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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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Nadar AC, Seligson D. Heterotopic ossification in the knee following retrograde nailing of a femur fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3181-3184. [PMID: 36797500 DOI: 10.1007/s00590-023-03491-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/05/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a pathologic bone formation in extra skeletal tissue and articular space. This was an objection to nailing of femur fractures across the knee; however, this has not been the case in many thousands of cases. Nonetheless, we present a patient in who placement of a retrograde nail resulted in calcification in the knee requiring excision. CASE PRESENTATION A 42-year-old male presented to the clinic complaining of pain, popping, clicking, and mocking in the right knee, especially in the patellar region. Nine months prior he suffered an ipsilateral femur fracture that was treated with a retrograde intramedullary nail. X-ray and CT scan were used to confirm the presentation of a heterotopic bone mass in the Hoffa area of the right knee. The patient underwent an arthrotomy for excision of the bone mass. The bone mass was excised, but bone in the ACL was not removed. The patient experienced pain relief and improved range of motion following excision. CONCLUSION Intraarticular heterotopic ossification is an infrequent event. We present a case of heterotopic ossification in the knee following retrograde nailing. The patient experienced improved symptoms and range of motion after excision of the intraarticular heterotopic bone mass.
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Affiliation(s)
- Arun C Nadar
- University of Louisville School of Medicine, 500 S. Preston St, Louisville, KY, 40202, USA
| | - David Seligson
- Department of Orthopaedic Surgery, University of Louisville, 550 S. Jackson St., 1st Floor ACB, Louisville, KY, 40202, USA.
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Baker HP, Krishnan P, Foy M, Strelzow J, Daccarett M, Dillman D. Effect of nailing technique on length of stay in isolated ballistic femoral shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:353-360. [PMID: 35088146 DOI: 10.1007/s00590-021-03191-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to investigate length of stay, postoperative mobilization and discharge disposition following intramedullary nailing of ballistic femoral shaft fractures stratified by nailing technique. METHODS All adult patients with isolated ballistic femoral shaft fractures between May 1, 2018, and September 1, 2021, were reviewed. The final cohort included 69 ballistic femur fractures in 69 patients. Of the 69 patients included, 29 were treated with retrograde nailing while 40 were treated with antegrade nailing. RESULTS The average length of stay of patients treated with antegrade nailing was 2.55 days (SD 1.3 days) compared with 3.45 days (SD 2.3 days) for patients treated with retrograde nailing; this was statistically significant (P = 0.04). Median steps on POD1 for antegrade nailing were 20 and 8 for retrograde. There was no significant difference in VAS pain scores between the two cohorts. All patients were discharged home. CONCLUSION The average length of stay for patients who underwent antegrade nailing was significantly shorter when compared with the retrograde nailing. Patients in the antegrade cohort mobilized further than the retrograde cohort in the immediate postoperative setting. We found no significant difference in VAS pain scores between the two cohorts. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL, 60637, USA.
| | - Pranav Krishnan
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL, 60637, USA
| | - Michael Foy
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL, 60637, USA
| | - Jason Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL, 60637, USA
| | - Miguel Daccarett
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL, 60637, USA
| | - Daryl Dillman
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL, 60637, USA
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Imaging Evaluation of Insertion Point Accuracy in Retrograde Intramedullary Femoral Nailing. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6068490. [PMID: 36337845 PMCID: PMC9635961 DOI: 10.1155/2022/6068490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/05/2022] [Indexed: 11/19/2022]
Abstract
Objective When compared with visual retrograde intramedullary nail placement in the femur, fluoroscopic retrograde intramedullary nail placement in the femur improved the accuracy of insertion. Methods Ninety-six patients treated with retrograde intramedullary nailing of the femur for femoral fracture were included in this retrospective case-control study, including 48 patients treated with nailing under direct vision and 48 patients treated with nailing under fluoroscopy. Influencing factors potentially associated with the deviation of the needle insertion point on the coronal and sagittal planes (including the needle insertion method, use of limited open reduction, side, intramedullary nail diameter, mechanism of injury, and fracture classification) were analyzed univariately; then, the variables with a p value < 0.20 on univariate analysis were included in the linear regression equation to assess the independent factors associated with needle insertion point deviation. Results On the coronal plane, the insertion point deviation in the visual nail placement group (1.11 ± 4.08 mm) was not significantly different (p = 0.13) from that in the fluoroscopic nail placement group (−0.44 ± 3.48 mm); on the sagittal plane, the insertion point deviation in the visual nail placement group (4.91 ± 4.67 mm) was significantly greater than that in the fluoroscopic nail placement group (2.08 ± 2.97 mm) (p < 0.01). Visual nail placement was a risk factor for insertion point deviation on the sagittal plane compared with fluoroscopic nail placement (β = −0.84, p < 0.01). Conclusion Compared with visual nail placement, fluoroscopic nail placement improves the accuracy of insertion on the sagittal plane, with no difference between the two methods on the coronal plane. These findings indicate that surgeons should exercise more caution when placing nails under direct vision.
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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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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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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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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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Tan L, Wang T, Li YH, Yang T, Hao B, Zhu D, Sun DH. Patellar tendon ossification after retrograde intramedullary nailing for distal femoral shaft fracture: A case report and review of the literature. Medicine (Baltimore) 2017; 96:e8875. [PMID: 29382009 PMCID: PMC5709008 DOI: 10.1097/md.0000000000008875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Retrograde femoral nailing was one of the most important treatment means for distal femoral shaft fracture. However, studies regarding heterotopic ossification of the patellar tendon after retrograde intramedullary nailing for distal femoral shaft fracture are limited. We herein present a rare complication, namely heterotopic ossification of the patellar tendon, after retrograde intramedullary nailing for displaced femoral shaft fracture. PATIENT CONCERNS We present a case of 25-year-old male with displaced femoral shaft fracture who was treated by retrograde intramedullary nailing. DIAGNOSES During the period of follow-up, the patient developed symptomatic heterotopic ossification of the patellar tendon with extensively hard ossification area. INTERVENTIONS Open surgery was recommended, but the patient has refused further treatment. OUTCOMES The patient resulted in pain and restricted the range of motion of the affected knee. LESSONS This case stresses the importance of longer-term follow-up and further attention into the possibility of heterotopic ossification of the patellar tendon.
