Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures

Gait pattern in patients treated with a total hip arthroplasty due to an acute displaced cervical neck fracture: a randomised comparison between 29 cases with a cemented femoral stem and 16 cases with an uncemented femoral stem

BACKGROUND

The choice between cemented or uncemented stem fixation in the treatment of a femoral neck fracture may influence patient rehabilitation and the resulting gait pattern, due to potential differences in implant positioning and fixation. We used gait analysis to study temporal gait parameters, hip kinematics and kinetics in patients who, 2 years previously, had been randomised to treatment with a cemented or uncemented stem and due to an acute femoral neck fracture.

METHODS

45 Patients implanted with a cemented Lubinus SP II (n = 29) and an uncemented (n = 16) Corail stem were studied. Gait analysis was performed using a 16-camera motion capture system and force plates. 28 subjects served as controls. Temporal gait parameters, hip kinematics and kinetics were analysed. The patients had no or minimum pain (median Harris pain score 44, range 40-44) and the majority had no limp (median Harris limp score 11, range 5-11).

RESULTS

Temporospatial gait parameters and abduction-adduction motions and moments did not differ between patients with cemented or uncemented stems (p > 0.05). Patients with cemented stems did, however, show more hip flexion and less extension during walking than those with an uncemented stem (p < 0.05). Moreover, the flexion-extension range was less in the cemented group (p < 0.04). Compared with controls, the hip fracture patients walked more slowly, with a shorter stride length and a longer stance phase.

CONCLUSIONS

Increased hip flexion and reduced extension in patients using the Lubinus SP II cemented stem could be an effect of its anteverted neck, but this question requires further study. Despite acute treatment with THA, hip fracture patients demonstrated a change in gait pattern compared with controls 2 years after the operation. This suggests that these changes are caused by the presence of an implant, or the soft-tissue trauma partly caused by the surgery than by any degenerative disease present in patients undergoing elective surgery.ClinicalTrials.gov Identifier: NCT04791605.

Traction methods in the retrograde intramedullary nailing of femur shaft fractures: the double reverse traction repositor or manual traction

OBJECTIVE

The purpose of this prospective study was to compare the double reverse traction repositor (DRTR) and manual traction in retrograde intramedullary nailing (RE-IMN) for femoral shaft fractures.

PATIENTS AND METHODS

Seventy-seven patients with femur shaft fractures were randomized to undergo surgery with either DRTR or manual traction (MT) to facilitate RE-IMN between January 2018 and January 2019. Demographics, fracture characteristics, surgical data, post-operative complications, and functional outcomes were assessed. Data from 72 patients completing the final follow-up (12 months) were analysed in this study.

RESULTS

The average number of intra-operative perspectives in the DRTR group was 27.7, which was significantly reduced compared with that in the MT group (31.3, p < 0.001). Fewer assistants were required in the DRTR group compared with the MT group (1.1 vs 1.9, p < 0.001). Fewer patients with open reduction were discovered in the DRTR group compared with the MT group (2.8 vs 19.4, p=0.024). Demographics, fracture characteristics, other surgical data, and prognostic parameters were comparative between the two groups.

CONCLUSIONS

The DRTR can be effectively and safely used to treat femur shaft fractures with RE-IMN. The DRTR achieves similar results as MT and is also superior to MT in terms of intra-operative perspectives, the number of assistants, and the open reduction rate.

Safety and efficacy of a novel cephalomedullary nail femoral shaft fractures: a retrospective observational cohort in 33 patients

BACKGROUND

Despite advances in femoral shaft fracture fixation, the nonunion rate remains relatively high; and there is limited data on the efficacy and failure rate of specific implants. A novel cephalomedullary nail provides the ability to treat femur shaft fractures in isolation, with associated ipsilateral femur injuries, and provides various options for proximal and distal fixation exists on the market; but literature remains limited on the safety and efficacy of this implant. The aim of this study is to evaluate the early failure rate of this cephalomedullary nail, while comparing the nonunion rate to what is currently presented in the literature. This study is the first of its kind in evaluation of a specific implant for treatment of femoral shaft fractures and ipsilateral pathology.

