Closed reduction and locked intramedullary nailing of diaphyseal long bone fractures without intra-operative imaging and fracture table

Incidence of complications and functional outcomes following segmental femoral shaft fractures: a critical review of the literature

BACKGROUND

Although segmental femoral shaft fractures (SFSF) are very challenging to manage, there has been no critical evaluation of the current practices and outcomes. The aim of this study is to evaluate their characteristics, management trends, outcomes, and complications.

METHODS

A literature search was conducted via the SCOPUS, Embase (via SCOPUS) and MEDLINE (via PubMed) between 1995 and 2023. Studies were included if they reported patient demographics, mechanism of injury, classification of fractures, associated injuries, type of management, outcomes, and complications.

EXCLUSION CRITERIA

only diaphyseal fractures were included and proximal and distal femoral fractures were excluded from this study.

RESULTS

Overall, 22 studies met the inclusion criteria reporting on 313 patients. Mean age was 36.2 years with male-female ratio of 4.8 to 1. The majority were high-energy fractures secondary to road traffic accidents and 16% were open. The most commonly associated injuries included chest injury (27%) and lower leg fractures (24%). Treatment consisted of intramedullary nailing (IMN) (72%), plating (22%) or both combined (6%). Outcomes reported: good in 70%, fair in 10%, excellent in 19% and poor in 2% of cases. Mean time to union was 20 weeks. Complications are reported in 24% of cases, with most common delayed union (5%) and non-union (4%).

CONCLUSION

SFSF are high-energy fractures occurring most commonly in young males, are open in 16% of cases and have significant associated injuries. In their overwhelming majority, IMN is the mainstay of treatment. The expected outcome is generally good in 70% of cases, although not devoid of complications in 24% of cases and patients must be aware of this during the consent process.

Reamed intramedullary nailing of diaphyseal multifragmentary femur fractures (AO/OTA 32-C) without fluoroscopy guidance: prospective analysis of methods and short-term outcomes in a low-resource setting

PURPOSE

To describe the methods and outcomes of reamed intramedullary nailing (IMN) of diaphyseal multifragmentary femur (AO/OTA C2 and C3) fractures (DMFFs) in a low-resource setting without fluoroscopy and fracture table.

METHODS

The prospective study involved 35 DMFFs among 318 femur fractures treated ≤ 3 weeks post-injury with SIGN nails. The fractures were fixed without fluoroscopy, fracture table and power reaming. Closed, mini-open or open reduction was done. Anatomical length and alignment were ensured using a surgical support triangle during retrograde nailing, and by an assistant during antegrade nailing. Follow-ups were done at 6 weeks, 12 weeks and 6 months.

RESULTS

DMFFs constituted 11.0% of the 318 fractures. Twenty-four (68.6%) were males. The mean age was 39.0 years (range 17-75 years). About 94.3% were injured in road traffic accidents. Fracture reduction was closed in 18, mini-open in 8 and full-open in 9. The operative times were significantly shorter for closed than open reduction (p = 0.001). Five fractures received a supplemental fixation with plate or lag screws. By the 12th post-operative week, 97.1% demonstrated continuing radiographic healing, 94.1% tolerated painless weight-bearing and 91.2% could squat & smile. There was no infection or noticeable rotational malunion. Five fractures healed with a limb-length discrepancy of < 2 cm.

CONCLUSION

The study demonstrates the feasibility of reamed IMN of DMFFs without fluoroscopy. The outcomes were satisfactory. Although the small sample size and short follow-up period are limitations, the study could serve as a basis for future larger studies in low-resource settings.

Retrograde intramedullary nailing with supplemental plate and lag screws allows early weight bearing following distal end-segment femur fractures (AO/OTA 33) in a low-resource setting

PURPOSE

To underline the feasibility of achieving early weight bearing in patients with distal end-segment femur fractures (AO/OTA 33) treated with retrograde intramedullary nailing and supplemental plate or lag screws in the absence of C-arm.

METHODS

41 distal end-segment femur fractures (DFFs) included in the study were treated with SIGN nails with or without a side plate in a center that lacked intraoperative fluoroscopy and fracture table. A medial or lateral para-patellar incision was used for fracture reduction, nail insertion and side plate placement. Follow-ups were done at six weeks, 12 weeks, and six months post-operatively.

RESULTS

Distal end-segment fractures constituted 13.2% of all femur fractures treated. The patients' mean age and range were 49.6 and 23-83 years respectively. They were mostly injured in road traffic accidents. 27 were daily-income earners. By the 12th week post-operatively, 82.1% of them could flex their knee beyond 90°, all of them could bear weight fully, and 71.8% could squat & smile.