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Affiliation(s)
- Lei Tan
- Department of Orthopedic Traumatology
| | | | - Yan-Hui Li
- Department of Cardiology and Echocardiography
| | - Tianye Yang
- Department of Plastic and Cosmetic Surgery, The First Hospital of Jilin University. Changchun, China
| | | | - Dong Zhu
- Department of Orthopedic Traumatology
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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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Zheng ZL, Yu X, Chen W, Liu YJ, Yu KL, Wu T, Zhang YZ. Femoral Condyles Tangential Views: An Effective Method to Detect the Screw Penetration of Femoral Condyles After Retrograde Nailing. Chin Med J (Engl) 2015; 128:3352-6. [PMID: 26668151 PMCID: PMC4797512 DOI: 10.4103/0366-6999.171441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Postoperative knee soft tissue irritation is a common complication after retrograde nail fixation of femoral fractures. Distal locking screw prominence is one of the causes for soft tissue irritation. This study aimed to determine whether the use of the femoral condyles tangential views improve the diagnostic accuracy compared with anteroposterior (A-P) view in detecting distal locking screw penetrations during retrograde femoral nailing. Methods: The angle between the sagittal plane and lateral aspect of the condyle and the angle between the sagittal plane and medial aspect of condyle were measured on computed tomography (CT) images. After the angles were measured and recorded, cadaveric femurs were used in a simulated surgical procedure. The retrograde femoral nail was inserted into the femur and placed distal locking screws, which were left 2, 4, and 6 mm proud of the medial and lateral condyles for each femur. A-P view, lateral condyle tangential view and medial condyle tangential view were obtained. All fluoroscopic images were recorded and sent to three observers blinded to the experimental procedure to determine whether screws penetrated the condyle cortex or not. Results: According to the results of CT scan, the lateral condyle view was 20.88 ± 0.98° and the medial condyle view was 40.46 ± 3.14°. In the A-P view, we detected 0% at 2 mm penetration, 16.7% (lateral condyle screw) and 25.0% (medial condyle screw) at 4 mm, and 41.7% (lateral condyle screw) and 58.3% (medial condyle screw) at 6 mm. In the lateral tangential view, we detected 91.7% at 2 mm penetration of the lateral condyle and 100% at 4 mm and 6 mm. In the medial tangential view, we detected 66.7% at 2 mm penetration of the medial condyle and 100% at 4 mm and 6 mm. The femoral condyle tangential views provided significant improvement in detecting screw penetrations at all lengths (2, 4, and 6 mm) compared with the A-P view (P < 0.05). Conclusions: The femoral condyles tangential views increased the accuracy of detecting screw penetrations on the medial and lateral condyles. Routine clinical use of the femoral condyles tangential views has the potential to increase accuracy in detecting distal locking screw penetration during retrograde femoral nailing.
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Affiliation(s)
| | | | | | | | | | | | - Ying-Ze Zhang
- Department of Orthopedic, The Thrid Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
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Mounasamy V, Mallu S, Khanna V, Sambandam S. Subtrochanteric fractures after retrograde femoral nailing. World J Orthop 2015; 6:738-43. [PMID: 26495251 PMCID: PMC4610916 DOI: 10.5312/wjo.v6.i9.738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/21/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023] Open
Abstract
Secondary fractures around femoral nails placed for the management of hip fractures are well known. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. Only a few reports in the existing literature have described these fractures. Two young men after sustaining a fall presented to us with pain, swelling and deformity in the upper thigh region. On enquiring, examining and radiographing them, peri-implant fractures of subtrochanteric nature through the distal interlocking screws were revealed in both patients who also had histories of previous falls for which retrograde intramedullary nailing was performed for their respective femora. Both patients were managed with similar surgical routines including removal of the existing hardware, open reduction and ace cephallomedullary antegrade nailing. The second case did show evidence of delayed healing and was additionally stabilized with cerclage wires. Both patients had uneventful postoperative outcomes and union was evident at the end of 6 mo postoperatively with a good range of motion at the hip and knee. Our report suggests that though seldom reported, peri-implant fractures around the subtrochanteric region can occur and pose a challenge to the treating orthopaedic surgeon. We suggest these be managed, after initial stabilization and resuscitation, by implant removal, open reduction and interlocking intramedullary antegrade nailing. Good results and progression to union can be expected in these patients by adhering to basic principles of osteosynthesis.
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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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14
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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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Shah S, Desai P, Mounasamy V. Retrograde nailing of femoral fractures: a retrospective study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1093-7. [PMID: 26126587 DOI: 10.1007/s00590-015-1658-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 06/02/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Retrograde femoral nailing is a common method to repair femoral shaft fractures in polytrauma patients. Studies have reported varying incidences of complications associated with retrograde femoral nailing such as knee pain, nonunion, and arthrofibrosis. The objective of this retrospective study was to describe healing and complication rates of 31 patients who underwent retrograde femoral nailing at our academic medical center. METHODS Clinical notes and radiographs were reviewed retrospectively. Data points such as demographics, fracture location on femur, time to union after surgery, presence or absence of comminution, associated injuries, and complications were assessed. RESULTS Average time to union was 4.69 months with no statistically significant relationship found between time to union and age, sex, comminution, or location of fracture. Knee pain was present in 23 % of patients, and distal screw removal was necessary in 19.4 % of patients. DISCUSSION Retrograde femoral nailing is an effective method of femoral shaft fracture fixation in polytrauma patients. The healing rate of femoral shaft fractures fixed with a retrograde nail is the same regardless of location of fracture, age, sex, or comminution. Prevention of tip of nail lying into the knee and early physical therapy are important to prevent arthrofibrosis knee.
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MESH Headings
- Adolescent
- Adult
- Aged
- Bone Nails
- Bone Screws
- Female
- Femoral Fractures/diagnostic imaging
- Femoral Fractures/physiopathology
- Femoral Fractures/surgery
- Follow-Up Studies
- Fracture Fixation, Intramedullary/instrumentation
- Fracture Fixation, Intramedullary/methods
- Fracture Healing/physiology
- Fractures, Comminuted/diagnostic imaging
- Fractures, Comminuted/physiopathology
- Fractures, Comminuted/surgery
- Fractures, Open/diagnostic imaging
- Fractures, Open/physiopathology
- Fractures, Open/surgery
- Humans
- Knee Joint
- Male
- Multiple Trauma/surgery
- Pain, Postoperative/diagnostic imaging
- Pain, Postoperative/etiology
- Pain, Postoperative/physiopathology
- Radiography
- Retrospective Studies
- Young Adult
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16
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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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17
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Somerson JS, Rowley D, Kennedy C, Buttacavoli F, Agarwal A. Electromagnetic navigation reduces surgical time and radiation exposure for proximal interlocking in retrograde femoral nailing. J Orthop Trauma 2014; 28:417-21. [PMID: 24164789 DOI: 10.1097/bot.0000000000000029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the time required for proximal locking screw placement between a standard freehand technique and the navigated technique, and to quantify the reduction in ionizing radiation exposure. METHODS A fresh frozen cadaver model was used for 48 proximal interlocking screw procedures. Each procedure consisted of insertion of 2 anteroposterior locking screws. Standard fluoroscopic technique was used for 24 procedures, and an electromagnetic navigation system was used for the remaining 24 procedures. Procedure duration was recorded using an electronic timer and radiation doses were documented. RESULTS Mean total insertion time for both proximal interlocking screws was 405 ± 165.7 seconds with the freehand technique and 311 ± 78.3 seconds in the navigation group (P = 0.002). All procedures resulted in successful locking screw placement. Mean ionizing radiation exposure time for proximal locking was 29.5 ± 12.8 seconds. CONCLUSIONS Proximal locking screw insertion using the navigation technique evaluated in this work was significantly faster than the standard fluoroscopic method. The navigated technique is effective and has the potential to prevent ionizing radiation exposure.