METHODS

Patients over 18 years of age, with traumatic femur shaft fractures, treated with this particular cephalomedullary nail and available for a minimum of 3-month follow-up were included for analysis. Data was collected by retrospective chart review and review of existing radiographs. Demographic data, injury details, AO/OTA fracture classification, and implant details were recorded for each patient. Primary outcome measured was implant failures (screw or nail breakage). Secondary outcomes measured included malunion, nonunion, deep infection, post-operative complications, and need for reoperation.

RESULTS

Of the 33 patients included for analysis, 1 patient went on to non-union. There were no cases of implant failure. The single nonunion was a high-energy mechanism, open fracture, and higher level AO/OTA classification. The remaining 32 reached radiographic union at 3 months.

CONCLUSION

The nonunion rate of this novel cephalomedullary nail is comparable to what is reported in the literature. This nail is a safe and effective implant to treat femoral shaft fractures with a variety of ipsilateral femoral shaft injuries and reliably leads fracture union. Further studies are needed analyzing implant failure and comparing specific implants.

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

Background

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

Methods

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

Results

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

Conclusion

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

Long-term Comparison of Retrograde and Antegrade Femoral Nailing

Antegrade or retrograde nailing for femoral shaft fractures remains the gold standard, but long-term data on functional outcomes after intramedullary nailing are lacking. In a retrospective review of prospectively collected patient registry data, patients with an isolated femoral shaft fracture treated with antegrade or retrograde femoral nailing from 1997 to 2012 were interviewed and their medical records analyzed. Functional reported outcome data were obtained via the visual analog scale (VAS) for pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 5 to 17 years postoperatively. Antegrade and retrograde intramedullary nailing of diaphyseal femur shaft fractures demonstrated a mean WOMAC of 23.5%±23.6% (range, 0%-82.3%) and 29.7%±24.0% (range, 0%-88%), respectively (P=.23). The mean VAS scores of the antegrade vs retrograde intramedullary nailing groups were 2.5±2.6 (range, 0-8) and 3.4±2.8 (range, 0-10), respectively (P=.11). Location of pain differed between groups as well, with the antegrade group noting an increased rate of hip pain (25.6% vs 7.0%, P=.01), but a nonsignificant difference in the rate of thigh pain (27.9% vs 15.5%, P=.15) and knee pain (18.6% vs 26.7%, P=.49) as compared with the retrograde group. Diaphyseal femur fractures are successfully treated with either antegrade or retrograde intramedullary nails without significantly differing long-term functional outcomes, which correlates with other reported findings in the literature at short-term follow-up. [Orthopedics. 2020;43(4):e278-e282.].

Functional results and isokinetic muscle strength in patients with Fraser type I floating knee treated with internal fixation

INTRODUCTION

According to Fraser's description, ipsilateral femoral and tibial diaphyseal fractures are characterised as type I floating knee and have a better prognosis than fractures with joint involvement (type II). There are few reports of functional and muscle strength in these patients. The objective of this study was to evaluate the functional and isokinetic muscle strength of patients with type I floating knee undergoing femoral and tibial internal fixation.

METHODS

Patients with type I floating knee undergoing concomitant femoral and tibial internal fixation were invited for clinical evaluation. The parameters evaluated included the following: Karlstrom and Olerud score; Lysholm score; isokinetic thigh and hip muscle evaluation; knee range of motion; pain level; investigation of associated knee injuries by clinical evaluation and MRI; and types of complications.

RESULTS

Twenty-one patients were included in the study; 11 of these were clinically evaluated, with a mean follow-up of 23.9 months. Six patients had an acceptable result according to the Karlstrom criteria, whereas eight patients had a poor result based on the Lysholm scale. The peak torque deficit was 61% for knee extensors, 37% for flexors and -9% for hip abductors. The mean pain level was 5.9. Three patients had a partial anterior cruciate ligament (ACL) injury; one patient had a posterior cruciate ligament (PCL) injury; and three patients had a meniscal injury. There were four cases of tibial or femoral nonunion at one year and two cases of chronic osteomyelitis.

