Outcome after intramedullary nailing of femoral shaft fractures

The design of an "H" joystick for closed reduction and its application in segmental and comminuted femoral shaft fractures: an innovative technique

Background

Closed reduction and locked intramedullary nailing has become a common surgical method in the treatment of femoral shaft fractures. Overlap and rotation displacements can usually be corrected through the use of an orthopedic traction table. However, lateral displacement and angulation persist.

Methods

In this paper, we describe a joystick that can be used in the closed reduction of a fracture. It can correct lateral displacement and angulation, and has the advantage of multi-direction reduction. The device described in this paper includes two parallel horizontal joysticks, one vertical main joystick and four assistant rods. Moreover, there are many specific spacing holes in the two parallel horizontal joysticks and a groove structure in the vertical main joystick. When the main “H” joystick is pressed, it can adjust lateral displacements and angulation because of the lever principle. The distance between parallel horizontal joysticks and assistant rods can be adjusted to the fracture position and body mass index of different patients.

Results

The study participants consisted of 11 males and 5 females with a mean age of 31.0 years. All participants had good closed reduction and achieved bony union without any complications such as infection, nerve injury, non-union, malunion, and limb length discrepancy. By using an “H” joystick, closed femoral shaft fracture reduction and locked intramedullary nailing becomes simpler and faster.

Conclusion

Based on the use of this instrument, we can easily and conveniently obtain the correct reduction situation, which leads to better surgical results. This device can be applied in the reduction of clinical femoral fractures and gradually extended to the reduction of other fractures.

Influence of Hip Fracture on Knee Pain During Postoperative Rehabilitation

Objective

To investigate whether fracture type, surgical procedure, or fracture grade affect knee pain during postoperative rehabilitation after a hip fracture.

Methods

We conducted a retrospective case-controlled study of 139 patients during postoperative rehabilitation after surgery for hip fractures. Patients were divided into two groups: patients experiencing knee pain during the first week of postoperative rehabilitation, and patients without knee pain. We compared the types of fracture, surgical procedure, and fracture grade between the two groups.

Results

We enrolled 52 patients (37.4%) with knee pain during the first weeks of postoperative rehabilitation. For type of fracture, knee pain was more common with intertrochanteric fracture than with femur neck fracture (48.8% vs. 21.1%, respectively; p=0.001). For the surgical procedure, there was no significant difference between the groups. For the fracture grade, the grades classified as unstable fractures were more common in the group of intertrochanteric fracture patients with knee pain than in those without knee pain (74.1% vs. 36.4%, respectively; p=0.002).

Conclusion

Intertrochanteric fracture affected knee pain after hip fracture surgery more than did femur neck fracture, particularly in unstable fractures. Furthermore, there was no difference in each fracture type according to the surgical procedure. Careful examination and management for knee pain is needed in patients with hip fracture surgery.

Femur fractures in professional athletes: a case series

OBJECTIVE

To discuss return to play after femur fractures in several professional athletes.

BACKGROUND

Femur fractures are rare injuries and can be associated with significant morbidity and mortality. No reports exist, to our knowledge, on return to play after treatment of isolated femur fractures in professional athletes. Return to play is expected in patients with femur fractures, but recovery can take more than 1 year, with an expected decrease in performance.

TREATMENT

Four professional athletes sustained isolated femur fractures during regular-season games. Two athletes played hockey, 1 played football, and 1 played baseball. Three players were treated with anterograde intramedullary nails, and 1 was treated with retrograde nailing. All players missed the remainder of the season. At an average of 9.5 months (range, 7-13 months) from the time of injury, all athletes were able to return to play. One player required the removal of painful hardware, which delayed his return to sport. Final radiographs revealed that all fractures were well healed. No athletes had subjective complaints or concerns that performance was affected by the injury at an average final follow-up of 25 months (range, 22-29 months).

UNIQUENESS

As the size and speed of players increase, on-field trauma may result in significant injury. All players returned to previous levels of performance or exceeded previous statistical performance levels.

CONCLUSIONS

In professional athletes, return to play from isolated femur fractures treated with either an anterograde or retrograde intramedullary nail is possible within 1 year. Return to the previous level of performance is possible, and it is important to develop management protocols, including rehabilitation guidelines, for such injuries. However, return to play may be delayed by subsequent procedures, including hardware removal.

