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Zhao Y, Li J, Liu Y, Cui G, Li Z. Comparison of reconstruction nails versus dual implants in the treatment of ipsilateral femoral neck and shaft fractures in adults: a meta-analysis and systematic review. BMC Musculoskelet Disord 2023; 24:800. [PMID: 37814281 PMCID: PMC10561477 DOI: 10.1186/s12891-023-06933-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/01/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE There is no consensus on the optimal treatment for ipsilateral femoral neck and shaft fractures. This meta-analysis aims to assess the effectiveness of reconstruction nails and dual implants in treating ipsilateral femoral neck and shaft fractures to provide a basis for decision-making when selecting the optimal approach. METHODS Relevant articles were retrieved from Pubmed, Embase, and Cochrane databases using the keywords "neck of femur", "shaft" and "fracture fixation" from inception until November 17, 2022. The screening process of the studies was conducted independently by two assessors, who assessed each study's eligibility and two assessors assessed the quality. Then compared differences in outcome measures using RevMan 5.3 software. RESULTS A total of ten retrospective cohort studies were included. There were no significant differences in union time, union rate, union-related complications (malunion, nonunion, delayed union) of femoral neck and shaft fractures, osteonecrosis of the femoral head, and functional outcomes (Friedman-Wyman scoring system) (P > 0.05). CONCLUSION Our pooled estimates indicated that reconstruction nails and dual implants for ipsilateral femoral neck and shaft fractures could yield satisfactory surgical results, and that there is no difference between the two treatment methods. TRIAL REGISTRATION This meta-analysis was registered on the PROSPERO website (registration number: CRD42022379606).
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Affiliation(s)
- Yongchao Zhao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jian Li
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China
| | - Yadong Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Guanlu Cui
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zhengwei Li
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China.
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2
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Cnossen JD, Van Lieshout EMM, Verhofstad MHJ. Surgical management of bifocal femoral fractures: a systematic review and pooled analysis of treatment with a single implant versus double implants. Arch Orthop Trauma Surg 2023; 143:6229-6241. [PMID: 37405462 PMCID: PMC10491515 DOI: 10.1007/s00402-023-04950-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 06/13/2023] [Indexed: 07/06/2023]
Abstract
INTRODUCTION Fractures of the proximal femur accompanied by a fracture of the femoral shaft are relatively rare, with a reported prevalence between 1 and 12%. Multiple surgical options are available, consisting of treatment with a single implant or with double implants. Controversy exists about the optimal management. A systematic review and pooled analysis were performed to assess the most reliable treatment for bifocal femoral fractures of the femur. MATERIALS AND METHODS A literature search was conducted on July 15, 2022. Selected studies were screened on title and abstract by two researchers independently, and full texts were read by both authors. Emphasis was put on adverse events such as postoperative infection, healing complications, malalignment, and functional outcome using either a single implant or double implants. RESULTS For the proximal femoral fractures, no significant difference could be confirmed for avascular necrosis of the femoral neck (5.1% for single implant and 3.8% for double implants), nonunion (6.4% for single implant and 7.8% for double implants), or varus malalignment (6.6% for single implant and 10.9% for double implants). This study also suggests that the number of implants is irrelevant for complications of the femoral shaft regarding the rates of postoperative infection and healing complications. Pooled rates of bone healing complications were 1.6-2.7-fold higher when patients were treated with a single implant, but statistical significance could not be confirmed. For hardware failure, revision surgery, leg length discrepancy, and functional outcome, no difference between the two groups was found either. CONCLUSIONS The pooled proportions of all postoperative complications had overlapping confidence intervals; thus, no inference about a statistically significant difference on the number of implants used for treating ipsilateral fractures of the femur can be made. Both treatment groups showed a similar functional outcome at the last moment of follow-up, with more than 75% of the patients reporting a good outcome.