CONCLUSION

Patients with type I floating knee had unsatisfactory functional results, significant knee extensor and flexor muscle strength deficits and a significant rate of complications at the two-year follow-up.

Unstable Proximal Femur Fractures Treated With Proximal Femoral Locking Plates: A Retrospective, Multicenter Study of 111 Cases

OBJECTIVES

A few small case series have found that proximal femur fractures treated with a proximal femur locking plate (PFLP) have experienced more failures than expected. The purpose of this study was to review the clinical results of patients with acute, unstable proximal femur fractures treated with proximal femoral locking plates in a large, multicenter patient cohort.

DESIGN

This is a retrospective clinical study.

SETTING

The study included patients from 12 regional trauma centers and tertiary referral hospitals.

PATIENTS

One hundred eleven consecutive patients with unstable proximal femur fractures stabilized with a PFLP and having required clinical and radiographic follow-up at a minimum of 12 months after injury.

INTERVENTION

Surgical repair of an unstable proximal femur fracture with a PFLP.

MAIN OUTCOME MEASUREMENTS

Treatment failures (failure of fixation, nonunion, and malunion) and need for revision surgery.

RESULTS

Forty-six patients (41.4%) experienced a major treatment failure, including failed fixation with or without nonunion (39), surgical malalignment or malunion (18), deep infection (8), or a combination of these. Thirty-eight (34%) patients underwent secondary surgeries, including 30 for failed fixation, nonunion, or both. Treatment failure was found to occur at a significantly higher rate in patients with major comorbidities, in femurs repaired in varus malalignment, and using specific plate designs.

CONCLUSIONS

Proximal femoral locking plates are associated with a high complication rate, frequently requiring revision or secondary surgeries in the treatment of unstable proximal femur fractures. Given the high complication rate with PFLPs, careful attention to reduction, use of a PFLP implant, and consideration should be given to alternative implants or fixation techniques when appropriate.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effect of antegrade femoral nailing on femoral head perfusion: a comparison of piriformis fossa and trochanteric entry points

INTRODUCTION

Piriformis fossa entry antegrade femoral nailing is a common method for stabilizing diaphyseal femur fractures. However, clinically significant complications such as chronic hip pain, hip abductor weakness, heterotopic ossification and femoral head osteonecrosis have been reported. A recent cadaveric study found that piriformis entry nailing damaged either the deep branch of the medial femoral circumflex artery (MFCA) or its distal superior retinacular artery branches in 100% of specimens and therefore recommended against its use. However, no study has quantitatively assessed the effect of different femoral entry points on femoral head perfusion.

MATERIALS AND METHODS

Twelve fresh-frozen cadaveric lower extremity specimens were randomly allocated to either piriformis fossa or trochanteric entry nailing using a 13-mm reamer. The contralateral hip served as an internal matched control. All specimens subsequently underwent gadolinium-enhanced fat-suppressed gradient-echo sequence MRI to assess femoral head perfusion. Gross dissection was also performed to assess MFCA integrity and distance to the opening reamer path.

RESULTS

MRI quantification analysis revealed near full femoral head perfusion with no significant difference between the piriformis and trochanteric starting points (95 vs. 97%, p = 0.94). There was no observed damage to the deep MFCA in either group. The mean distance from the reamer path to the deep MFCA was 3.2 mm in the piriformis group compared to 18.5 mm in the trochanteric group (p = 0.001). Additionally, there was a significantly greater number of mean terminal superior retinacular vessels damaged by the opening reamer in the piriformis cohort (1 vs. 0; p = 0.007).

CONCLUSIONS

No statistically significant difference in femoral head perfusion was found between the two groups. Therefore, we cannot recommend against the use of piriformis entry femoral nails. However, we caution against multiple errant starting point attempts and recommend meticulous soft tissue protection during the procedure.

Predicting the optimal entry point for femoral antegrade nailing using a new measurement approach

PURPOSE

To establish a new reliable approach for measuring proximal femoral anatomical parameters and determining the optimal entry point of the antegrade intramedullary (IM) nailing.

