One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening

Management of Subtrochanteric Femoral Fracture Nonunions

Compared with other proximal femoral fractures, subtrochanteric fractures are at a higher risk for nonunion because of the high deforming forces in this region, the associated increased risk of malreduction, and the risk of poor bone healing secondary to bisphosphonate use frequently associated with these fractures. Further understanding of nonunion of subtrochanteric fractures is of increasing importance given the rise in incidence of subtrochanteric hip fractures. Surgeons should be aware of risk factors for nonunion and techniques for prevention as well as surgical management and complications associated with surgical implantation devices. Surgeons should also consider using adjuncts including bone-grafting and biologic agents.

Characteristics and Surgical Outcomes of Intertrochanteric or Subtrochanteric Fractures Associated with Ipsilateral Femoral Shaft Fractures Treated with Closed Intramedullary Nailing: A Review of 31 Consecutive Cases over Four Years at a Single Institution

Purpose

To evaluate the clinical characteristics of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures and assess the surgical outcomes of a novel, closed intramedullary nailing surgical approach designed to minimize fixation failure.

Materials and Methods

Between May 2013 and April 2017, 31 patients with intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures treated with closed intramedullary nailing or long proximal femoral nail antirotation (PFNA) were enrolled in this study. Preoperative data included age, sex, injury severity score, body mass index, location of shaft fracture, injury mechanism, accompanying traumatic injury, walking ability before injury, and surgical timing. Perioperative outcomes, including follow-up period, types of intramedullary nails, number of blocking screws used, operation time, and blood loss were assessed. Radiologic outcomes, including union rate, time from surgery to union, and femoral shortening, and clinical outcomes, including hip flexion, walking ability, and Harris hip score were also evaluated.

Results

A total of 29 unions (93.5%) were achieved. The time to union was 16.8 months (range, 11–25 months) for hip fractures (15.7 weeks for intertrochanteric fractures and 21.7 weeks for subtrochanteric fractures) and 22.8 months for femoral shaft fractures. There were no significant differences in surgical outcomes between the two groups except for type of intramedullary nail.

Conclusion

Closed intramedullary nailing in the treatment of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures may be a good surgical option. However, fixation of femoral shaft fractures might not be sufficient depending on the implant design.

Effect of inherent tibial asymmetry on leg length discrepancy measurements after intramedullary nailing of comminuted femoral shaft fractures

Introduction: Locked intramedullary nailing (IMN) is the standard treatment for femoral shaft fractures in adults with high rates of union and relatively low rates of complications. Leg length discrepancy (LLD) after IMN of femoral shaft fractures is common, and is reported in 20–43% of cases. A known surgical challenge when trying to obtain equal leg lengths is comminuted fracture, which results in a loss of bony landmarks that guide reduction. The purpose of this study was to assess the effect of inherent tibial asymmetry on LLD measurements after IMN.

Methods: Postoperative CT scanograms were performed on 79 consecutive patients after locked IMN for comminuted femoral shaft fracture. Leg lengths were determined by measurements taken from the scout view of a CT scanogram. Calculations of discrepancy were made for both femurs, tibias, and total leg length. Assessment was also made on the frequency wherein the tibial discrepancy compounded the femoral discrepancy. In situations where a limb segment was exactly symmetric to the contralateral side, the total leg was not regarded as a having compounded asymmetry.

Results: Notable discrepancies were found in tibial length that significantly departed from the null of symmetry (p < 0.0001). Forty-two patients (53.2%) were found to have a tibial asymmetry of 3 mm or more, and 20 patients (25.3%) were found to exhibit a difference of 6.3 mm or more. Median femoral discrepancy was 5.3 mm and median tibial discrepancy was 3.0 mm. Seven patients were found to be asymmetric in total leg length as a consequence of underlying tibial asymmetry. Conversely, 11 patients benefited from their tibial asymmetry, which compensated for femoral asymmetry after IMN.

Conclusion: Tibial symmetry cannot be assumed. If not accounted for, inherent tibial asymmetry may influence LLD after IMN of femur fractures.

Is clinical measurement of anatomic axis of the femur adequate?

Background and purpose - The accuracy of using clinical measurement from the anterior superior iliac spine (ASIS) to the center of the knee to determine an anatomic axis of the femur has rarely been studied. A radiographic technique with a full-length standing scanogram (FLSS) was used to assess the adequacy of the clinical measurement. Patients and methods - 100 consecutive young adult patients (mean age 34 (20-40) years) with chronic unilateral lower extremity injuries were studied. The pelvis and intact contralateral lower extremity images in the FLSS were selected for study. The angles between the tibial axis and the femoral shaft anatomic axis (S-AA), the piriformis anatomic axis (P-AA), the clinical anatomic axis (C-AA), and the mechanical axis (MA) were compared between sexes. Results - Only the S-AA and C-AA angles were statistically significantly different in the 100 patients (3.6° vs. 2.8°; p = 0.03). There was a strong correlation between S-AA, P-AA, and C-AA angles (r > 0.9). The average intersecting angle between MA and S-AA in the femur in the 100 patients was 5.5°, and it was 4.8° between MA and C-AA. Interpretation - Clinical measurement of an anatomic axis from the ASIS to the center of the knee may be an adequate and acceptable method to determine lower extremity alignment. The optimal inlet for antegrade femoral intramedullary nailing may be the lateral edge of the piriformis fossa.