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Affiliation(s)
- J D Cnossen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Alcaraz JG, Fernandez EA, Martín IA, Recuenco DB, González CO, Agundez AC. Ipsilateral proximal and shaft femoral fractures: Results of two treatment strategies. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:354-364. [PMID: 36924841 DOI: 10.1016/j.recot.2023.03.007] [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: 01/22/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/17/2023] Open
Abstract
INTRODUCTION Ipsilateral proximal and shaft femoral fractures typically occur in young adults after high-energy trauma. No consensus exists regarding the optimal internal fixation device or surgical strategy for these complex fractures. Our main objective is to identify differences on outcomes and complications between patients treated with one or combined implants. MATERIAL AND METHOD This is a single-center retrospective cohort study in patients with associated fractures of the proximal (31 AO) and shaft femur (32 AO). We divided the patients into two groups according to the use of single (Group I) or combined implants (Group II). Demographic, clinical, radiological, surgical data and development of complications were collected. RESULTS We identified 28 patients (19 men and 9 women) with an average age of 43 years. We used an anterograde femoral nail in group I (17 patients) and a retrograde femoral nail or a plate associated with hip lag screws or sliding hip screw in Group II (11 patients). Patients were followed up for 26.28 (9.12-62.88) months. Osteonecrosis of the femoral head, osteoarthritis, infection or nonunion was found in 9 patients (32%). No significant differences (p 0.70) were found in complications between two groups or between definitive surgical fixation before or after the first 24h. CONCLUSIONS No differences in the development of complications or timing of definitive fixation were found between the use of one or combined implants in ipsilateral proximal femur and shaft fractures. Regardless of the implant chosen, an appropriate osteosynthesis technique is crucial, even so high complication rates are expected. LEVEL OF EVIDENCE IV. Grade of Recommendation: C.
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Affiliation(s)
- J G Alcaraz
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain.
| | - E A Fernandez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
| | - I A Martín
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
| | - D B Recuenco
- Department of Orthopaedic Surgery and Traumatology, Hospital General de Nuestra Señora del Prado, Talavera, Spain
| | - C O González
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
| | - A C Agundez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
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4
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Gómez Alcaraz J, Ajuria Fernández E, Auñón Martín I, Bustamante Recuenco D, Olaya González C, Capel Agúndez A. Ipsilateral proximal and shaft femoral fractures: Results of two treatment strategies. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T354-T364. [PMID: 37311476 DOI: 10.1016/j.recot.2023.06.006] [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: 01/22/2023] [Accepted: 03/06/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Ipsilateral proximal and shaft femoral fractures typically occur in young adults after high-energy trauma. No consensus exists regarding the optimal internal fixation device or surgical strategy for these complex fractures. Our main objective is to identify differences on outcomes and complications between patients treated with one or combined implants. MATERIAL AND METHOD This is a single-center retrospective cohort study in patients with associated fractures of the proximal (31 AO) and shaft femur (32 AO). We divided the patients into two groups according to the use of single (GroupI) or combined implants (GroupII). Demographic, clinical, radiological, surgical data and development of complications were collected. RESULTS We identified 28 patients (19 men and 9 women) with an average age of 43years. We used an anterograde femoral nail in GroupI (17 patients) and a retrograde femoral nail or a plate associated with hip lag screws or sliding hip screw in GroupII (11 patients). Patients were followed up for 26.28 (9.12-62.88) months. Osteonecrosis of the femoral head, osteoarthritis, infection or nonunion was found in 9 patients (32%). No significant differences (P=.70) were found in complications between two groups or between definitive surgical fixation before or after the first 24h. CONCLUSIONS No differences in the development of complications or timing of definitive fixation were found between the use of one or combined implants in ipsilateral proximal femur and shaft fractures. Regardless of the implant chosen, an appropriate osteosynthesis technique is crucial, even so high complication rates are expected.
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Affiliation(s)
- J Gómez Alcaraz
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - E Ajuria Fernández
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - I Auñón Martín
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - D Bustamante Recuenco
- Departamento de Cirugía Ortopédica y Traumatología, Hospital General de Nuestra Señora del Prado, Talavera de la Reina, Toledo, España
| | - C Olaya González
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - A Capel Agúndez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
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Singh S, Ravi A, Maurya PK, Surana R, Rai A. Outcome Analysis of Dual Implant Osteosynthesis for Ipsilateral Proximal and Shaft Femur Fractures: Do We Need Cephalomedullary Nails? Cureus 2021; 13:e16613. [PMID: 34458031 PMCID: PMC8383820 DOI: 10.7759/cureus.16613] [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: 07/24/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Most surgeons prefer a single implant for segmental proximal and diaphyseal femur fractures, although results are controversial and still no consensus for proper management is present. This prospective study analyses the functional and radiological outcome of managing 17 patients with ipsilateral shaft and proximal femur fractures by dual implant osteosynthesis at our center. Methods Over a two-year period, we managed 17 patients with a mean age of 35 years, with cancellous cannulated screws or dynamic hip screws for intracapsular femur fractures and improvised proximal femoral nail for extracapsular proximal femur fractures. Distal femoral locking plates or distal femoral nails were used for shaft femur fractures depending upon fracture morphology. The patients had a maximum follow-up of 18 months. Results A total of 80% of patients had a good functional outcome (using the Friedman-Wyman scoring system) while 60% had an excellent Harris Hip Score. The mean time taken for the bone union for proximal femur fractures was 4.75 months and for shaft femur fractures, it was 6 months. Conclusion We had a satisfactory functional and clinical outcome of managing these fractures with two implants, one focusing biomechanically on each fracture. This principle of dual implant osteosynthesis can reliably be used in such difficult fracture patterns and it negates the use of the single cephalomedullary nail for fixating both fractures.