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Affiliation(s)
- Jeremy S Somerson
- Department of Orthopaedics, The University of Texas Health Science Center at San Antonio, San Antonio, TX
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18
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Akinyoola AL, Yusuf MB, Orekha O. Challenges in the management of floating knee injuries in a resource constrained setting. Musculoskelet Surg 2013; 97:45-9. [PMID: 23307508 DOI: 10.1007/s12306-012-0239-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 12/27/2012] [Indexed: 10/27/2022]
Abstract
Floating knee injuries pose major challenges in management. There is little information on the patterns of these injuries and the challenges of managing them in our setting. Patients with floating knee injuries who were seen and treated over a 5-year period at our center were retrospectively reviewed. The patterns of the injuries, associated injuries, methods of management and factors that influenced the outcome were analyzed. Twenty-five patients, consisting of 19 males and 6 females with a mean age of 33.4 ± 16.04 years, satisfied the study criteria. All were caused by road traffic injuries, motor cycle crashes accounting for 19 (76%). Twenty-two (88%) injuries were Blake and McBryde type 1, while 3 (12%) were of type 2A. Thirty-two percent of the patients had surgical fixation of both fractures, while 40% of the patients had both fractures managed non-operatively. Non-operative management strongly correlated with development of malunion. The results of management of floating injuries in our setting are not satisfactory. Orthopedic and trauma care should be made accessible to those requiring it.
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Affiliation(s)
- A L Akinyoola
- Department of Orthopaedic Surgery and Traumatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.
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el Moumni M, Voogd EH, ten Duis HJ, Wendt KW. Long-term functional outcome following intramedullary nailing of femoral shaft fractures. Injury 2012; 43:1154-8. [PMID: 22483542 DOI: 10.1016/j.injury.2012.03.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 12/06/2011] [Accepted: 03/06/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND The management of femoral shaft fractures using intramedullary nailing is a popular method. The purpose of this study was to evaluate the long-term functional outcome after antegrade or retrograde intramedullary nailing of traumatic femoral shaft fractures. We further determined predictors of these functional outcome scores. METHODS In a retrospective study, patients with a femoral shaft fracture but no other injuries to the lower limbs or pelvis were included. A total of 59 patients met the inclusion criteria. Functional outcome scores (Short Musculoskeletal Functional Assessment (SMFA), Western Ontario and McMaster University Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and the Lysholm knee function scoring scale) were measured at a mean of 7.8 years (± 3.5 years) postoperatively. The Visual Analogue Scale (VAS) was used to determine pain complaints of the lower limb. RESULTS The range of motion (ROM) of the hip and knee joints was comparable between the injured and uninjured leg, regardless of the nailing technique. Correlation between ROM and the final outcome scores was found to be fair to moderate. Even years after surgery, 17% of the patients still reported moderate to severe pain. A substantial correlation was observed between VAS and the patient-reported outcome scores. The most significant predictor of functional outcome was pain in the lower limb. CONCLUSIONS Our findings suggest that the ROM of hip and knee returns to normal over time, regardless of the nailing method used. However, pain in the lower limb is an important predictor and source of disability after femoral shaft fractures, even though most patients achieved good functional outcome scores.
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Affiliation(s)
- Mostafa el Moumni
- Department of Traumatology, University Medical Center Groningen, Groningen, The Netherlands.
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20
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Abstract
Because standard femoral supracondylar nails have certain disadvantages, they are often replaced by traditional femoral or tibial locked nails. The purpose of this study was to make a biomechanical comparison between both types of traditional locked nails to determine which technique was more suitable for treating unstable femoral supracondylar fractures. Fourteen left Sawbones femurs (Pacific Research Laboratories, Vashon, Washington) were osteotomized in the femoral supracondylar area. One centimeter of the medial cortex in the proximal fragment was obliquely removed to simulate an unstable fracture without shortening. Seven specimens were treated with traditional retrograde dynamic femoral locked nails, and the other 7 with traditional retrograde dynamic tibial locked nails. All specimens were tested with a servohydraulic materials testing machine to compare their relative stability. Static compression, dynamic cyclic compression, and static compression to failure were tested. An extensometer was used to measure the displacement of fragments. Displacement between the fragments increased following the increment in loads in both nails. The load-displacement curve was nearly linear up to 1000 N for both nails. The femoral nail had a greater stiffness compared with the tibial nail at 100 and 200 N (P=.02 and P=.04, respectively) in static compression and at 700 to 1000 N (P=.01 in each case) in dynamic cyclic compression, as well as larger loads in static compression to failure (8663 vs 7547 N, respectively; P<.001). Clinically, a traditional femoral locked nail may be more suitable to replace a standard femoral supracondylar nail in a retrograde fashion to treat an unstable femoral supracondylar fracture.
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Affiliation(s)
- Chi-Chuan Wu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
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21
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Han HS, Kim DH, Kang SB. The use of a ti-ni shape memory alloy ring bone fixator during the retrograde nailing of supracondylar femoral fractures. Knee Surg Relat Res 2011; 23:231-5. [PMID: 22570840 PMCID: PMC3341807 DOI: 10.5792/ksrr.2011.23.4.231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 11/06/2011] [Accepted: 11/08/2011] [Indexed: 01/25/2023] Open
Abstract
Purpose To identify the effects of using a Ti-Ni shape memory alloy ring shaped bone fixator (SMA-rBF) during the retrograde nailing of supracondylar femoral fractures. Materials and Methods The authors reviewed 25 patients with a supracondylar femoral fracture treated by retrograde intramedullary nailing with or without SMA-rBF (group S, 12/25; group N, 13/25). Radiological measurements of angular deformity were performed and functional assessments were made using the Sanders grading system. Results All fractures healed after an average of 12.2 weeks (range, 9-15 weeks) in group N and after 11.6 weeks (range, 10-13 weeks) in group S (p=0.351). The mean angle of coronal angular deformity was valgus 0.8° (range, varus 2.3°-valgus 4.5°) in group N and valgus 0.7° (range, varus 1.0°-valgus 2.4°) in group S (p=0.892). The mean angle of sagittal angular deformity was 1.0° in extension (range, flexion 3.2°-extension 3.1°) in group N and 0° (range, flexion 2.1°-extension 1.2°) in group S (p=0.022). However, functional grading evaluations revealed no differences between the two groups. Conclusions When reduction of a distal femoral fracture with retrograde nailing was difficult additional mini-open reduction and fixation with a ring shaped SMA did not delay or prevent bony union and resulted in good postoperative alignment.