CONCLUSION

The study highlighted the procedure for retrograde nailing of DFFs in a setting without the requisite facilities for minimally-invasive surgeries. The findings demonstrated the feasibility of achieving an expedited weight bearing for the predominantly daily-income-earning victims to ensure early return to work and poverty reduction. While the small sample size is a limitation, the study does provide information that could serve as a basis for future randomized controlled trials in low-resource settings.

Geriatric distal femoral fractures: post-operative complications and nine-year mortality-a retrospective analysis of two tertiary trauma centres

PURPOSE

This study aimed to estimate the mortality at various post-operative intervals and explore influential variables for these outcomes in elderly patients with distal femur fractures (DFF).

METHODS

A retrospective observational study was conducted across two tertiary care institutions, between 2014 and 2020. The primary outcomes were mortality rates at 30-day, six month, and one year post-surgery. Secondary outcomes included 1-year readmission and reintervention rates along with their correlated complications.

RESULTS

A total of 37 DFF in 35 patients was analyzed; average age was 83.6 years (range, 65-98 years). The overall mortality rate at a maximum follow-up of 8.8 years was 74% (26/35 patients). The median survival time was 3.2 years and the survival probability at five years was 27% (95% confidence interval [CI], 13 to 43%). Mortality rates at 30 days, six months, and one year after surgery were 8.6% (3 patients), 23% (8 patients), and 34% (12 patients), respectively. Overall mortality rate was 64% (15/24 patients) for native distal femur fractures, and 92% (13/14 patients) for periprosthetic fractures (p = 0.109). Patients older than 85 years and male gender were identified as risk factors for mortality within the first year post-operatively.

CONCLUSION

Elderly fractures have a high mortality at eight years of follow-up. Mortality at one year was much higher than in other studies of the same nature. We did not find statistically significant differences when comparing native bone fractures with periprosthetic fractures. Factors that impact mortality were being a man, advanced age, elevated index comorbidity, and dementia. There is no relationship between the time to be taken to the surgical procedure and mortality results.

Locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, fracture table and power reaming: retrograde affords greater procedural efficiency than antegrade approach

PURPOSE

To compare the intraoperative procedural efficiency of antegrade and retrograde locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, power reaming devices and fracture tables.

METHODS

A secondary analysis of prospectively collected data was conducted on 238 isolated diaphyseal femur fractures fixed with SIGN Standard and Fin nails within three weeks of injury. The data included baseline patient and fracture characteristics, nail type and diameter, fracture reduction methods, operative times and outcome measures.

RESULTS

There were 84 and 154 fractures in the antegrade and retrograde groups respectively. Both groups were similar vis-a-vis baseline patient and fracture characteristics. Closed reduction of the fractures was significantly easier for retrograde than an antegrade approach. The retrograde approach more readily permitted the use of Fin nails. The mean nail diameter used for retrograde was significantly larger than that for antegrade. The time taken to achieve retrograde nailing was significantly lesser than that of antegrade. There was no statistically significant difference between the outcomes of the two groups.

CONCLUSION

In the absence of expensive fracture-surgery gadgets, retrograde nailing offers many procedural advantages over antegrade, such as easier closed reduction and canal reaming, the greater possibility of using the Fin nail with fewer interlocking screws and shorter operative times. However, we acknowledge the lack of randomisation and the presence of an unequal number of fractures in the two groups as limitations of this study.

Locked intramedullary nailing of open fractures in resource-poor settings: a prospective observational study of challenges and functional outcomes in 101 fractures at Ogbomoso, Nigeria

BACKGROUND

Trauma is now one of the fastest growing epidemics globally but low and middle-income countries (LMICs) are more severely affected in terms of cost, disability and death. The high-energy trauma of road traffic accidents and violence often produces open fractures which can be difficult to manage in resource-poor settings. Adequate stabilization, such as provided by locked nails, has been found to ensure better outcome for open fractures. There is dearth of published studies on the use of locked intramedullary nail in the treatment of open fractures in Nigeria.

METHODS

This is a prospective observational study of all the 101 open fractures of the humerus, femur and tibia treated over a period of 92 months with Surgical Implant Generation Network (SIGN) nail. Fracture severity was classified according to the modified Gustilo-Anderson system. The intervals between fracture and antibiotics administration, débridement and definitive fixation, as well as surgery duration and method of fracture reduction were noted. Outcomes measured at follow-up included infection, ongoing radiographic healing, knee flexion/shoulder abduction beyond ninety degrees (KF/SA > 90⁰), full weight bearing (FWB), painless squatting (PS&S)/shoulder abduction-external rotation (SAER).