Primary unreamed and unlocked intramedullary nailing of femoral shaft fractures

ABSTRACT

In this retrospective study, we present our experience using open Küntscher nailing (K-nailing) which is still performed in developing countries for femoral fractures. Of 157 acute fractures treated between January 2003 and December 2009, 100 were stable (63.7%) and 135 were located within the middle third of the shaft (86%). Comminution was absent or minimal in 135 (86%) cases. Fracture union was achieved at an average of 14 weeks (range, 10 - 25). The duration of follow-up was 17 months (range, 6 - 36). Final evaluation showed that 129 (82.2%) patients had a good result according to modified Kempf's criteria. The predominant complications were infection (n=5; 3.2%), nonunion (n=9; 5.5%), implant failure (n=11; 7%), and malunion (n=27; 17.3%). Open reduction and fixation with a tight fitting Knail can give good results in selected acute femoral shaft fractures but knowledge of potential complications is needed.

KEY WORDS

femoral shaft fracture, Intramedullary nailing, Open reduction.

Health outcomes of delayed union and nonunion of femoral and tibial shaft fractures

INTRODUCTION

Knowledge about the functional consequences of lower limb long bone fractures is helpful to inform patients, clinicians and employers about their recovery process and prognosis. This study aims to describe the epidemiology and health outcomes of femoral and tibial shaft fractures treated at two level I trauma centres, by comparing the differences between patients with delayed union or nonunion and patients with union.

PATIENTS AND METHODS

An analysis of registry data over two years, supplemented with medical record review, was conducted. Fracture healing was retrospectively assessed by clinical and radiological evidence of union, and the need for surgical intervention. SF-12 scores, and work and pain status were prospectively recorded at six and twelve months post injury.

RESULTS

285 fractures progressed to union and 138 fractures developed delayed union or nonunion. There was a significant difference between the two cohorts with regards to the mechanism of injury, association with multi-trauma, open fractures, grade of Gustilo classification, patient fund source, smoking status and presence of comorbidities. The SF-12 physical component score was less than 50 at both six and twelve months with improvement in the union group, but not in the delayed union or nonunion group. 72% of patients with union had returned to work at one year, but 54% continued to have pain. The difference compared to patients with delayed union or nonunion was significant.

DISCUSSION

Even patients whose fractures unite in the expectant time-frame will have residual physical disability. Patients with delayed union or nonunion have still poorer outcomes, including ongoing problems with returning to work and pain. It is important to educate patients about their injury so that they have realistic expectations. This is particularly relevant given that the patients most likely to sustain femoral or tibial shaft fractures are working-age healthy adults, and up to a third of fractures may develop delayed union or nonunion.

CONCLUSION

Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. Patients with delayed union or nonunion can expect poorer outcomes.

A three-dimensional comparison of intramedullary nail constructs for osteopenic supracondylar femur fractures

OBJECTIVES

This study developed a new 6 degree-of-freedom, unconstrained biomechanical model that replicated the in vivo loading environment of femoral fractures. The objective of this study was to determine whether various distal fixation strategies alter failure mechanisms and/or offer mechanical advantages when performing retrograde intramedullary nail (IMN) stabilization of supracondylar femur fractures in osteoporotic bone.

METHODS

Forty fresh-frozen human femora were allocated into 2 groups of matched pairs: "locked" (fixed angle locking construct with both distal locking screws rigidly attached to the IMN) versus "unlocked" (conventional locking technique with 2 distal locking screws targeted through the distal locking screw holes of the IMN) and "locked" versus "washer" (fixed angle locking with the most distal screw exchanged for a bolt with condyle washers) distal fixation of a retrograde IM nails. A comminuted fracture (OTA 33-A3) was simulated with a wedge osteotomy. Bone density measurements were completed on all specimens before instrumentation. Instrumented femurs were loaded axially to failure, whereas 6 degree-of-freedom translations and angulations were measured using Roentgen stereophotogrammetric analysis.

RESULTS

Mean (± SD) load born by "locked" specimens (1609 ± 667 N) at clinical failure was 38.1% greater (P = 0.09) than the corresponding mean load born by "unlocked" specimens (1165 ± 772 N). Clinical failure for the "washer" group (1738 ± 772 N) was 29.9% greater (P = 0.07) than the corresponding mean of the "locked" counterparts (1338 ± 822 N). Failure load was most clearly related to bone density in the "unlocked" fixation group.