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Affiliation(s)
- Hyuk-Soo Han
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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22
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Clement H, Heidari N, Kosuge D, Grechenig W, Tesch NP, Weinberg AM. Anatomical structures at risk with the proud retrograde femoral nail. Arch Orthop Trauma Surg 2011; 131:1539-44. [PMID: 21706305 DOI: 10.1007/s00402-011-1347-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Indexed: 01/29/2023]
Abstract
BACKGROUND Post-operative knee pain is common following retrograde nailing, with its etiology often multifactorial although a well-established cause is nail protrusion from the intercondylar notch. The aim of this study was to assess the structures at risk if the nail is left proud of the femoral articular surface. METHODS A retrograde femoral nail (Synthes Distal Femoral Nail) was inserted into the distal femur of 15 cadaveric lower limbs using the standard technique. The nail was left 10 mm proud of the articular surface and locked in this position. The knee was then put through a full range of movement while recording the intra-articular structures that came into contact with the distal end of the nail as well as the position of the knee when this occurred. This was repeated with the nail 5 mm proud. RESULTS With the nail 10 mm proud, it impinged on the anterior horn of the medial meniscus in 14 cases and the anterior horn of the medial meniscus as well as the tibial insertion of the ACL in one case at 15° of flexion. At 70° of flexion the nail came into contact with the distal margin of the patellar articular surface in the midline in all 15 cases. With the nail 5 mm proud, it impinged on the anterior horn of the medial meniscus in seven cases and the tibial insertion of the ACL as well as the anterior horn of the medial meniscus in eight cases as the knee was brought into full extension. In flexion the distal margin of the patellar articular surface in the midline came into contact with the nail at 70° of flexion in all 15 cases. CONCLUSION Correct positioning of a retrograde femoral nail is of paramount importance to avoid further iatrogenic injury to intra-articular structures.
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Affiliation(s)
- Hans Clement
- Department of Traumatology, Medical University of Graz, Auenbruggerplatz 7a, 8036, Graz, Austria
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23
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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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24
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Streubel PN, Gardner MJ, Ricci WM. Management of femur shaft fractures in obese patients. Orthop Clin North Am 2011; 42:21-35, v. [PMID: 21095432 DOI: 10.1016/j.ocl.2010.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Given the ongoing epidemic of obesity, femoral fracture management in the population affected by this condition is likely to become more frequent. Fracture treatment in obese patients poses a special challenge given greater difficulty in establishing an accurate diagnosis and confirming associated injuries. Adequate intraoperative positioning and obtaining accurate reduction and stable fixation may require special considerations. Obese patients have a high predisposition for complications such as compartment syndrome, nerve injuries, and pressure ulcers, and are at increased risk for medical complications given the high prevalence of comorbidities. A thorough understanding of the risks associated with obesity and the diagnostic and therapeutic challenges involved with femoral shaft fractures in this setting is paramount to achieve adequate results.
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Affiliation(s)
- Philipp N Streubel
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
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25
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Abstract
OBJECTIVES Retrograde nailing of open femoral fractures has presumed increased risk of knee sepsis. Our hypothesis was that the incidence of secondary knee infection after retrograde nailing of open femoral fractures is low. DESIGN Retrospective, multicenter. SETTING Four Level I trauma centers. PATIENTS AND METHODS A retrospective review of prospective trauma registries and fracture databases identified all open femoral fractures treated with retrograde intramedullary nailing from January 1, 2003, through February 15, 2007. Patients with ballistic injuries and those with less than 1 month follow up were excluded. Ninety-three open femoral fractures were identified in 90 patients. We defined a septic knee as a knee with infection that required reoperation with arthrotomy or arthroscopy. Infections at an open fracture site were defined as those treated with local irrigation and débridement and intravenously and/or orally administered antibiotics. INTERVENTION Open femoral shaft fractures treated with a retrograde approach. MAIN OUTCOME MEASUREMENTS Occurrence of an ipsilateral postoperative septic knee. RESULTS One acute septic knee was identified (1.1%; 95% confidence interval, 0.0%-3.2%) noted at time of repeat irrigation and débridement of a massive degloving wound that left no skin coverage over the knee. We also observed one late knee sepsis 2.5 years after the index procedure occurring after quadricepsplasty. The nail had been removed 1.5 years before surgery, so we did not include that case in our knee sepsis rate. Two additional infections at the open wound site did not involve the knee. CONCLUSIONS Previous publications have argued that retrograde nailing of open femoral fractures provides a potential conduit for knee infection. Our data show that risk of a septic knee as a direct result of retrograde nailing of an open femoral fracture is relatively low (1.1%; 95% confidence interval, 0.0%-3.2%). To our knowledge, this is the first case series to document the relative safety associated with retrograde nailing of open femoral fractures.
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Biomechanical strain analysis of the proximal femur following retrograde intramedullary nailing. CURRENT ORTHOPAEDIC PRACTICE 2010; 21:385-389. [PMID: 21151706 DOI: 10.1097/bco.0b013e3181d73bae] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND: The purpose of this study was to examine the influence of proximal retrograde intramedullary nail position on proximal femoral strain, since stress risers occurring at the end of an implant can increase fracture risk. METHODS: Proximal femoral strains during axial and torsional loading were measured in composite Sawbone femurs after placement of retrograde intramedullary nails that ended at three different locations (2 cm proximal, 4 cm distal, and at the level of the lesser trochanter). RESULTS: No statistically significant difference was found between the axial or torsional strain observed in the intact femur and that seen after placement of a retrograde femoral nail ending at any of the three positions. Gages proximal to the nail tip demonstrated higher strains than the strains for the intact femur when compared with gages distal to the nail tip. CONCLUSION: The ending location of a retrograde nail in the proximal femur does not appear to significantly alter strain in the proximal femur under the axial and torsional loading methods used in the study.
