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Bhale R, Campbell ST, Fitzpatrick E, Soles G, Lee M, Saiz AM. Rates of interlock screw back-out are high with the retrograde femoral nailing advanced system for distal femur fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2909-2913. [PMID: 38806688 PMCID: PMC11377647 DOI: 10.1007/s00590-024-04006-5] [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: 03/04/2024] [Accepted: 05/19/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE The retrograde femoral nailing advanced (RFNA) system (DePuy synthes) is a commonly used implant for the fixation of low distal femur and periprosthetic fractures. There is concern that the rate of distal interlock screw back-out may be higher for the RFNA compared to other nails (ON). The purpose of this study was to evaluate the incidence of interlock screw back-out and associated screw removal for RFNA versus ON, along with associated risk factors. METHODS A retrospective comparative study of patients who underwent retrograde nailing for a distal femur fracture at an academic level one trauma center was performed. The incidence of distal interlock screw back-out and need for screw removal were compared for RFNA versus a propensity score matched cohort who received other nails. RESULTS One hundred and ten patients underwent retrograde nailing with the RFNA for a distal femur fracture from 2015 to 2022 (average age: 66, BMI: 32, 52.7% smokers, 54.5% female, 61.8%). There was a significantly higher rate of interlock back-out in the RFNA group compared to the ON (27 patients, 24.5% vs 12 patients, 10.9%, p = 0.01), which occurred 6.3 weeks postoperatively. Screw removal rates for back-out were not significantly different for the RFNA group versus ON (8 patients, 7.3% vs 3 patients, 2.7%, p = 0.12). CONCLUSION In this retrospective comparative study of distal femur fractures treated with retrograde nailing, the RFNA implant was associated with an increased risk of distal interlock screw back-out compared to other nails.
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Affiliation(s)
- Rahul Bhale
- Davis Department of Orthopaedic Surgery, University of California, 4860 Y St #1700, Sacramento, CA, 95817, USA
| | - Sean T Campbell
- Davis Department of Orthopaedic Surgery, University of California, 4860 Y St #1700, Sacramento, CA, 95817, USA
| | - Ellen Fitzpatrick
- Davis Department of Orthopaedic Surgery, University of California, 4860 Y St #1700, Sacramento, CA, 95817, USA
| | - Gillian Soles
- Davis Department of Orthopaedic Surgery, University of California, 4860 Y St #1700, Sacramento, CA, 95817, USA
| | - Mark Lee
- Davis Department of Orthopaedic Surgery, University of California, 4860 Y St #1700, Sacramento, CA, 95817, USA
| | - Augustine M Saiz
- Davis Department of Orthopaedic Surgery, University of California, 4860 Y St #1700, Sacramento, CA, 95817, USA.
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Miller B, Phillips M, Krech L, Biberstein B, Parker J, Pounders S, Fisk C, Chapman AJ, Moffitt G. Outcomes of simultaneous versus staged intramedullary nailing fixation of multiple long bone lower extremity fractures. Injury 2023:110831. [PMID: 37236854 DOI: 10.1016/j.injury.2023.05.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Repair of multiple lower extremity long bone fractures with intramedullary nail (IMN) fixation is associated with significant cardiopulmonary burden and may result in mortality. These patients are at an increased risk for fat embolism syndrome, pulmonary embolism, Acute Respiratory Distress Syndrome (ARDS), and pneumonia. No standardized guidelines exist to guide treatment of these patients. Further, there is a paucity of data regarding the risk of simultaneous versus staged fixation of multiple long bone fractures that includes both tibial and femoral injuries, as patients with multiple concomitant fractures are often excluded from relevant analyses. Our level one trauma center aimed to identify whether simultaneous fixation, defined by definitive fixation of multiple lower extremity long bone fractures during one operative event, led to increased cardiopulmonary complications as compared to a staged approach, defined as multiple operations to reach definitive fixation. PATIENTS AND METHODS The Michigan Trauma Quality Improvement Program (MTQIP) database from 35 Level I and II trauma centers was queried to identify patients from January 2016 - December 2019. The primary outcome was incidence of cardiopulmonary complications for staged and simultaneous IMN fixation. RESULTS We identified 11,427 patients with tibial and/or femoral fractures during the study period. 146 patients met the inclusion criteria of two or more fractures treated with IMN fixation. 118 patients underwent simultaneous IMN fixation, and 28 patients received staged IMN fixation. There were no significant differences in injury severity score (ISS), demographics, pre-existing conditions, and cardiopulmonary complications between the two groups. There was a statistically significant difference in hospital length of stay (LOS) (p = 0.0012). The median hospital LOS for simultaneous fixation was 8.3 days versus 15.8 days for the staged cohort, a difference of 7.5 days. CONCLUSION This is the largest retrospective study to date examining simultaneous versus staged IMN fixation in patients with multiple long bone lower extremity fractures. In contrast to previous studies, we found no difference in cardiopulmonary complications. Given these findings, patients with multiple long bone lower extremity fractures should be considered for simultaneous IMN, an approach which may decrease hospital LOS.