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Affiliation(s)
- Saurabh Singh
- Orthopedic Surgery, Banaras Hindu University, Varanasi, IND
| | - Achyut Ravi
- Orthopedic Surgery, Banaras Hindu University, Varanasi, IND
| | | | - Rishabh Surana
- Orthopedic Surgery, Banaras Hindu University, Varanasi, IND
| | - Alok Rai
- Orthopedic Surgery, Banaras Hindu University, Varanasi, IND
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Toro G, Moretti A, Ambrosio D, Pezzella R, De Cicco A, Landi G, Tammaro N, Florio P, Cecere AB, Braile A, Medici A, Siano A, Di Maggio B, Calabrò G, Gagliardo N, Di Fino C, Bruno G, Pellegrino A, Negri G, Monaco V, Gison M, Toro A, Schiavone Panni A, Tarantino U, Iolascon G. Fractures around Trochanteric Nails: The "Vergilius Classification System". Adv Orthop 2021; 2021:7532583. [PMID: 33520318 PMCID: PMC7817309 DOI: 10.1155/2021/7532583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/29/2020] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The fractures that occurred around trochanteric nails (perinail fractures, PNFs) are becoming a huge challenge for the orthopaedic surgeon. Although presenting some specific critical issues (i.e., patients' outcomes and treatment strategies), these fractures are commonly described within peri-implant ones and their treatment was based on periprosthetic fracture recommendations. The knowledge gap about PNFs leads us to convene a research group with the aim to propose a specific classification system to guide the orthopaedic surgeon in the management of these fractures. MATERIALS AND METHODS A steering committee, identified by two Italian associations of orthopaedic surgeons, conducted a comprehensive literature review on PNFs to identify the unmet needs about this topic. Subsequently, a panel of experts was involved in a consensus meeting proposing a specific classification system and formulated treatment statements for PNFs. Results and Discussion. The research group considered four PNF main characteristics for the classification proposal: (1) fracture localization, (2) fracture morphology, (3) fracture fragmentation, and (3) healing status of the previous fracture. An alphanumeric code was included to identify each characteristic, allowing to describe up to 54 categories of PNFs, using a 3- to 4-digit code. The proposal of the consensus-based classification reporting the most relevant aspects for PNF treatment might be a useful tool to guide the orthopaedic surgeon in the appropriate management of these fractures.
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Affiliation(s)
- Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Daniele Ambrosio
- Unit of Orthopaedics and Traumatology, Evangelical Hospital Betania, Naples, Italy
| | - Raffaele Pezzella
- Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Orthopaedics and Traumatology, L'Aquila, Italy
| | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Giovanni Landi
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Nicola Tammaro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Pasquale Florio
- Unit of Orthopaedics and Traumatology, Evangelical Hospital Betania, Naples, Italy
| | - Antonio Benedetto Cecere
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Adriano Braile
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antonio Medici
- Unit of Orthopaedics and Traumatology, AORN S. Giuseppe Moscati, Avellino, Italy
| | - Antonio Siano
- Unit of Orthopaedics and Traumatology, Santa Maria Della Speranza Hospital, Battipaglia, Italy
| | - Bruno Di Maggio
- Unit of Orthopaedics and Traumatology, “Ave Gratia Plena” Civil Hospital, Piedimonte Matese, Italy
| | - Giampiero Calabrò
- Unit of Orthopaedics and Traumatology, San Francesco D'Assisi Hospital, Oliveto Citra, Italy
| | - Nicola Gagliardo
- Unit of Orthopaedics and Traumatology, San Giuliano Hospital, Giugliano, Italy
| | - Ciro Di Fino
- Unit of Orthopaedics and Traumatology, AOR San Carlo, Potenza, Italy
| | - Gaetano Bruno
- Unit of Orthopaedics and Traumatology, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Achille Pellegrino
- Unit of Orthopaedics and Traumatology, San Giuseppe Moscati Hospital, Aversa, Italy
| | - Giacomo Negri
- Unit of Orthopaedics and Traumatology, Evangelical Hospital Betania, Naples, Italy
| | - Vincenzo Monaco
- Unit of Orthopaedics and Traumatology, Santa Maria Incoronata Dell'Olmo Hospital, Cava de' Tirreni, Italy
| | - Michele Gison
- Unit of Orthopaedics and Traumatology, Villa Malta Hospital, Sarno, Italy
| | - Antonio Toro
- Unit of Orthopaedics and Traumatology, Villa Malta Hospital, Sarno, Italy
| | - Alfredo Schiavone Panni