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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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28
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Baldwin KD, Babatunde OM, Russell Huffman G, Hosalkar HS. Open fractures of the tibia in the pediatric population: a systematic review. J Child Orthop 2009; 3:199-208. [PMID: 19343389 PMCID: PMC2686810 DOI: 10.1007/s11832-009-0169-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 03/16/2009] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The management of open fractures of the tibia in a pediatric population represents a challenge to the clinician. Several case series over the course of many years have been performed describing the results of treating these injuries. It remains unclear, however, whether there is a preferred modality of treatment for these injuries, if a more severe injury confers a greater risk of infection, and if time to union is affected by Gustilo type, although trends seem to exist. The purpose of this study was to assemble the available data to determine (1) the risk of infection and time to union of various subtypes of open tibia fractures in children and (2) the changes in treatment pattern over the past three decades. METHODS A systematic review of the available literature was performed. Frequency weighted mean union times were used to compare union times for different types of open fractures. Mantel Haentzel cumulative odds ratios were used to compare infection risk between different types of open fractures. Linear regression by year was used to determine treatment practices over time. RESULTS No significant change in practice patterns was found for type I and III fractures, although type II fractures were more likely to be treated closed in the later years of the study compared to the earlier years. Type III fractures conferred a 3.5- and 2.3-fold greater odds of infection than type I and type II fractures, respectively. There was no significant difference in odds of infection between type I and II fractures. There was a significant delay in mean time to union between type I and type II fractures, and between type II and type III fractures. CONCLUSIONS With the exception of type II fractures, the philosophy of treatment of open fractures of the tibia has not significantly changed over the past three decades. Closed treatment or internal fixation are both viable options for type II fractures based on their relatively low incidence of infection. This study also demonstrates a strong relationship between Gustillo sub-types and odds of infection in this population. Not surprisingly, union rates are also delayed with increasing injury severity.
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Affiliation(s)
- Keith D. Baldwin
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
| | - Oladapo M. Babatunde
- />University of Pennsylvania School of Medicine, 3620 Hamilton Walk, Philadelphia, PA 19104 USA
| | - G. Russell Huffman
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
| | - Harish S. Hosalkar
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
- />Department of Orthopaedic Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, 2nd Floor, Wood Building, Philadelphia, PA 19104 USA
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29
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Abstract
Intramedullary nailing is the preferred method for treating fractures of the femoral shaft. The piriformis fossa and greater trochanter are viable starting points for antegrade nailing. Alternatively, retrograde nailing may be performed. Each option has relative advantages, disadvantages, and indications. Patient positioning can affect the relative ease of intramedullary nailing and the incidence of malalignment. The timing of femoral intramedullary nailing as well as the use of reaming must be tailored to each patient to avoid systemic complications. Associated comorbidities, the body habitus, and associated injuries should be considered when determining the starting point, optimal patient positioning for nailing, whether to use reduction aids as well as which to use, and any modifications of standard technique. Intramedullary nailing of diaphyseal femur fractures provides a stable fixation construct that can be applied using indirect reduction techniques. This method yields high union rates and low complication rates when vigilance is maintained during preoperative planning, the surgical procedure, and the postoperative period.
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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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Abstract
OBJECTIVE The purpose of this study was to evaluate the use of retrograde nailing to treat patients with bilateral femur fractures. DESIGN AND SETTING A retrospective review of prospectively obtained trauma databases was completed at 9 Level 1 trauma centers. PATIENTS In all, 3767 patients with femur fractures were identified. Of those, 89 (46 males, 43 females) had bilateral femur fractures treated with reamed, retrograde intramedullary nails within 48 hours after injury. The charts were reviewed for pertinent data. RESULTS The average cohort age was 30 years (16-63 years). The average Injury Severity Score was 21 (9-50). Eighty-five patients (96%) had associated injuries. Thirteen patients (14.6%) developed adult respiratory distress syndrome; 8 had thoracic injuries. There were 4 patients (4%) with fat embolism syndrome, 2 were delayed longer than 24 hours to the operating room. There were 5 deaths (5.6% mortality) in the retrograde nailing group. Thoracic injury was found to be associated with death rate (P < 0.07). CONCLUSIONS Bilateral femur fractures are indicative of severe injuries with mortality rates as high as 40%. There are no specific studies addressing the outcomes of bilateral femur fractures treated with retrograde nailing. In this largest retrospective study to date, the overall death rate of 5.6% was significantly lower than historical controls. The effect of timing and duration of surgery and other injuries is not completely known. In conclusion, retrograde nailing of bilateral femur fractures is an acceptable treatment for bilateral femur fractures.
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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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Tucker MC, Schwappach JR, Leighton RK, Coupe K, Ricci WM. Results of femoral intramedullary nailing in patients who are obese versus those who are not obese: a prospective multicenter comparison study. J Orthop Trauma 2007; 21:523-9. [PMID: 17805018 DOI: 10.1097/bot.0b013e31813347ac] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Antegrade femoral nailing through a piriformis fossa starting point in patients who are obese has been demonstrated to be problematic. Retrograde femoral nailing therefore has been advocated in this patient population, but little data exist to support such a recommendation. The purpose of this study was to evaluate and compare antegrade and retrograde femoral nailing technique in both patients who are and are not obese. DESIGN Prospective, multicenter, nonrandomized, internal review board (IRB)-approved study. SETTING Four Level 1 trauma centers. PATIENTS Patients (151) with a femoral shaft fracture (OTA 32) treated with intramedullary nailing were studied. Thirty-two with a body mass index (BMI) of >or=30 comprised the obese group (OG), and 119 with a BMI of <30 comprised the nonobese group (NOG). Antegrade nailing was performed in 15 patients from the OG and 84 from the NOG. Retrograde nailing was performed in 17 patients from the OG and 35 from the NOG. INTERVENTION Reamed intramedullary nailing of a femoral shaft fracture. MAIN OUTCOME MEASURES Patient and fracture characteristics, operative time, fluoroscopy time, healing, complications, and functional outcome based on the lower extremity measure (LEM) were evaluated. RESULTS Antegrade technique in the OG was associated with a 52% greater average operative time (94 minutes) compared with antegrade nailing in the NOG (62 minutes; P < 0.003). For retrograde nailing technique, there was no difference in the average operative time between the OG (67 minutes) and NOG (62 minutes; P = 0.51). Antegrade technique in the OG was associated with a 79% greater average radiation exposure time (247 seconds) compared with antegrade nailing in the NOG (135 seconds; P < 0.03). For retrograde nailing technique, average fluoroscopy time was similar between the OG (76 seconds) and the NOG (63 seconds; P = 0.44). Within the OG, antegrade nailing required 40% greater average operative time (94 minutes versus 67 minutes, P < 0.02) and more than 3 times more average fluoroscopy time (242 seconds versus 76 seconds, P < 0.002) than retrograde nailing. Thirty-eight patients from the original cohort were not available for follow-up. Of the 113 patients followed (average 9 months, range: 4 to 25 months), healing complications occurred similarly between the 2 groups, with 1 nonunion and 2 delayed unions in the OG (12%), and 3 nonunions and 9 delayed unions in the NOG (14%). CONCLUSIONS This study provides evidence, in the form of decreased operative and radiation exposure times, to support the use of retrograde nailing technique for the treatment of femoral shaft fractures in patients who are obese. Also, antegrade nailing was found to require significantly more operative and radiation exposure time in the patient who is obese as opposed to the patients who is not obese. Although having similar baseline functional scores, patients who are obese recovered at a slower rate and more incompletely than patients who are not obese.