Combined tibial lengthening and ankle arthrodesis for patients with certain type of sequelae of poliomyelitis

PURPOSE

Following far advancement of modern medicine and technology, functional disability in a certain type of sequelae of poliomyelitis may be effectively improved.

METHODS

Eight consecutive adult patients with unilateral sequelae of poliomyelitis were treated. These patients had shortened lower extremity of an average of 4.8 cm (range, 4.0-5.5 cm) in the lesion side. Muscle power of the ipsilateral knee was nearly intact (grade 4 or 5) but the ankle extension was completely flaccid. The tibia was osteotomized and lengthened with external fixation. Consequently, all external fixators were converted to plates supplemented with autogenous corticocancellous bone graft and bone graft substitute. Ankle arthrodesis was performed concomitantly.

RESULTS

Seven patients were followed up for an average of 3.7 years (range, 2.2-5.4 years). All seven lengthened sites healed with an average union time of 3.9 months (range, 3.5-4.5 months) after plating. One ankle infection occurred. Gait function significantly improved by modified Mazur scoring evaluation ( p = 0.02). At the latest follow-up, all patients had a minimal or unnoticed limp in level walking.

CONCLUSION

The described combined techniques may be an excellent alternate for treating selected patients with sequelae of poliomyelitis. The procedure is not complex but the efficiency is extremely prominent.

The efficacy of single-stage open intramedullary nailing of neglected femur fractures

BACKGROUND

Neglected femur fractures are not rare in the developing world. Treatment options include single-stage open reduction and intramedullary nailing, or open release, skeletal traction, and then second-stage open intramedullary nailing, with bone grafting. Single-stage procedures have the potential advantage of avoiding neurovascular complications secondary to acute lengthening, but they require a second operation, with potentially increased resource use and infection risk.

QUESTIONS/PURPOSES

We sought to determine the (1) likelihood of union, (2) complications and reoperations, and (3) functional results with single-stage open intramedullary nailing without bone grafting in patients with neglected femur fractures.

METHODS

Between January 2003 and December 2007, 17 consecutive patients presented to our practice with neglected femoral shaft fractures. All were treated with single-stage nailing without bone grafting. There were 15 men and two women with a median age of 27 years. The average time from fracture to treatment was 13 weeks (range, 4-44 weeks). Eleven patients underwent open nailing with interlocked nails and six were treated with cloverleaf Kuntscher nails. Patients were followed for a minimum of 6 months (mean, 33 months; range, 6-72 months). The mean preoperative ROM of the knee was 28° (range, 10°-150°) and femoral length discrepancy was 3.1 cm (range, 1-5 cm).

RESULTS

All fractures united and the mean time to union was 16 weeks (range, 7-32 weeks). There were no neurologic complications secondary to acute lengthening. The mean postoperative ROM of the knee was 130° (range, 60°-150°). All patients were able to return to preinjury work. Sixteen patients regained their original femoral length.

CONCLUSIONS

One-stage open intramedullary nailing of neglected femoral diaphyseal fractures without bone grafting was safe and effective, and obviated the need for a two-stage approach. Although the findings need to be replicated in larger numbers of patients, we believe this technique may be useful in treating patients with this injury, and may offer advantages in resource-constrained environments.

Integrating various common indexes of bony alignment in femoral supracondyle

OBJECTIVE

Indexes, which can optimally represent the bony alignment around the knee, are still controversial. Three common indexes, mechanical axis (MA), anatomic axis (AA), and anatomic lateral distal femoral angle (aLDFA), were integrated to simplify patient follow-up in the femoral supracondylar region.

MATERIALS AND METHODS

Eighty consecutive adult patients (40 men, 40 women; age range 19-40 years) were studied using a full-length standing scanogram. Thirteen indexes, including MA, AA, and aLDFA, were measured and integrated. The relationships among these indexes were analyzed.

RESULTS

The MA of the lower extremity passed with an average of 6.6 mm (9.2% of the tibial articular surface width) medial to the knee center. The supracondylar axis (SA) was an average of 2.0° more valgus than the AA in the femoral supracondyle. An average 1.1° deviation was noted in the AA, as measured by the femoral shaft axis or a line connecting the piriformis fossa to the knee center.

CONCLUSION

The femoral MA may be more favorable than the MA of the lower extremity in order to represent an ideal weight-bearing line. The AA and aLDFA may be measurable via the SA in the anteroposterior view of the plain knee radiograph. Thus, patient follow-up becomes much more convenient.

External fixator followed by a plate for distraction, reduction, and fixation in neglected femoral diaphyseal fractures

INTRODUCTION

This study aims to investigate the outcome of a two-stage surgery in the treatment of neglected femoral diaphyseal fractures which are not uncommon in developing nations.