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Kang L, Liu H, Ding Z, Ding Y, Hu W, Wu J. Ipsilateral proximal and shaft femoral fractures treated with bridge-link type combined fixation system. J Orthop Surg Res 2020; 15:399. [PMID: 32912270 PMCID: PMC7488305 DOI: 10.1186/s13018-020-01929-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although many treatments for ipsilateral proximal and shaft femoral fractures have been developed, controversy exists regarding their optimal management. The purpose of this retrospective study was to discuss the effectiveness of the bridge-link type combined fixation system (BCFS) and evaluate functional outcomes in treating patients with these complex fractures. PATIENTS AND METHODS We retrospectively reviewed 14 cases of ipsilateral proximal and shaft femoral fractures treated from January 2012 to December 2016. All cases were treated by BCFS combined with minimally invasive percutaneous plate osteosynthesis (MIPPO). Clinical and radiographic data were collected during regular post-operative follow-up visits. Functional outcomes were determined according to the Friedman and Wyman scoring system. RESULTS The proximal femoral fractures were emergency diagnoses in 11 cases and delayed diagnoses in 3 cases. The delay time was 5-6 days, with an average of 5.3 days. The mean operation time was 179.6 min (range 135-231 min) with a blood loss volume that ranged from 430 to 535 ml (average 483.6 ml). Follow-up was conducted in 13 cases between 9 and 30 months post-operation, with an average follow-up time of 17.3 months. The proximal femoral fractures were united in 12 cases at the final follow-up. One case had nonunion 13 months after the operation, underwent valgus intertrochanteric osteotomy, and healed 6 months later. The femoral shaft fractures obtained rigid union at the latest follow-up in 12 cases. One case endured nonunion 12 months after the operation. After the revision surgery and iliac bone grafting, the fracture healed 6 months later. Eight of the cases had good functional results, 4 had fair results, and results were poor in 1 case at the final follow-up. CONCLUSIONS The treatment of ipsilateral proximal femoral and shaft fractures with BCFS in combination with MIPPO demonstrated a high likelihood of union for both fractures and good functional results.
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Affiliation(s)
- Liangqi Kang
- Department of Orthopedics, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, 363000, China
| | - Hui Liu
- Department of Orthopedics, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, 363000, China
| | - Zhenqi Ding
- Department of Orthopedics, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, 363000, China
| | - Yiqiang Ding
- The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, 363000, China
| | - Wei Hu
- The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, 363000, China
| | - Jin Wu
- Department of Orthopedics, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, 363000, China.
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Wu KT, Lin SJ, Chou YC, Cheng HH, Wen PC, Lin CH, Yeh WL. Ipsilateral femoral neck and shaft fractures fixation with proximal femoral nail antirotation II (PFNA II): technical note and cases series. J Orthop Surg Res 2020; 15:20. [PMID: 31959205 PMCID: PMC6971944 DOI: 10.1186/s13018-019-1524-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/18/2019] [Indexed: 11/30/2022] Open
Abstract
Background Combined ipsilateral femoral neck and shaft fractures are an uncommon type of fractures. A number of different implant options are available for the management of this injury. Two-device procedures were suggested because of the higher rate of malunion by single-device treatment. However, surgical treatment using a cephalomedullary nail is still an alternative option that provides better mechanical advantage and minimal invasion. This study details the technique of treating these pattern fractures with proximal femoral nail anti-rotation II (PFNA-II) to achieve an acceptable reduction in both fracture sites. Methods Ten cases of ipsilateral femoral neck and shaft fractures under reduction by PFNA II were included and reviewed. A saw-bone model was also utilized to perform the detailed technique of reduction and fixation of PFNA II. Results Under the special technique by using the PFNA II, all ten cases achieved optimal reduction and alignment of both fracture sites in intra-operative fluoroscopy. There was no intra-operative complication noted. After 6 months of follow-up, radiography revealed proper alignment and well union of the fractures. Conclusions Fixation of ipsilateral femoral neck and shaft fractures with a single construct provides advantages of good biomechanical function, minimal invasion, reduced blood loss, and less operation time when comparing to two-device fixation. Thus, if acceptable reduction could be achieved, fixation by one PFNA II was a good alternative choice for this injury pattern.