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Affiliation(s)
- Michael C Tucker
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia 30912, USA.
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Stoffel K, Lorenz KU, Kuster MS. Biomechanical considerations in plate osteosynthesis: the effect of plate-to-bone compression with and without angular screw stability. J Orthop Trauma 2007; 21:362-8. [PMID: 17620993 DOI: 10.1097/bot.0b013e31806dd921] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We compared the biomechanical stability of bone-plate constructs using a compression plate (CP), an internal fixator (IF), and a combination plate (CP/IF). METHODS Standardized simulated shaft fractures with a segmental defect in composite bones (n=60) and intraarticular distal femur fractures with a comminuted supracondylar zone in fresh frozen cadaveric femurs (n=36) were stabilized by CP, IF, and CP/IF. Construct stiffness, plastic deformation, and fixation strength were measured under axial compression and torsion using a biaxial testing machine. RESULTS The experimental results indicate for the distal femur fracture model that IF has less loss of reduction by plastic deformation under axial load compared to CP (IF 61% of CP). Under torsion, the CP showed significantly (P<0.05) decreased plastic deformation compared to the IF (CP 51% of IF). The combination (CP/IF) of the 2 fixation principles generally resulted in a higher load to failure under axial compression and torsion (145% failure load of CP and 118% of IF under axial compression, 88% of CP and 109% of IF under torsion). Results were similar between the 2 fracture models. CONCLUSIONS Under compression, IF provides similar fixation in comminuted fractures and was better than the CP for avoiding loss of reduction, whereas under torsional loading, CP was more important for stiffness, plastic deformation, and load to failure than IF. However, combination (CP/IF) fixation seems advisable in intraarticular and extraarticular fractures of long bones with a metaphyseal comminution. These data may be utilized by surgeons to build a more specific treatment plan in patients with these fracture types.
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Affiliation(s)
- Karl Stoffel
- Fremantle Orthopaedic Unit, University of Western Australia, and Orthopaedic Department, Kantonsspital St.Gallen, Switzerland.
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37
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Hung SH, Lu YM, Huang HT, Lin YK, Chang JK, Chen JC, Tien YC, Huang PJ, Chen CH, Liu PC, Chao D. Surgical treatment of type II floating knee: comparisons of the results of type IIA and type IIB floating knee. Knee Surg Sports Traumatol Arthrosc 2007; 15:578-86. [PMID: 17203298 DOI: 10.1007/s00167-006-0252-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2006] [Accepted: 11/15/2006] [Indexed: 11/29/2022]
Abstract
The prognosis of type II floating knee injuries was not as good as that of type I. Our purpose is to clarify the factors affecting the outcome of type II floating knee injuries. Thirty-five patients (36 limbs) with type II floating knee injury were studied with a mean follow-up of 52 months (26-96). Blake and McBryde had classified these injuries into type I for pure diaphyseal (true type) fracture and type II if the intra-articular involvements are one or more including hip, knee and ankle joints (variant type). According to this classification, we divided these patients into two groups depending on whether their knees were involved or not. Those cases with intra-articular knee involvement were classified as type IIA, while those without intra-articular knee involvement were classified as type IIB. Of the 36 cases, 21 were classified as type IIA and 15 were type IIB. The functional outcomes of these injuries were evaluated by using the criteria of Karlström and Olerud and analyzed with multivariate analysis. After multivariate analysis with logistic regression, we show the following results: first, the poor functional outcome of type II floating knee is contributed by type IIA. Second, the type IIA group has severer femoral open fracture grading (P = 0.027) and poorer functional outcome (P = 0.009) than type IIB. Third, the significant contributing factors to final outcome are the group (P = 0.013) and the fixation time after injury in femur (P = 0.015). Intra-articular knee involvement is the most important factor contributing to poor outcome of type II floating knee. The treatment of floating knee injuries with intra-articular knee involvement is still difficult. Further efforts to search better methods of treatment are required for these complex injuries in the future.
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Affiliation(s)
- Shao-Hung Hung
- Department of Orthopedics, Faculty of Medical School, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Moed BR, Tracy Watson J. [Not Available]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2006; 10:198-209. [PMID: 17003971 DOI: 10.1007/s00064-006-0057-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- B R Moed
- Orthopaedic Trauma Service Department of Orthopaedic Surgery, University Health Center (Suite 7C), 4201 St. Antoine Boulevard, 48202, Detroit, MI, USA
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Born CT, King PJ, Rehman S, Khoury L, Delong WG. Arthroscopically-assisted removal of retrograde intramedullary femoral nails. J Orthop Trauma 2006; 20:212-5. [PMID: 16648703 DOI: 10.1097/01.bot.0000184139.67577.97] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Retrograde nailing of femoral shaft fractures has become more prevalent as a result of its growing acceptance and familiarity to orthopaedic surgeons. Nail removal is occasionally indicated, which may require a formal arthrotomy. We describe an arthroscopic removal technique that has several advantages. The percutaneous technique imparts less morbidity than a more extensive arthrotomy. More importantly, additional intra-articular pathology can be thoroughly assessed and treated, such as meniscal tears and chondral injury, which may have occurred at the time of injury. These are potential causes of knee pain, which usually cannot be properly diagnosed without arthroscopy. Our findings also support the existence of a stable fibrous cap, which forms over the entry portal of a well-seated retrograde femoral nail as well as no evidence of intra-articular metallosis.