PATIENTS AND METHODS

Ten patients with neglected or late-presenting femoral diaphyseal fractures were considered in this study. All patients underwent a two-stage surgery, which consisted of distraction by an external fixator and open reduction by internal plate fixation. All patients received a supervised regimen of physiotherapy. Patients were followed up clinically and with radiographs at 2 months to assess union and at monthly intervals thereafter.

RESULTS

All patients achieved bony union in an average of 3.7 months (2-6 months) with no one lost follow-up. Seven patients regained full range of motion, and the mean knee range of motion was 139.5°. No wound related or neurovascular complications were detected. One patient with stiff knee was re-admitted 1 year after surgery for metal removal, arthrolysis and quadricepsplasty for improving knee range of motion to 90° flexion.

CONCLUSIONS

We conclude that the treating of neglected femoral diaphyseal fractures with a two-stage surgery is a satisfactory therapy showing reliable bony union, however continuing medical education is necessary for physicians in primary medical facilities as well as for patients with traditional views.

Operative treatment for femoral shaft nonunions, a systematic review of the literature

The objective of this article is to systematically review the currently available literature to formulate evidence-based guidelines for the treatment of femoral shaft nonunions for clinical practice and to establish recommendations for future research. Articles from PubMed/MEDLINE, Cochrane Clinical Trial Register, and EMBASE, that presented data concerning treatment of nonunions of femoral shaft fractures in adult humans, were included for data extraction and analysis. The search was restricted to articles from January 1970 to March 2011 written in the English, German, or Dutch languages. Articles containing data that were thought to have been presented previously were used once. Reports on nonunion after periprosthetic fractures, review articles, expert opinions, abstracts from scientific meetings, and case reports on 5 or fewer patients were excluded. The data that were extracted from the relevant articles included: type of nonunion, type of initial and secondary treatments, follow-up, union rate, and general complications. Most studies had different inclusion criteria and outcome measures, thus prohibiting a proper meta-analysis. Therefore, only the union rate and number of complications were compared between the different treatments. Methodological quality was assessed by assigning levels of evidence as previously defined by the Centre for Evidence-Based Medicine. This systematic review provides evidence in favour of plating if a nail is the first treatment; after failed plate fixation, nailing has a 96 % union rate. After failed nailing, augmentative plating results in a 96 % union rate compared to 73 % in the exchange nailing group.

Locked nailing for shortened subtrochanteric nonunions: a one-stage treatment

Subtrochanteric nonunions may involve considerable shortening. A convincing method of concomitantly treating both combined disorders has not been reported. Twenty-three consecutive patients with these combined disorders were treated by femoral condylar skeletal traction, one-stage lengthening to 4 cm maximum, static locked nail stabilization, and corticocancellous bone grafting. Indications for this technique included subtrochanteric aseptic nonunions, patient younger than 60 years, and 2.0 to 5.0 cm shortening. Postoperatively, protected weightbearing ambulation was encouraged as early as possible. Twenty-one patients were followed for a minimum of 1.2 years (mean, 3.2 years; range, 1.2-6.7 years). All nonunions healed with a union rate of 100% (21 of 21) and a median union period of 4.0 months (range, 3.5-11 months). One nonunion healed at 11 months despite nail breakage. In all patients, hip function improved from unsatisfactory grades preoperatively to satisfactory grades at latest followup. Knee function grade remained satisfactory throughout the treatment course in all patients. Although no surgical technique has clearly proven superior in treating subtrochanteric nonunions associated with considerable shortening, the described approach may be the optimal treatment alternative. Protected weightbearing to reduce nail stress throughout the treatment course improves the success rate.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Femoral supracondylar malunions with varus medial condyle and shortening

Femoral supracondylar malunions associated with varus deformity of the medial femoral condyle and shortening are rare, and all techniques for treatment of this complication reported to date have limitations. A one-stage antegrade locked intramedullary nailing technique to concomitantly treat these combined disorders was performed in 19 consecutive patients. The following procedures were performed: removal of previous implants, supracondylar corrective osteotomy, one-stage lengthening on a fracture table, antegrade static locked intramedullary nail stabilization, and corticocancellous bone grafting. Seventeen patients with malunions received regular followup for a median of 2.4 years (range, 1.1-5.2 years). Sixteen malunions healed with a union rate of 94.1% (16 patients) and a median union period of 4.5 months (range, 3-7 months). Only one nonunion associated with nail breakage occurred (5.9%; one patient) and one deep infection recurred (5.9%; one patient). Both patients recovered after appropriate treatment. All patients had improved knee alignment and function. Antegrade locked intramedullary nailing is an effective technique for one-stage treatment of combined disorders in patients with femoral supracondylar malunions. Complications can be avoided if patients and surgeons are careful during the treatment course. Protected weightbearing until fracture healing is crucial to successful treatment.

Exchange nailing of ununited fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

Exchange nailing of ununited fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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