RESULTS

Most of the patients fall between ages 20 and 49 years; 75.5% of them were males. There were more Gustilo-Anderson type IIIA fractures than other types but nine type IIIB tibia fractures were also nailed. The overall infection rate was 15%, contributed mostly by the type IIIB fractures. By the 12th post-operative week, at least 79% had ongoing radiographic healing and had achieved all of KF/SA > 90⁰, FWB, and PS&S/SAER.

CONCLUSION

The SIGN nail's solid construct reduces the risk of infection and allows earlier use of the limb, making it particularly suitable in LIMCs where socioeconomic functioning often requires an unhindered use of the limbs.

Infection complicating locked intramedullary nailing of open lower-extremity fractures: incidence, associated risk factors, and lessons for improving outcome in a low-resource setting

Introduction: Infection is the chief complication that makes open fractures difficult to treat. Most low- and middle-income countries (LMICs) are missing out on modern management techniques developed to achieve better outcomes in high-income countries (HICs). One of these is the use of locked intramedullary (IM) nails. This study aimed to determine the factors associated with infection of open fractures treated with the surgical implant generation network (SIGN) nail at a Nigerian tertiary hospital. Methods: Data were collected prospectively on 101 open fractures of the femur and tibia over an 8-year period. Active surveillance for infection was done on each patient. Infection was diagnosed as the presence of wound breakdown or purulent discharge from (or near) the wound or surgical incision. Potential risk factors were tested for association with infection. Results: There were 101 fractures in 94 patients with a mean age of 37.76 years. The following treatment-related factors demonstrated significant associations with infection - timings of antibiotic administration (p < 0.001 ) and definitive fracture fixation (p = 0.002 ); definitive wound closure (p < 0.001 ), fracture-reduction methods (p = 0.005 ), and surgery duration (p = 0.007 ). Conclusions: Although this study has limitations precluding the drawing up of final conclusions, the findings suggest that the risk factors for infection of nailed open fractures in LMICs are similar to those in HICs. Consequently, outcomes can potentially improve if LMICs adopt the management principles used in HICs in scientifically sound ways that are affordable and socially acceptable to their people. Further studies are suggested to establish our findings.

Preoperative Anemia and Risk of In-hospital Postoperative Complications in Patients with Hip Fracture

Purpose

To evaluate the impact of preoperative anemia on postoperative complications after hip fracture surgery.

Patients and Methods

We conducted a retrospective study including hip fracture patients at a teaching hospital between 2005 and 2022. We defined preoperative anemia as the last hemoglobin measurement level before surgery < 130 g/L for men and < 120 g/L for women. The primary outcome was a composite of in-hospital major complications, including pneumonia, respiratory failure, gastrointestinal bleeding, urinary tract infection, incision infection, deep venous thrombosis, pulmonary embolism, angina pectoris, arrhythmia, myocardial infarction, heart failure, stroke, and death. Secondary outcomes were cardiovascular events, infection, pneumonia, and death. We used multivariate negative binomial or logistic regression to evaluate the impact of anemia and its severity, categorized as mild (90-130 g/L for men, 90-120 g/L for women) or moderate-to-severe (< 90 g/L for both) anemia on outcomes.

Results

Of the 3540 included patients, 1960 had preoperative anemia. 188 anemic patients experienced 324 major complications, while 63 non-anemic patients had 94 major complications. The risk of major complications was 165.3 (95% CI, 149.5-182.4) and 59.5 (95% CI, 48.9-72.3) per 1000 persons in anemic and non-anemic patients, respectively. Anemic patients were more likely to have major complications than non-anemic patients (adjusted incidence rate ratio (aIRR), 1.87; 95% CI, 1.30-2.72), which was consistent in mild (aIRR, 1.77; 95% CI, 1.22-2.59) and moderate-to-severe (aIRR, 2.97; 95% CI, 1.65-5.38) anemia. Preoperative anemia also increased the risk of cardiovascular events (aIRR, 1.96; 95% CI, 1.29-3.01), infection (aIRR, 1.68; 95% CI, 1.01-2.86), pneumonia (adjusted odds ratio (aOR), 1.91; 95% CI, 1.06-3.57), and death (aOR, 3.17; 95% CI, 1.06-11.89).

Conclusion

Our findings suggest that even mild preoperative anemia is associated with major postoperative complications in hip fracture patients. This finding highlights considering preoperative anemia as a risk factor in surgical decision-making for high-risk patients.

Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria

Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work. One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied. We found the mean age to be 47.97 years. Males constituted 63.9% of the patients' population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 90°, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully. The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.