METHODS

A new method for measuring the proximal femoral anatomy and locating the optimal entry point for the antegrade nailing was developed using Mimics and 3-Matic softwares (Materialise, Haasrode, Belgium). After verifying the reliability of the measurement method using 15 pairs of the femoral models by the intraclass correlation coefficient, the anatomical parameters of 200 Chinese femurs were measured, and statistical analyses were performed to compare the proximal femoral anatomical parameters between different genders or lateralities and determine the most relevant factors of the optimal entry point.

RESULTS

Reliability study showed that both intraobserver reliability and interobserver reliability of the current measurement approach were excellent. After independent samples [Formula: see text]-test, the proximal femoral anatomical parameters were shown significant difference between genders. Stepwise regression statistical analyses showed that the most relevant factors of the distances between the optimal entry point and the femoral head centre, the femoral neck axis and the tip of the greater trochanter were the 3D femoral neck-shaft angle (Pearson's [Formula: see text]; the model's [Formula: see text]), the femoral radius (Pearson's [Formula: see text]; the model's [Formula: see text]) and the femoral length (Pearson's r = 0.316; the model's [Formula: see text]), respectively.

CONCLUSIONS

The current study provided a new and reliable measurement approach to evaluating the anatomical morphology of the proximal femur and revealed the most influential factors on the locations of the simulated optimal entry point for the proximal femoral antegrade IM nailing. Furthermore, this study was useful for establishing methodological basis for future researches and developments of the custom-made IM nailing and affiliated surgical instruments.

Femur fractures in professional athletes: a case series

OBJECTIVE

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

BACKGROUND

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

TREATMENT

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

UNIQUENESS

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

CONCLUSIONS

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

Decreased muscle strength is associated with impaired long-term functional outcome after intramedullary nailing of femoral shaft fracture

PURPOSE

To examine the long-term outcome after intramedullary nailing of femoral diaphysial fractures measured as disease-specific patient reported function, walking ability, muscle strength, pain and quality of life (QOL).

METHODS

Cross-sectional study. Retrospective review and follow-up with clinical examination of 48 patients treated with intramedullary nailing after femoral shaft fracture between 2007 and 2010. The patients underwent a clinical examination and assessment of walking ability, maximal muscle strength during knee flexion and extension and hip abduction. Hip disability and Osteoarthritis Outcome Score (HOOS) and questionnaire evaluating QOL (Eq5D-5L) were completed by patients.

RESULTS

Fourty-eight patients agreed to participate. Mean time for follow-up was 4.7 years. The mean HOOS scores were 84.9 (Pain), 86.6 (ADL), 85.0 (Symptoms), 72.6 (QOL), and 69.1 (Sport). The mean muscle strength of knee flexion with the injured leg (226.0 N) was significantly lower then knee flexion with the non-injured leg (259.5 N, P < 0.0001). Likewise for knee extension (335.2 vs 406.4 N, P < 0.001) and hip abduction (129.2 vs 156.0 N, P < 0.001). Significant association between HOOS and an increase in the difference in muscle strength were observed as well as between worse HOOS outcome and increasing body mass index.

CONCLUSION

This study showed that decreased muscle strength for knee flexion, knee extension and hip abduction was associated with worse long-term functional outcome measured with a disease-specific questionnaire (HOOS) after intramedullary nailing of femoral shaft fracture.

[Femoral nailing using a helical nail shape (LFN(®))]

OBJECTIVE

Antegrade femoral nailing through a greater trochanteric entry portal avoids damage to the proximal external rotators and to the ramus profundus of the medial femoral circumflex artery, furthermore eases insertion in adipose subjects. However a helical nail shape is necessary for this pathway because bending in two perpendicular planes has to be passed by the nail.

INDICATIONS

All femoral shaft fractures suitable for antegrade nailing (type 32-A/B/C). Additional femoral neck fractures (type 31-B) by using proximal Recon-interlocking screws.

CONTRAINDICATIONS

The common contraindications for femoral nailing. In certain subtrochanteric fractures (Type 32-A/B) the proximal femoral nail may be favorable.