CONCLUSIONS

Predicting failure load based on bone density using a least squares estimate suggests that the washer construct provides superior fixation to other treatment techniques. The failure mechanism for a comminuted, supracondylar fracture cannot be analyzed accurately with a 1-dimensional measurement. The most common failure mechanism in this model was medial translation and varus angulation.

Morphometric Study of the Atlas Vertebra using Manual Method

ABSTRACT

The atlas (first cervical vertebra) has undergone many structural modifications. It is critically located and close to the 'life centres'. For this study, one hundred dried intact human atlas vertebrae from the Indian population were measured using a digital Vernier calliper that provides accurate resolution up to 0.01 mm. The distance between the tips of the transverse process, the outer and the inner distance between the foramen transversaria and various diameters of vertebral foramen were measured. The mean width of the measured atlases was 69.37 mm. The mean distance between the lateral margins of foramen transversaria was 55.66 mm and the inner distance was 45.93 mm. The mean thickness of vertebral artery grooves was 3.72 ± 1.06 mm. The observations made in the present study may help in improving understanding of various bony dimensions while operating close to important structures like nerve roots and the vertebral artery.

KEY WORDS

Atlas, Atypical cervical vertebra, C1, morphology.

Impaired fracture healing associated with amino acid disturbances

BACKGROUND

Five percent to 10% of all fracture patients experience an inadequate healing process that results in a nonunion of fracture parts. Previous experimental studies have indicated the importance of sufficient nitric oxide production from arginine during normal fracture healing. However, during conditions of stress, such as inflammation, arginine availability can become limited, which may lead to a nonunion as a result of insufficient callus formation.

OBJECTIVE

The aim of this study was to measure callus and plasma amino acid concentrations in patients with and without a fracture nonunion.

DESIGN

Amino acid concentrations in plasma and callus were measured with HPLC in atrophic nonunions (n = 12) and compared with those in hypertrophic nonunions (n = 12), acute fractures (n = 15), and healed fractures (n = 8).

RESULTS

Arginine (61 compared with 180 μmol/mg; P < 0.0001), citrulline (13 compared with 44 μmol/mg; P < 0.0001), and ornithine (25 compared with 149 μmol/mg; P < 0.0001) in callus were significantly lower in atrophic-nonunion patients than in healed-fracture patients. In hypertrophic nonunions, arginine was significantly higher and ornithine was lower than in healed fractures. Plasma arginine concentrations were significantly lower in patients with hypertrophic nonunions (62 μmol/L; P < 0.001) and acute-fracture patients (41 μmol/L; P < 0.001) but not in atrophic-nonunion patients. Plasma ornithine concentrations were lower in all groups than in acute-fracture patients.

CONCLUSIONS

Amino acid concentrations were significantly changed in nonunion patients. Atrophic nonunions had lower concentrations of all amino acids, whereas hypertrophic nonunions had higher arginine and lower ornithine concentrations at fracture sites than did healed-fracture and acute-fracture patients.

The effectiveness of the antegrade reamed technique: the experience and complications from 415 traumatic femoral shaft fractures

This retrospective study presents the experience gained through use of reamed femoral nails and reports results and respective complications. This study included 415 femur fractures (312 men and 101 women with a mean age of 27.8 years) that were treated from 1993 to 2004. The fractures were classified according to AO, and 74 open fractures were included and typed according to the Gustilo classification. Dynamic nailing was performed for nearly all type A fractures and static nailing for types B and C. After a mean follow-up of 1.5 years, union rate was 97.8%. The complications were: 9 non-unions, 14 delayed-unions, 4 torsional malunions, 6 limb length discrepancies (shortening) and 30 nerve pareses due to traction. Deep venous thrombosis (DVT) occurred below the knee in 4 patients, while there were recorded 3 pulmonary and 2 fat embolisms, 1 superficial and 1 deep infection. There were 28 broken screws identified postoperatively. Logistic regression analysis revealed that type B and C were associated with increased risk of complications, with respective odds ratios of 3.1 (95% CI = 1.3–7.2, P = 0.011) and 4.3 (95% CI = 1.8–10.3, P = 0.001) when compared to type A patterns. All patients returned to their activities in a mean time of 10 months. Intramedullary nailing is still the treatment of choice for femoral shaft fractures, but knowledge of potential complications and their association with certain fracture patterns is needed.