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Affiliation(s)
- Christopher T Born
- Department of Orthopaedic Surgery, Brown University, Providence, RI 02905, USA
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Dwyer AJ, Paul R, Mam MK, Kumar A, Gosselin RA. Floating knee injuries: long-term results of four treatment methods. INTERNATIONAL ORTHOPAEDICS 2005; 29:314-8. [PMID: 16132984 PMCID: PMC3456641 DOI: 10.1007/s00264-005-0679-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2005] [Accepted: 05/09/2005] [Indexed: 11/27/2022]
Abstract
One hundred twenty-four consecutive patients with true floating knee injury presented between 1987 and 2001. They were treated with non-operative, operative (external fixation and intramedullary nailing) and combined modalities. Sixty patients were followed up, at an average of 7.2 years, for age, gender, type of trauma and fracture; time to fracture union and time to mobilisation. Complications that were encountered and return to normal activities were recorded. Better and comparable union rates of fractures, earlier return to activities and higher excellent and good long-term functional results were observed among combined and operative (intramedullary nail) groups. Using combined modalities of treatment is an affordable, practicable and effective approach, especially for a resource-poor environment. External fixation of the fractured femur resulted in a decreased range of movement at the knee due to quadriceps muscle fixation. Fractured tibia, treated by any of the method, did not interfere with patient's joint mobilisation whereas associated injuries did.
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Affiliation(s)
- A J Dwyer
- Department of Orthopaedic Surgery, Christian Medical College and Hospital, Ludhiana, Panjab, 141008, India.
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Papadokostakis G, Papakostidis C, Dimitriou R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury 2005; 36:813-22. [PMID: 15949481 DOI: 10.1016/j.injury.2004.11.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Accepted: 11/25/2004] [Indexed: 02/08/2023]
Abstract
The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6 degrees . The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6 degrees . The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union.
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Affiliation(s)
- G Papadokostakis
- Department of Trauma, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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Pertrochanteric femur fracture at the proximal end of a retrograde intramedullary nail—a case report. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.injury.2004.12.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Pingsmann A, Lederer M, Wüllenweber C, Lichtinger TK. Early patellofemoral osteoarthritis caused by an osteochondral defect after retrograde solid nailing of the femur in sheep. ACTA ACUST UNITED AC 2005; 58:1024-8. [PMID: 15920419 DOI: 10.1097/01.ta.0000171986.10452.f4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Retrograde femoral nailing (RFN) is an increasingly used technique for internal fixation of femoral fractures. Geometrically and empirically, the nail entry zone is close to the center of the femoral groove, causing concern about the development of patellofemoral osteoarthritis. METHODS We studied the effect of opening the distal femur through the femoral groove on the development of osteoarthritis in sheep after retrograde reamed insertion of a solid titanium nail into the femoral canal. Knees were radiographically and macroscopically studied for the presence of osteophytes and signs of cartilage degeneration. Controls underwent the same procedure without opening the femoral groove. RESULTS The study group showed time-dependent macroscopic and radiographic signs of osteoarthritis with predominant involvement of the patellofemoral joint. CONCLUSION RFN can cause patellofemoral osteoarthritis. Care should be exercised to use RFN in isolated supracondylar or shaft fractures of the femur in healthy young adults.
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Affiliation(s)
- Andreas Pingsmann
- Department of Orthopedics, Essen University Medical School, Essen, Germany.
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Oh CW, Oh JK, Min WK, Jeon IH, Kyung HS, Ahn HS, Park BC, Kim PT. Management of ipsilateral femoral and tibial fractures. INTERNATIONAL ORTHOPAEDICS 2005; 29:245-50. [PMID: 15928912 PMCID: PMC3474524 DOI: 10.1007/s00264-005-0661-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2005] [Accepted: 03/09/2005] [Indexed: 10/25/2022]
Abstract
This is a retrospective study of 18 patients who had ipsilateral femoral and tibial fractures. They were treated by the retrograde femoral and antegrade tibial intramedullary nail from a single incision in the knee. The average time for union of femoral shaft fractures was 27.6 (18--40) weeks. One patient required antegrade nailing with a bone graft due to metal failure after using the short nail. Two tibial fractures required bone grafting due to bone loss, with an initial open fracture. The average time for union of tibial fractures was 24.5 (18--30) weeks. Functional results using the Karlstrom-Olerud criteria were excellent in 14, good in three, and acceptable in one. The only acceptable result was in a supra- and inter-condylar femoral fracture, with protrusion of the nail tip into the knee joint, which created moderate limitation of knee motion. Simultaneous retrograde femoral and antegrade tibial nailing with a single incision in the knee can achieve satisfactory results in the management of these types of fracture.
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Affiliation(s)
- Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, 50 Samdok, Chung-gu, Daegu, 700-721, South Korea.
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Friemert B, Keppler P, von Lübken F, Willy C, Claes L, Gerngross H, Wörz D. Ein neues retrogrades Femurmarknagelsystem mit durchleuchtungsfreier proximaler Verriegelung. Unfallchirurg 2005; 108:189-99. [PMID: 15778831 DOI: 10.1007/s00113-004-0863-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Conventional retrograde nailing of the femur causes two important disadvantages: the proximal locking of the nail is difficult because of the anatomic conditions and a chondral defect was left into the knee. MATERIAL AND METHODS After the retrograde implantation the new nail was lead through the greater trochanter. An additional proximal aiming device for proximal interlocking can be fixed. The entrance portal will be sealed by an osteochondral cylinder. 50 cases of femur fractures were selected for the prospective study. We recorded all intraoperative complications and technical difficulties. The cases were followed up for 52 weeks, both clinical and radiology examinations were performed. RESULTS The mean follow up was 15.5+/-5 months. All fractures were healed. Knee movement was 125+/-14 degrees. The Leung Score was 84+/-12.6 points; HSS Score was 90+/-9 points. In two cases wound infections were developed. Mal-union was observed in three cases, in two cases nail brake down. CONCLUSIONS The new retrograde interlocking nail could be used to manage femur fractures successfully. Two aiming devices enable a easy interlocking. Replacement of the osteochondral cylinder into the entry portal reduces cartilage damage.
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Affiliation(s)
- B Friemert
- Chirurgische Klinik, Bundeswehrkrankenhaus Ulm.