SURGICAL TECHNIQUE

General or spinal anesthesia. Supine position with flexion/abduction of the contralateral leg in order to facilitate fluoroscopy of the proximal femur in a true lateral view. Closed reduction of length and axis. Measurement of length and diameter of the nail using a radiolucent ruler. Dorsolateral approach to the greater trochanter. Insertion of the guide wire 10 mm lateral to the trochanteric tip (anteroposterior view) and in the middle third of the trochanter (lateral view). Reaming of the insertion point using a flexible reamer. If reaming of the entire medullary canal is desired, this should be done using a long intramedullary guide wire in combination with a long flexible reamer. Insertion of the nail starts in an anterior position and ends in a lateral position of the insertion instrument, so a 90° external rotation of the nail occurs during insertion. Proximal interlocking is performed using the guide of the insertion instrument. Check interfragmentary rotation. Distal interlocking using a radiolucent drill device.

POSTOPERATIVE MANAGEMENT

Depends on the fracture shape: stable interfragmentary support may allow early full weight bearing. Otherwise, reduced weight bearing is recommended for at least 6 weeks.

RESULTS

In a prospective mulicentric study, 227 helical femoral nails were used for antegrade femoral nailing. Follow-up after 12 month was available in 74 %. Surgeons' rating for ease of identifying entry site was excellent or good in 89 %. Functional and radiological results after 12 months do not prove significant benefits over conventional antegrade femoral nails.

Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients

BACKGROUND

Debate exists over the safety of rigid intramedullary nailing of femoral shaft fractures in skeletally immature patients. The goal of this study was to describe functional outcomes and complication rates of rigid intramedullary nailing in pediatric patients.

METHODS

A retrospective review was performed of femoral shaft fractures in skeletally immature patients treated with trochanteric rigid intramedullary nailing from 1987 to 2009. Radiographs made at initial injury, immediately postoperatively, and at the latest follow-up were reviewed. Patients were administered the Nonarthritic Hip Score and a survey.

RESULTS

The study population of 241 patients with 246 fractures was primarily male (75%) with a mean age of 12.9 years (range, eight to seventeen years). The majority of fractures were closed (92%) and associated injuries were common (45%). The mean operative time was 119 minutes, and the mean estimated blood loss was 202 mL. The mean clinical follow-up time was 16.2 months (range, three to seventy-nine months), and there were ninety-three patients with a minimum two-year clinical and radiographic follow-up. An increase of articulotrochanteric distance of >5 mm was noted in 15.1% (fourteen of ninety-three patients) at a minimum two-year follow-up; however, clinically relevant growth disturbance was only observed in two patients (2.2%) with the development of asymptomatic coxa valga. There was no femoral head osteonecrosis. Among the 246 fractures, twenty-four complications (9.8%) occurred. At the time of the latest follow-up, 1.7% (four of 241 patients) reported pain. The average Nonarthritic Hip Score was 92.4 points (range, 51 to 100 points), and 100% of patients reported satisfaction with their treatment.

CONCLUSIONS

Rigid intramedullary nailing is an effective technique for treatment of femoral shaft fractures in pediatric patients with an acceptable rate of complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The evidence-based principles of negative pressure wound therapy in trauma & orthopedics

Negative pressure wound therapy is a popular treatment for the management of both acute and chronic wounds. Its use in trauma and orthopedics is diverse and includes the acute traumatic setting as well as chronic troublesome wounds associated with pressure sores and diabetic foot surgery. Efforts have been made to provide an evidence base to guide its use however this has been limited by a lack of good quality evidence. The following review article explores the available evidence and describes future developments for its use in trauma and orthopaedic practice.

Complications and functional recovery in treatment of femoral shaft fractures with unreamed intramedullary nailing

INTRODUCTION

Fracture of the femoral shaft is a common fracture encountered in orthopedic practice. In the 1939, Küntscher introduced the concept of intramedullary nailing for stabilization of long bone fractures. Intramedullary nailing has revolutionized the treatment of fractures.

MATERIAL AND METHODS

The study included 37 male patients and 13 female patients, averaged 39 +/- 20.5 years (range, 16 to 76 years).