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Affiliation(s)
- Kuen-Ting Wu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Shih-Jie Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Ying-Chao Chou
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hsiang-Hen Cheng
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Po-Chong Wen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Che-Han Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Wen-Ling Yeh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.
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9
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Mohan K, Ellanti P, French H, Hogan N, McCarthy T. Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review. Orthop Rev (Pavia) 2019; 11:7963. [PMID: 31316738 PMCID: PMC6603431 DOI: 10.4081/or.2019.7963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Indexed: 01/10/2023] Open
Abstract
Concomitant ipsilateral femoral neck and shaft fractures are uncommon, occurring in 1-9% of femoral shaft fractures. While this injury typically occurs in young patients following high-energy trauma, little consensus has been established regarding the optimal fixation approach. A multitude of treatment strategies exist, with limited evidence as to which is more favorable. The aim of this study was to appraise current evidence, comparing management with either one single or separate devices for both fractures. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1992 and 2018 comparing the rate of postoperative nonunion, malunion, delayed union, avascular necrosis, infection or reoperation between at least one method of single device fixation and one method of separate device fixation were included. Six non-randomized cohort studies assessing 173 patients were suitable for inclusion, each comparing single device cephalomedullary nail fixation of both fractures with a combination of devices. All patients presented following high-energy trauma, at a median age of 32 years. While low complication rate and favorable outcomes were found across both groups, no significant difference could be inferred between either treatment strategy. This injury continues to occur in the traditionally described patient group, and results in acceptable postoperative outcomes. A paucity of randomized studies limits the ability to recommend a single or separate device treatment approach, and as such prospective, randomized trials with adequately powered sample sizes are required to definitively compare surgical management strategies in this rare but complex injury.
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Affiliation(s)
- Kunal Mohan
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Prasad Ellanti
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin
| | - Helen French
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niall Hogan
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin
| | - Tom McCarthy
- Department of Trauma and Orthopedics, Saint James's Hospital, Dublin
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Labza S, Fassola I, Kunz B, Ertel W, Krasnici S. Delayed recognition of an ipsilateral femoral neck and shaft fracture leading to preventable subsequent complications: a case report. Patient Saf Surg 2017; 11:20. [PMID: 28702088 PMCID: PMC5504794 DOI: 10.1186/s13037-017-0134-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/21/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Ipsilateral femoral shaft and neck fractures are rare injuries, affecting mostly young patients who sustained high-energy traumas. In 19-50% of cases, the femoral fracture is misdiagnosed or overlooked at the initial presentation, with reportedly increased risk of complications such as non-union and avascular necrosis. We present a case of an ipsilateral femoral neck and shaft fracture, which was missed at initial presentation despite radiographic and computed tomography (CT) scan evaluation. CASE PRESENTATION A 56-year old female was admitted to our institution following a high-energy trauma (fall from 6 m). Initial radiographic and CT scan evaluation revealed a displaced femoral shaft fracture but no other femoral fractures were detected. Closed reduction and external fixation of the femoral shaft fracture was performed in the emergency setting. Follow-up radiologic evaluations revealed an ipsilateral laterally displaced femoral neck fracture. Despite cephalomedullary nail fixation of both fractures performed on the third day from the initial injury, the patient developed a non-union of the femoral neck fracture, which led to cut-out of the lag screw with associated varus failure of the femoral neck fracture requiring surgical revision and implant of a bipolar hemiarthroplasty at one year follow up. The postoperative course was uneventful and the patient had a full long-term recovery. CONCLUSION This case report exemplifies the need to maintain the highest level of suspiciousness for the concomitant presence of an ipsilateral femoral neck fracture when treating polytraumatized patients who sustained a femoral shaft fracture as a consequence of a high-energy trauma. Furthermore, the pre-operative standardized radiological evaluation (plain x-ray and CT scan) might not always help in ruling out these fractures. It is therefore necessary to adopt additional standardized radiographic protocols not only in the pre-operative but also in the intra-operative and immediate post-operative settings.