Femoral nailing-related coagulopathy determined by first-hit magnitude: an animal study

We asked whether coagulopathy worsened during femoral intramedullary nailing in the presence of lung contusion and hemorrhagic shock and whether reamed or unreamed nailing influenced these results. In 30 Merino sheep, we induced hemorrhagic shock and/or standardized lung contusion followed by femoral nailing. Six groups of five each were assigned as follows: thoracotomy control groups treated with reamed or unreamed nailing, lung contusion groups treated with reamed or unreamed nailing, and shock and lung contusion groups treated with reamed or unreamed nailing. After lung contusion alone (first hit), the serum values of antithrombin III, factor V, and fibrinogen were considerably altered after reamed and unreamed femoral nailing (second hit) 4 hours postoperatively. In the lung contusion and shock groups, we found a substantial reduction for all serum coagulative parameters between baseline and fixation after reamed and unreamed nailing. The magnitude of the first hit is increased if hemorrhagic shock is added to a lung contusion determined by hemostatic reactions. The magnitude of the injury appears equally important as the type of subsequent surgery and should be considered in planning for fracture fixation in patients at high risk for complications.

Reoperation rate in diaphyseal tibia fractures

BACKGROUND

Tibia fractures often require secondary surgery to achieve union. Reoperation is an objective outcome measure that is clinically relevant to the patients and treating doctors. This study determined the complication and reoperation rates for diaphyseal tibia fractures and identified variables predictive of reoperation.

METHODS

One-hundred and sixty-seven patients with 175 consecutive tibia shaft fractures (Association for the Study of Internal Fixation classification 42) presenting between July 2000 and June 2003 were included in the study. There were 4 deaths and 12 patients lost to follow up. The remaining 151 patients (159 fractures) were reviewed at a minimum of 6 months post-injury for the main outcome measures; union and reoperation. Univariate and multivariate analyses by logistic regression were used to identify any relationship between revision surgery and fracture classification, grade of the soft-tissue injury, mechanism of injury, age, sex, and treating surgeon.

RESULTS

The overall reoperation rate was 35.8% (57/159) with 13.2% (21/159) tibiae requiring minor revision surgery and 22.6% (36/159) tibiae requiring major revision surgery. Thirteen (8.2%) patients underwent major revision surgery specifically for non-union. The fracture classification and the Gustilo grade of soft-tissue injury were significant predictors of revision surgery overall, and of major revision surgery.

CONCLUSIONS

Tibial shaft fractures have a high revision rate as a consequence of non-union and infection. Revision surgery is best predicted by the fracture classification and the severity of the soft-tissue injury. This information is important for patient information and clinical decision making.

ASSESSING LEG LENGTH DISCREPANCY AFTER FEMORAL FRACTURE: CLINICAL EXAMINATION OR COMPUTED TOMOGRAPHY?

INTRODUCTION

Femoral shaft fractures treated with intramedullary nailing often heal with a leg length discrepancy (LLD). LLD is commonly evaluated by clinical examination and computed tomography (CT) scanogram. We assessed the correlation between these two techniques of calculating LLD.

METHODS

We reviewed 35 skeletally mature patients who sustained a femoral shaft fracture between January 1997 and December 1999. Leg length was measured clinically with direct measurement and a block test. Each patient was asked whether they felt they walked with a limp and whether they felt they had a leg length discrepancy. Each patient underwent a CT scanogram to measure femoral and total leg length. The correlation between clinical examination and scanogram was analysed using the Pearson Product Moment Correlation.

RESULTS

Of the 35 patients, 15 patients (43%) had a measurable LLD. There was a positive correlation between direct leg length measurement and the block test (P = 0.003), and between the block test and patient perception of limp and LLD. CT scanogram was performed on 29/35 patients. There was no correlation between CT scanogram and clinical measurement of leg length or between CT scanogram and patient perception of LLD or limp.

DISCUSSION

Leg length discrepancy commonly occurs following treatment of femoral shaft fractures. We found that there was a strong correlation between direct leg length measurement and the block test, and between both methods of clinical leg length measurement and patient perception of a limp or LLD. Our study found no correlation between CT scanogram and clinical leg length measurement or patient perception of limp or LLD.

CONCLUSION

Our study shows that physical examination (direct measurement and the block test) is more reliable and clinically relevant than CT scanogram measurement in the assessment of LLD after femoral fracture.