-300') and the total time for the whole procedure was 216 minutes (range: 80'-410'). The mean follow up is 34.2 months. According the functional score of Karlström and Olerud, 23 patients were rated as excellent, 38 as good, 35 as fair and 20 as bad. The contributing factors influencing bad functional outcome are the age, a type II lesion, a femoral fracture located at the distal third, and an open fracture. The IM using a single knee incision does not show in this series better results but the shortening of the operating time was highly significant.
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Affiliation(s)
- G Piétu
- Clinique chirurgicale traumatologique et orthopédique, Hôtel-Dieu, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes Cedex 1.
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Rethnam U, Yesupalan RS, Nair R. The floating knee: epidemiology, prognostic indicators & outcome following surgical management. J Trauma Manag Outcomes 2007; 1:2. [PMID: 18271992 PMCID: PMC2241764 DOI: 10.1186/1752-2897-1-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 11/26/2007] [Indexed: 12/19/2022]
Abstract
Background Floating Knee injuries are complex injuries. The type of fractures, soft tissue and associated injuries make this a challenging problem to manage. We present the outcome of these injuries after surgical management. Methods 29 patients with floating knee injuries were managed over a 3 year period. This was a prospective study were both fractures of the floating knee injury were surgically fixed using different modalities. The associated injuries were managed appropriately. Assessment of the end result was done by the Karlstrom criteria after bony union. Results The mechanism of injury was road traffic accident in 27/29 patients. There were 38 associated injuries. 20/29 patients had intramedullary nailing for both fractures. The complications were knee stiffness, foot drop, delayed union of tibia and superficial infection. The bony union time ranged from 15 – 22.5 weeks for femur fractures and 17 – 28 weeks for the tibia. According to the Karlstrom criteria the end results were Excellent – 15, Good – 11, Acceptable – 1 and Poor – 3. Conclusion The associated injuries and the type of fracture (open, intra-articular, comminution) are prognostic indicators in the Floating knee. Appropriate management of the associated injuries, intramedullary nailing of both the fractures and post operative rehabilitation are necessary for good final outcome.
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Affiliation(s)
- Ulfin Rethnam
- Department of Orthopaedics, Glan Clwyd Hospital, Bodelwyddan, UK.
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Chalidis B, Metha SS, Tsiridis E, Giannoudis PV. (ii) The “floating knee” in adults and children. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.cuor.2006.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Elmrini A, Elibrahimi A, Agoumi O, Boutayeb F, Mahfoud M, Elbardouni A, Elyaacoubi M. Ipsilateral fractures of tibia and femur or floating knee. INTERNATIONAL ORTHOPAEDICS 2006; 30:325-8. [PMID: 16525817 PMCID: PMC3172778 DOI: 10.1007/s00264-006-0084-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Revised: 01/14/2006] [Accepted: 01/16/2006] [Indexed: 10/24/2022]
Abstract
Ipsilateral fractures of the femur and the tibia are relatively uncommon lesions, with critical consequences to the knee. We report a series of 18 ipsilateral fractures of the femur and the tibia treated at the Department of orthopaedics, CHU Hassan II of Fez, over an eight-year period (1996-2004). Various surgical procedures were used, in particular, intramedullary nailing. After an average follow-up of 2.5 years, we re-examined the 18 patients. The functional results were evaluated using the Schiedts' criteria, and we had seven excellent results (38.9%), six good (33.4%), and five bad (27.8%). There was one major lesion of the popliteal artery that led to an emergency amputation, two cases of osteitis, one septic non-union, one case of late deep sepsis, one insignificant shortening of 2 cm, two cases of varus, three cases of stiffness, and one ankylosis of the knee. Through this work we will try to show the repercussions of this type of fracture of the knee and to evaluate our therapeutic choices.
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Affiliation(s)
- A Elmrini
- Department of Orthopaedics, UH Hassan II Fez, UH Avicenne Rabat, Fez, Morocco.
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