RESULTS AND DISCUSSION

There were 31 left femurs and 21 right femurs fractured. 46 fractures were the result of blunt trauma. Low energy trauma was the cause of fractures in six patients, of which five in elderly females. 49 fractures were closed. Healing time given in weeks was 19.36 +/- 6.1. The overall healing rate was 93.6%. There were three (6.25%) major complications nonunion. There were one (2%) delayed union, one (2%) rotational malunion and no infection. The shortening of 1 cm were in two patients. Antercurvatum of 10 degrees was found in one patient. There was no statistically significant reduction of a motion in the hip and knee (p < 0.05). There was statistically significant in the thigh (knee extensors) muscle weakness (p < 0.001).

CONCLUSION

: Intramedullary nailing is the treatment of choice for femoral shaft fractures.

Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series

Donor site morbidity and complication rate using the reamer-irrigator-aspirator (RIA) system for intramedullary, non-structural autogenous bone graft harvesting were investigated in a retrospective chart and radiographic review at a University affiliated Level-1 Trauma Centre. 204 RIA procedures in 184 patients were performed between 1/1/2007 and 12/31/2010. RIA-indication was bone graft harvesting in 201 (98.5%), and intramedullary irrigation and debridement in 3 (1.5%) cases. Donor sites were: femur - antegrade 175, retrograde 4, tibia - antegrade 7, retrograde 18. Sixteen patients had undergone two RIA procedures, two had undergone three procedures, all using different donor sites. In 4 cases, same bone harvesting was done twice. Mean volume of bone graft harvested was 47 ± 22ml (20-85 ml). The complication rate was 1.96% (N=4). Operative revisions included 2 retrograde femoral nails for supracondylar femur fractures 6 and 41 days postoperatively (antegrade femoral RIA), 1 trochanteric entry femoral nail (subtrochanteric fracture) 17 days postoperatively (retrograde femoral RIA) and 1 prophylactic stabilization with a trochanteric entry femoral nail for intraoperative posterior femoral cortex penetration without fracture. In our centre, the RIA technique has a low donor site morbidity and has been successfully implemented for harvesting large volumes of nonstructural autogenous bone graft.

Arthroscopic removal of proximal femoral locking screws: a novel application of hip arthroscopy

The authors describe a novel application of hip arthroscopy. Symptomatic proximal locking screws can readily be removed via an arthroscope. Not only can the proximal screw be removed with much less morbidity than in previously described procedures, but the abductor mechanisms can also be evaluated for injury sustained during the index procedure. Furthermore, scarred or inflamed trochanteric bursal tissue may be resected during this arthroscopic approach.

Physical therapy in the postoperative of proximal femur fracture in elderly. Literature review

The proximal femoral fracture in the elderly is a serious public health problem. Surgical treatment of this fracture is used to reduce morbidity, together with postoperative physical therapy. The objective was to conduct a systematic review of physical therapy protocols in postoperative for fractures of the proximal femur in elderly. We selected randomized controlled trials in elderly in the past 10 years, in Portuguese and English. There were 14 articles in the literature. Physical therapy has an important role in functional recovery of the elderly. Level of Evidence I, Systematic Review RCTs (Study results were homogenous).

The variable angle hip fracture nail relative to the gamma 3: a finite element analysis illustrating the same stiffness and fatigue characteristics

Ten percent of the 250,000 proximal femur fractures that occur in the United States each year are malreduced into a varus position after treatment. Currently, there is no cephalomedullary nail available that allows the physician to dynamically change the lag-screw-to-nail angle. The Variable Angle Nail (VAN) was designed to allow movement of the lag screw relative to the shaft of the nail. This study compared the characteristics of the VAN to the Gamma 3 nail via finite element analysis (FEA) in stiffness and fatigue. The results of the FEA model with the same loading parameters showed the Gamma 3 and the VAN with lag-screw-to-nail angle of 120° to have essentially the same stiffness values ranging from 350 to 382 N/mm. The VAN with lag-screw-to-nail angles of 120°, 130°, and 140° should be able to withstand more than 1,000,000 cycles from 1,400 N to 1,500 N loading of the tip of the lag screw. The Gamma 3 should be able to last more than 1,000,000 cycles at 1,400 N. In summary, the VAN is superior or equivalent in stiffness and fatigue when compared to the Gamma 3 using FEA.