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Brown GA, Firoozbakhsh K, Summa CD. Potential of increased risk of neurovascular injury using proximal interlocking screws of retrograde femoral nails in patients with acetabular fractures. J Orthop Trauma 2001; 15:433-7. [PMID: 11514771 DOI: 10.1097/00005131-200108000-00009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Neurologic and vascular structures are at risk of iatrogenic injury from proximal interlocking screw insertion after retrograde nailing. This risk may increase in the presence of acetabular fractures because of the displacement of soft tissues resulting from hematoma. The purpose of this study was to establish and compare the relative safe zones (RSZs) for interlocking screw insertion in adults with and without concomitant acetabular fractures. MATERIALS AND METHODS Thirty pelvic computed tomography scans of patients with acute unilateral acetabular fracture and magnetic resonance imaging scans of five healthy legs were used to evaluate the course of the femoral sheath, neurovascular complex, and the sciatic nerve as they course through the proximal thigh in sixty-five limbs. RESULTS The anatomy of the neurovascular structures on the fractured side was statistically different from that of the normal side. On the normal side, the RSZ at the lesser trochanteric level was identified from +7 degrees medial to +20 degrees lateral to the sagittal axis (27-degree angle zone) for anteroposterior screw placement. These values for the fractured side, respectively, changed to +1 degrees and +14 degrees (13-degree angle zone), a 52 percent decrease. The RSZ for lateral-medial screw placement was 28 degrees anterior to 39 degrees posterior to the coronal axis (67-degree angle zone) for the normal side, which changed, respectively, to 32 degrees and 41 degrees (73-degree angle zone) for the fractured side. At the level of the lesser trochanter, rotation in the femoral shaft was mimicked only in part (approximately 50 percent) by the neurovascular structures. CONCLUSION Lateral-medial screw insertion is safer than anteroposterior insertion. Anteroposterior screw insertion becomes even more critical if the acetabulum is fractured. Femoral external rotation after rod insertion, but before screw insertion, will enlarge the safe zones.
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Affiliation(s)
- G A Brown
- Department of Orthopaedics and Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131-5296, USA
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Abstract
Ipsilateral fractures of the femur and tibia have been called "floating knee" injuries and may include combinations of diaphyseal, metaphyseal, and intra-articular fractures. These are often high-energy injuries and most frequently occur in the polytrauma patient. Many of these fractures are open, with associated vascular injuries. Surgical stabilization of both fractures and early mobilization of the patient and the extremity produce the best clinical outcomes. The use of a radiolucent operating room table and the introduction of retrograde intramedullary fixation of femoral fractures have facilitated surgical stabilization of some floating-knee fracture patterns. Although treatment planning for each fracture in the extremity should be considered individually to achieve the optimal result, the effect of that decision must be considered in light of the overall injury status of the entire extremity. Collateral ligament and meniscal injuries may also be associated with this fracture complex. Complications (such as compartment syndrome, loss of knee motion, failure to diagnose knee ligament injury, and the need for amputation) are not infrequent. Better results and fewer complications are observed when both fractures are diaphyseal than when one or both are intra-articular.
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Affiliation(s)
- D W Lundy
- Orthopaedic Trauma Service, Orthopaedic Center of the Rockies, Fort Collins, CO 80525, USA
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Theodoratos G, Papanikolaou A, Apergis E, Maris J. Simultaneous ipsilateral diaphyseal fractures of the femur and tibia: treatment and complications. Injury 2001; 32:313-5. [PMID: 11325368 DOI: 10.1016/s0020-1383(00)00189-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We present our experience of intramedullary nailing (IM) and external fixation in the treatment of 54 patients with ipsilateral diaphyseal fractures of the femur and tibia. Eight femoral and 24 tibial fractures were open. They were classified into three groups: IM nailing of both fractures (group A, 19 patients); IM nailing of the femoral and external fixation of the tibial fracture (group B, eight patients); and external fixation of both fractures (group C, 27 patients). In group C (which included all but one grade III open fracture), two patients died and four underwent amputation. Femoral fractures treated with external fixation had significantly more complications and reoperations than those treated with IM nailing. In tibial fractures this difference was also present but not statistically significant. We believe that IM nailing is the method of choice for femoral fractures and is preferable for tibial fractures, with the exception probably of grade III B and C open injuries.
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Affiliation(s)
- G Theodoratos
- Orthopaedic Department, Hellenic Red Cross Hospital, Athens, Greece
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Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001; 15:161-9. [PMID: 11265005 DOI: 10.1097/00005131-200103000-00003] [Citation(s) in RCA: 166] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing. DESIGN Retrospective. SETTING Level I trauma center. PATIENTS Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05). INTERVENTION Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques. MAIN OUTCOME MEASURES Union, delayed union, nonunion, malunion, and complication rates. RESULTS After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05). CONCLUSIONS Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.
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Affiliation(s)
- W M Ricci
- Department of Orthopaedic Surgery, Barnes-Jewish Hospital, Washington University, St. Louis, Missouri 63110, USA
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Ricci WM, Bellabarba C, Lewis R, Evanoff B, Herscovici D, Dipasquale T, Sanders R. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma 2001; 15:90-5. [PMID: 11232660 DOI: 10.1097/00005131-200102000-00003] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine factors associated with angular malalignment of femoral shaft fractures treated with intramedullary nails and to determine differences in the incidence of angular malalignment based on fracture location, fracture comminution, and method of treatment (i.e., antegrade or retrograde). DESIGN Retrospective. SETTING Level I trauma center. PATIENTS Three hundred sixty patients with 374 femoral shaft fractures were identified from a prospectively obtained orthopaedic trauma database. Complete sets of immediate postoperative anteroposterior and lateral radiographs were available for 355 (95 percent) of the 374 fractures. INTERVENTION Patients were treated with antegrade (183 cases) or retrograde (174 cases) intramedullary femoral nailing. MAIN OUTCOME MEASURE Goniometric measurements were made on all immediate postoperative radiographs to determine the coronal plane and sagittal plane angular alignments. A multiple linear regression statistical analysis was used to determine factors associated with increasing angular malalignment. The incidence of malalignment was determined using more than 5 degrees of deformity in any plane as the definition of malalignment. RESULTS Proximal fracture location, distal fracture location, and unstable fracture pattern were associated with increasing fracture angulation (p < 0.001). Fracture location in the middle third, stable fracture pattern, method of treatment (i.e., antegrade or retrograde), and nail diameter were not associated with increasing fracture angulation (p > 0.05). The incidence of malalignment was 9 percent for the entire group of patients, 30 percent when the fracture was of the proximal third of the femoral shaft, 2 percent when the fracture was of the middle third, and 10 percent when the fracture was of the distal third. The incidence of malreduction was 7 percent for patients with stable fracture patterns and 12 percent for those with unstable fracture patterns. CONCLUSIONS Patients with fractures of the proximal third of the femoral shaft treated with intramedullary nails are at highest risk for malalignment. Proximal fracture location, distal fracture location, and unstable fracture pattern are associated with increasing fracture angulation.
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Affiliation(s)
- W M Ricci
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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