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Affiliation(s)
- Sönke Labza
- Klinik für Unfallchirurgie und Orthopädie, DRK Kliniken Berlin
- Westend, Berlin, 14050 Germany
| | - Isabella Fassola
- Klinik für orthopädische und Unfallchirurgie, CHARITÉ - Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - Benedict Kunz
- Klinik für orthopädische und Unfallchirurgie, CHARITÉ - Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - Wolfgang Ertel
- Klinik für orthopädische und Unfallchirurgie, CHARITÉ - Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - Senat Krasnici
- Klinik für orthopädische und Unfallchirurgie, CHARITÉ - Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
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Successful treatment of infected femoral shaft nonunion with teriparatide after eradication of infection. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lin YB, Li RB, Xiong GS, Zhuang Y, Xiong SR, Huang XG, Zhang YY. Treatment of Middle-up Part Long-segment Femoral Fracture with Long Proximal Femoral Nail Antirotation. Orthop Surg 2015; 7:138-45. [PMID: 26033995 DOI: 10.1111/os.12166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 01/25/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To investigate the outcomes of treating middle-up part long-segment fractures of the femur by long proximal femoral nail antirotation (PFNA-long). METHODS From June 2006 to December 2013, 139 cases (35 women, 104 men; mean age 48.8, range, 18-86 years) of long-segment femoral fracture in middle-up part were treated with long proximal femoral nail antirotation (PFNA, 320-380 mm) by minimally invasive percutaneous fixation and autogenous iliac bone graft. Fifty-eight cases were graded as type IA long-segment femoral fractures (41.73%), 25 type IB (17.99%), four type IC (2.88%), 28 type II (20.14%), 12 type IIIA (8.63%), five type IIIB (3.60%), and seven type IV (5.04%). Clinical efficacy was evaluated with Harris hip function scores and postoperative pain with visual analogue scale. RESULTS The operative time was 35-90 min (mean, 45 min) and mean intraoperative blood loss 78.6 mL (range 30-200 mL). Most patients were walking with assistance 4-10 days postoperatively. All patients were followed up for 3-37 months (mean, 19 months). There were no serious complications. All fractures healed after 2.8-6.8 months (mean, 3.9 months). According to Harris criteria, the clinical results were excellent in 108 patients, good in 22, fair in eight and poor in one. Ninety-three cases had no pain, 33 mild pain, 13 moderate pain and 25 occasionally needed non-steroidal analgesics. CONCLUSION Closed reduction or limited open reduction with PFNA-long is an effective treatment for long-segment femoral fracture in middle-up part, with good strength in fixation, high rate of fracture union, early functional recovery and low rate of complications.
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Affiliation(s)
- Yan-bin Lin
- Department of Orthopaedics, Fuzhou Second Hospital, Affilated Hospital of Xiamen University, Fuzhou, China
| | - Ren-bin Li
- Department of Orthopaedics, Fuzhou Second Hospital, Affilated Hospital of Xiamen University, Fuzhou, China
| | - Guo-sheng Xiong
- Department of Orthopaedics, Fuzhou Second Hospital, Affilated Hospital of Xiamen University, Fuzhou, China
| | - Yan Zhuang
- Department of Orthopaedics, Fuzhou Second Hospital, Affilated Hospital of Xiamen University, Fuzhou, China
| | - Sheng-ren Xiong
- Department of Orthopaedics, Fuzhou Second Hospital, Affilated Hospital of Xiamen University, Fuzhou, China
| | - Xian-gui Huang
- Department of Orthopaedics, Fuzhou Second Hospital, Affilated Hospital of Xiamen University, Fuzhou, China
| | - Yi-yuang Zhang
- Department of Orthopaedics, Fuzhou Second Hospital, Affilated Hospital of Xiamen University, Fuzhou, China
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Slobogean GP, Sprague SA, Scott T, Bhandari M. Complications following young femoral neck fractures. Injury 2015; 46:484-91. [PMID: 25480307 DOI: 10.1016/j.injury.2014.10.010] [Citation(s) in RCA: 212] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/06/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Femoral neck fractures in patients 60 years of age or younger are challenging injuries to treat because of the high-energy trauma mechanisms and the displaced fracture patterns typically found in this patient population. Understanding the burden of disease is an important first step in addressing treatment controversies in this population. The purpose of the current study is to quantitatively pool the incidence of patient important complications following internal fixation of young femoral neck fractures. METHODS A comprehensive search of the Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, and Central databases was completed under the direction of a biomedical librarian. Multiple outcomes of interest (complications) were collected and included: reoperation, femoral head avascular necrosis, fracture non-union, infection, implant failure, and malunion. RESULTS 1558 fractures from 41 studies were included in the meta-analysis. An18.0% pooled reoperation incidence was observed for isolated femoral neck fractures. The total pooled incidence of avascular necrosis (AVN) was 14.3%, and the total incidence of nonunion was 9.3%. When stratified for fracture displacement displaced fractures were more likely to undergo reoperation and to result in AVN or non-union. The total incidence of malunion was 7.1%, implant failure was 9.7%, and surgical site infection was 5.1%. Complications associated with a femoral neck fracture treated in conjunction with an ipsilateral femoral shaft fracture were lower overall than the pooled estimates for isolated neck fractures. CONCLUSIONS The results of our analysis demonstrate that the incidence of complications experienced by young femoral neck fracture patients is relatively high. Reoperation following internal fixation of isolated femoral neck fractures occurred in nearly 20% of cases, and AVN and nonunion were the most common complications that likely contributed to repeat surgeries. These results highlight the importance of further efforts to improve the clinical outcomes in this population.