Factors affecting the closed reduction of diaphyseal fractures of the femur

INTRODUCTION

This level II prospective study investigates patient and fracture-related factors likely to affect closed reduction time in the surgical treatment of femur fractures, and the effect these factors have on closed reduction time.

PATIENTS AND METHODS

Seventy-nine diaphyseal femur fractures of 75 patients were included in the present study. All fractures were treated with indirect closed reduction by manual traction using antegrade nailing and static, locked, reamed intramedullary nails. The three variables considered to influence the duration of closed reduction, that is, the type of fracture, BMI, and the preoperative period (time from injury to surgery), were evaluated either separately or in a combination of two or three of the variables. Their influence on the closed reduction time was analyzed and evaluated.

RESULTS

In this study according to the outcomes, a preoperative period ≤24 h had a significant effect in shortening the reduction time. The reduction time was not significantly affected by the type of fracture. The reduction time was prolonged in overweight patients, but the difference was not significant. When the three variables BMI, preoperative period, and fracture types were evaluated together, the common effect of these three variables was not significant.

CONCLUSION

In conclusion, based on these results, we think that closed reduction should certainly be aimed for in femur fractures in which intramedullary nailing is planned. Also, early surgical intervention appears to have a beneficial effect on the success of closed reduction.

The safe zone for external fixator pins in the femur

OBJECTIVE

To define the anatomic "safe zone" for placement of external fixator half pins into the anterior and lateral femur.

METHODS

In 20 fresh-frozen hemipelvis specimens, the femoral nerve and all branches crossing the femur were dissected out to their final muscular locations. The location where the nerves crossed the anterior femur was measured from the anterior superior iliac spine and inferior margin of the lesser trochanter. The knee joint was then opened, and the distance from the superior reflection of the suprapatellar pouch to the last branch of the femoral nerve crossing the anterior femur was measured, defining the safe zone for anterior pin placement.

RESULTS

The last branch of the femoral nerve crossed at an average distance from the anterior superior iliac spine of 174 ± 43 mm (range, 95-248 mm) and from the lesser trochanter at a distance of 58 ± 36 mm (range, 0-136 mm). The average distance from the proximal pole of the patella to the superior reflection of the suprapatellar pouch was 46.3 ± 13.1 mm (range, 20-74 mm). Using the linear distance between the last crossing femoral nerve branch and the superior reflection of the pouch, the average safe zone measured 199 ± 39.8 mm (range, 124-268 mm). The safe zone correlated with thigh length (r = 0.48, P = 0.03). All nerve branches terminated at their muscular origins without crossing lateral to a line from the anterior greater trochanter to the anterior aspect of the lateral femoral condyle.

CONCLUSIONS

The safe zone for anterior external fixator half pin placement into the femur is on average 20 cm in length and can be as narrow as 12 cm. Anterior pins should begin 7.5 cm above the superior pole of the patella to avoid inadvertent knee joint penetration. Because the entire lateral femur is safely available for half pin placement, including distally, we recommend the use of alternative frame constructs with either anterolateral or lateral pins given the limitations and risks of anterior pin placement.

Long-term functional outcome following intramedullary nailing of femoral shaft fractures

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.

[Experiences with a helical femoral nail (LFN®). A multicenter study]

INTRODUCTION

Antegrade intramedullary nailing is the method of choice in most femoral shaft fractures. The trochanteric entry portal of classic femoral nails is in close proximity to the piriformis tendon, the gluteus minimus tendon, the obturator tendons, and the medial femoral circumflex artery. Nail insertion lateral to the tip of the greater trochanter may be more favorable but needs the use of a helical implant.

MATERIAL AND METHODS

Measurement of the reamer pathway through an entry point lateral to the superior trochanteric border was performed with a three-dimensional motion tracking sensor in human cadaveric femurs. These results provided a scientific rationale for the design of a helical femoral nail (LFN®). In a prospective multicenter study a total of 227 femoral shaft fractures were treated by nailing with the LFN. Patients were followed at 3 months (n=193) and 12 months (n=167).