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Affiliation(s)
- G P Slobogean
- Department of Orthopaedic Surgery, University of British Columbia, Canada; Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Canada.
| | - S A Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Canada; Department of Clinical Epidemiology and Biostatics, McMaster University, Canada
| | - T Scott
- Department of Clinical Epidemiology and Biostatics, McMaster University, Canada
| | - M Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Canada; Department of Clinical Epidemiology and Biostatics, McMaster University, Canada
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Abstract
INTRODUCTION Femoral neck fractures in younger aged patients are particularly devastating injuries with profound impairments of quality of life and function. As there are multiple differences in patient and injury characteristics between young and elderly femoral neck fracture patients, the geriatric hip fracture literature is unlikely to be generalisable to patients under age 60. We conducted a systematic review to determine if clinically relevant outcome measures have been used in previously published clinical studies of internal fixation in young adults with femoral neck fractures. METHODS We conducted a comprehensive literature search using multiple electronic databases and conference proceedings to identify studies which used internal fixation for the management of femoral neck fractures in patients between the ages of 15 to 60. Eligibility screening and data abstraction were performed in duplicate. We classified the reported outcomes into the following categories: operative and hospital outcomes, radiographic outcomes, clinical outcomes, and functional outcomes and health-related quality of life. We calculated the frequencies of reported outcomes. RESULTS Fort-two studies met our inclusion criteria. Operative and hospital outcomes were poorly reported with less than one-quarter of studies reporting relevant data. Important radiographic outcomes were also inadequately reported with only one-third of studies reporting the quality of the fracture reduction, and methods for assessment were highly variable. The assessment of avascular necrosis was reported in almost all the included studies (95.2%); however, the assessment of nonunion was only reported in three-quarters of the studies. Re-operations were reported in 73.8% of the included studies and the assessment of fracture healing was only reported in two-thirds of the studies. Less than half of the studies reported functional outcomes or health-related quality of life (overall patient evaluation scales and systems (45.2%), patient functional outcomes (30.9%), and health-related quality of life (4.8%). DISCUSSION Our systematic review found that the assessment of clinically relevant outcomes in the young femoral neck fracture literature is lacking, which makes utilising the literature to guide clinical practice challenging. Future studies should aim to include important radiographic measures, fracture-healing complications, functional outcomes, and health-related quality of life during any assessment of young femoral neck fracture treatment.
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Boulton CL, Pollak AN. Special topic: Ipsilateral femoral neck and shaft fractures--does evidence give us the answer? Injury 2015; 46:478-83. [PMID: 25593045 DOI: 10.1016/j.injury.2014.11.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 11/17/2014] [Indexed: 02/02/2023]
Abstract
Ipsilateral fractures of the femoral neck and shaft are rare, high-energy injuries that typically occur in young polytrauma patients. The associated fracture of the neck is often vertical in nature and is more frequently non-displaced than in isolated femoral neck fractures. Historically the diagnosis of an associated femoral neck fracture was delayed or missed in approximately one third of cases. Studies have shown that detection can be significantly improved with the implementation of a protocolized approach to hip imaging in all patients with femoral shaft fractures. Prompt recognition of an associated femoral neck fracture allows for timely stabilization and may decrease the risks of non-union and avascular necrosis. In contrast, failure to recognize a non-displaced or minimally displaced associated neck fracture prior to fixation of the shaft can lead to displacement, a decrease in neck fixation options, a technically challenging secondary procedure and increased risk of long-term sequelae. A vast array of treatment strategies have been described for this combined injury. Published options range from spica casting to open reduction and internal fixation of both fractures and include almost all conceivable combinations in between. While timely surgical stabilization is now universally recommended for both shaft and neck, no consensus exists as to the most appropriate method of fixation for either fracture. Most authors recommend prompt, but not emergent, surgery with priority given to anatomic reduction and stabilization of the neck fracture by either closed or open methods. Fixation of the shaft fracture follows as patient condition allows. The rare nature of this injury makes it very challenging to study and most published series' are retrospective with very small sample sizes. In short, no scientificallycompelling study is available to definitively support any one implant choice or method of stabilzation over another for the treatment of associated fractures of the femoral neck and shaft.
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Affiliation(s)
- Christina L Boulton
- Department of Orthopaedics, Division of Orthopaedic Traumatology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 South Greene Street, Baltimore, MD 21201, United States
| | - Andrew N Pollak
- Department of Orthopaedics, Division of Orthopaedic Traumatology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 South Greene Street, Baltimore, MD 21201, United States.
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Shen L, Zhang Y, Shen Y, Cui Z. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies. Orthop Traumatol Surg Res 2013; 99:377-83. [PMID: 23707739 DOI: 10.1016/j.otsr.2012.12.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 11/26/2012] [Accepted: 12/13/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Previous studies comparing proximal femoral nail antirotation (PFNA) with dynamic hip screw (DHS) for peritrochanteric fractures reported conflicting findings. The objective of this meta-analysis was to compare the efficacy and safety of PFNA and DHS for pertrochanteric fractures. HYPOTHESIS PFNA achieves better efficacy for peritrochanteric fractures compared with DHS. MATERIALS AND METHODS Relevant randomized controlled trials comparing PFNA with DHS for pertrochanteric fractures were assessed for eligibility and included into this meta-analysis. Data were extracted independently and methodological quality was further assessed. The inclusion criteria of this meta-analysis were: randomized controlled trials comparing PFNA with DHS for pertrochanteric fractures and reporting at least one of these main outcomes, including operating time, blood loss, all causes mortality, and complications. RESULTS Five randomized controlled trials were finally included into this meta-analysis. Pooled results showed there were less blood loss (weighted mean difference Blood loss=-249.75ml, 95%CI -303.83 to -195.67, P<0.0001) and fewer complications (Odds ratio=0.40, 95%CI 0.23 to 0.70, P=0.001) in the PFNA group compared with the DHS group. However, there was no difference in term of mortality between those two groups (Odds ratio mortality=1.13, 95%CI 0.47 to 2.69, P=0.79). Sensitivity analysis by sequential omission of individual studies showed that the significance of pooled odds ratios was robust, which suggested this outcome was credible. DISCUSSION PFNA can benefit peritrochanteric fractures patients with less blood loss and fewer complications compared with DHS. The significant heterogeneity among the included trials for intraoperative blood loss, and operation time may be attributable to variation in the skills of the surgeons and the different types of perirochanteric fractures. In addition, more powered randomized studies are needed to identify the findings from this meta-analysis, and the effects of long-term follow-up also need further study, especially the impact on the mortality. LEVEL OF EVIDENCE Level II, meta-analysis of low powered randomized study.
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Affiliation(s)
- L Shen
- Department of Orthopedics, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai 200092, China
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Wang WY, Yang TF, Liu L, Pei FX, Xie LM. A comparative study of ipsilateral intertrochanteric and femoral shaft fractures treated with long proximal femoral nail antirotation or plate combinations. Orthop Surg 2012; 4:41-6. [PMID: 22290818 DOI: 10.1111/j.1757-7861.2011.00166.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare the results of long proximal femoral nail antirotation (PFNA-long) and plate combinations in the treatment of ipsilateral intertrochanteric and femoral shaft fractures. METHODS Between March 2004 and April 2009, 23 patients with ipsilateral intertrochanteric and femoral shaft fractures were treated with PFNA-long or plate combinations. The patients were divided into two groups. Group I contained 13 patients who were treated with dynamic hip screws (DHS) combined with compression plate fixation. The 10 patients in Group II were treated with PFNA-long. RESULTS The average follow-up was 17.8 and 16.8 months for Groups I and II, respectively. The average union time for intertrochanteric fractures was 17.4 and 16.6 weeks in Groups I and II, respectively, and for femoral shaft fracture 22.2 and 21.5 weeks, respectively. There were nine good, two fair, and two poor functional results in Group I, and eight good, one fair, and one poor in Group II. There was nonunion of two femoral shaft fractures in Group I and one in Group II. There were no significant differences between the two groups in functional outcomes or major complications. CONCLUSION Both treatment methods achieve satisfactory functional outcomes in patients with ipsilateral intertrochanteric and femoral shaft fractures. PFNA-long is the better choice for the treatment of complex fractures, having the advantages of minimal exposure, reduced perioperative blood loss, and achievement of biological fixation of both fractures with a single implant.
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Affiliation(s)
- Wen-yue Wang
- Department of Orthopaedic Surgery, Guang'anmen Hospital, China Academy of Chinese Medicine Science, Beijing, China
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