RESULTS

The ease of defining the entry point and inserting the nail was rated as"very good and good" by 90% of the surgeons. Intraoperative technical complications included incomplete reduction (14%), additional iatrogenic fractures (6%), and difficulties in interlocking (3.5%). At the 1-year follow-up, delayed unions were seen in 10%, secondary loss of reduction in 3%, and deep infection in 1.8% of the patients. Angular malalignment of more than 5° was seen in 5%, mostly in valgus. A normal walking capacity was seen in 68% and normal active hip flexion in 45%.

CONCLUSION

The results obtained in this study during 1 year do not provide evidence for an advantage of the LFN over conventional antegrade femoral nails.

Intramedullary femoral nailing through the trochanteric fossa versus greater trochanter tip: a randomized controlled study with in-depth functional outcome results

PURPOSE

In a level 1 university trauma center, an explorative randomized controlled study was performed to compare soft tissue damage and functional outcome after antegrade femoral nailing through a trochanteric fossa (also known as piriform fossa) entry point to a greater trochanter entry point in patients with a femoral shaft fracture.

MATERIALS AND METHODS

Nineteen patients were enrolled and randomly assigned to two nail insertion groups; ten patients were treated with an Unreamed Femoral Nail(®) (UFN, Synthes(®), Solothurn, Switzerland) inserted at the trochanteric fossa and nine patients were treated with an Antegrade Femoral Nail(®) (AFN, Synthes(®), Solothurn, Switzerland) inserted at the tip of the greater trochanter. The main outcome measures were pain, gait, nerve and muscle function, along with endurance. Magnetic resonance imaging (MRI), electromyography (EMG), and Cybex isokinetic testings were performed at, respectively, 2 and 6 weeks and at a minimum of 12 months after surgery.

RESULTS

The MRI and EMG showed, in both groups, signs of iatrogenic abductor musculature lesions (four in the UFN group and four in the AFN group) and superior gluteal nerve injury (five in the UFN group and four in the AFN group). The isokinetic measurements and the patient-reported outcomes showed moderate reduction in abduction strength and endurance, as well as functional impairment with slight to moderate interference with daily life in both groups, with no appreciable differences between the groups.

CONCLUSIONS

Anatomical localization of the entry point seems to be important for per-operative soft tissue damage and subsequent functional impairment. However, the results of this study did not show appreciable differences between femoral nailing through the greater trochanter tip and nailing through the trochanteric fossa.

UKA in combination with PFR at average 12-year follow-up

INTRODUCTION

Safety and efficacy of unicompartmental knee arthroplasty (UKA) has been shown in large patient series. Patellofemoral replacement (PFR) is known to be a viable solution to end-stage patellofemoral arthritis. Bicompartmental osteoarthritis (OA) affecting the medial tibio-femoral and the patello-femoral compartment (medio-patellofemoral OA) is often treated with total knee arthroplasty (TKA). It was hypothesized that medio-patellofemoral OA can successfully be treated with bicompartmental arthroplasty.

METHOD

In a retrospective approach nine patients who had received UKA in combination with PFR were included into the study. Intact ACL and lateral compartment were conditions for the indication. Patients were clinically examined including clinical scores (KSS and WOMAC) and radiographies were evaluated. Satisfaction of patients was recorded under four categories.

RESULTS

Average follow-up after bicompartmental arthroplasty was 11.8 ± 5.4 years (4-17 years). Among the nine patients there were eight females and one male at an average age at operation of 64 ± 5 years. No surgical revisions were required following bicompartmental arthroplasty. The KSS score increased from a preoperative 68.8 ± 26.2 to 175.5 ± 22.9 at latest follow-up (p = 0.002). WOMAC was 18.3 ± 8.6 at latest follow-up. All patients included were satisfied (n = 3) or very satisfied (n = 6) with the outcome of this surgical procedure.

CONCLUSION

This small case series shows that a bicompartmental arthroplasty can be a successful approach to prevent or postpone TKA. However, this intervention is technically demanding and requires experience in both UKA and PFR.

How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe

BACKGROUND

The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA).

METHODS

Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05).

RESULTS

Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values.

CONCLUSIONS

Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.

Intramedullary nailing of femoral shaft fractures: current concepts

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.