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Affiliation(s)
- Blake Miller
- Orthopaedic Associates of Muskegon, 260 Jefferson Ave SE Suite 115 Grand Rapids, Michigan, 49503, United States.
| | - Maxwell Phillips
- McLaren Flint Orthopaedic Surgery Residency, 401 South Ballenger Highway Flint, Michigan, 48532, United States
| | - Laura Krech
- Trauma Research Institute, Spectrum Health, 100 Michigan St NE Grand Rapids, Michigan, 49503, United States.
| | - Bryce Biberstein
- Spectrum Health Butterworth Hospital, 100 Michigan St NE Grand Rapids, Michigan, 49503, United States
| | - Jessica Parker
- Spectrum Health, Scholarly Activity and Scientific Support, Spectrum Health Office of Research, 100 Michigan St NE Grand Rapids, Michigan, 49503, United States.
| | - Steffen Pounders
- Trauma Research Institute, Spectrum Health, 100 Michigan St NE Grand Rapids, Michigan, 49503, United States.
| | - Chelsea Fisk
- Trauma Research Institute, Spectrum Health, 100 Michigan St NE Grand Rapids, Michigan, 49503, United States.
| | - Alistair J Chapman
- Trauma Research Institute, Spectrum Health, 100 Michigan St NE Grand Rapids, Michigan, 49503, United States.
| | - Gable Moffitt
- Spectrum Health Butterworth Hospital, 100 Michigan St NE Grand Rapids, Michigan, 49503, United States.
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Baker HP, Lin Y, Dahm J, Portney DA, Dillman DB, Strelzow JA. Bilateral femur fractures are associated with concomitant femoral neck fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:409-414. [PMID: 35038011 DOI: 10.1007/s00590-022-03207-0] [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: 01/05/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of this study is to determine the rate of femoral neck fractures in patients who have sustained bilateral femur fractures compared to unilateral femur fractures. DESIGN AND SETTING A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS All patients treated for a femur fracture between May 1, 2018 and December 31, 2020 were included. RESULTS Twenty-one patients sustained bilateral femur fractures (11%) and 166 sustained unilateral femur fractures. Fifteen associated ipsilateral femoral neck fractures were identified. Eight of the 15 (53%) associated femoral neck fractures were observed in patients who sustained bilateral femur fractures. Eight of the 21 patients with bilateral femur fractures, 42 fractures in total, had an associated ipsilateral femoral neck fracture (38% of patients; 19% of fractures, respectively), while only seven of the 166 patients (4%) with a unilateral femur fracture had an associated femoral neck fracture (p < 0.001). Of the 208 femur fractures, 19 (9%) were open fractures. Ten of the 21 patients with bilateral femur fractures, 42 fractures in total, were identified to have an open femur fracture (48% of patients, 24% of fractures), while only nine of the 166 (5%) unilateral femur fractures were open (p < 0.001). CONCLUSIONS Our results demonstrate an association between bilateral femur fractures, open femur fractures, and associated femoral neck fractures. Surgeons treating these injuries should maintain a high index of suspicion for associated ipsilateral proximal.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA. .,, 5758 S. Maryland Avenue, Department 4B, Chicago, IL, 60637, USA.
| | - Ye Lin
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - James Dahm
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Daniel A Portney
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Daryl B Dillman
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Jason A Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, 60637, USA
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Mansour A, Vivace BJ, Nyland J, Rashid SF, Wilson A, Engorn JR, Swindle JS, Zamora R. Early intramedullary nailing of bilateral femur fractures: who might benefit most? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03453-2. [PMID: 36538126 DOI: 10.1007/s00590-022-03453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/25/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Identifying which patients can receive immediate intramedullary nailing (IMN) after bilateral femoral shaft fracture may improve health-related quality of life outcomes and decrease healthcare costs. This retrospective study evaluated the perioperative factors that guided emergency department transfer of patients to the operating room (OR) where IMN or temporizing external fixation (TEF) was performed, to the intensive care unit (ICU), or to the orthopedic ward. The hypothesis was that patients referred initially to the OR or to the ICU had more serious co-morbidities, complications, or orthopedic polytrauma, increasing the likelihood that they would benefit from "damage control orthopedics" and TEF use. METHODS A Level I Trauma Center database (2010-2020) review identified the records of 23 patients that met study inclusion and exclusion criteria. Most sustained their injury in a motor vehicle accident (87%) and were not wearing a seatbelt. RESULTS Patients transferred to the operating room had a greater body mass index and shorter times between admission and surgery. Those transferred to the OR or ICU had higher injury severity scores (ISS), higher arterial blood O2 partial pressure (paO2) values on the first post-surgical day, and had more red blood cell unit (RBCU) transfusions during hospitalization. Patients transferred to the ICU more often underwent TEF and had shorter initial surgical procedure duration. Those with pneumothorax, rib fractures, or with other orthopedic comorbidities were more often transferred to the OR or ICU and those with acute complications requiring exploratory laparotomy were transferred to the OR. CONCLUSIONS Patients with higher BMI, ISS, greater RBCU transfusion needs, with pneumothorax, rib fractures, or acute complications requiring exploratory laparotomy were more likely to be initially transferred to the OR or ICU. Patients transferred to the orthopedic ward represented a more heterogenous group with greater possibility for benefitting from earlier definitive IMN.
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Affiliation(s)
- Ali Mansour
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | | | - John Nyland
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
- Norton Orthopedic Institute, Louisville, 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, 40202, USA
| | - Ayana Wilson
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, USA
- University of Louisville School of Medicine, Louisville, USA
| | - 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, 40202, USA
- University of Louisville School of Medicine, Louisville, USA
| | - Jordan Scot Swindle
- Department of Orthopaedic Surgery, University of Louisville, University of Louisville School of Medicine, 550 South Jackson Street 1st Floor Ambulatory Care Building, Louisville, KY, 40202, 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, 40202, USA.
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Cosgrove CT, Wolinsky PR, Berkes MB, McAndrew CM, Stwalley DL, Miller AN. A Comparison of the Prevalence of, Demographics of, and Effects on Outcomes of Bilateral Versus Unilateral Femoral Shaft Fractures: A Retrospective Cohort Analysis From the National Trauma Data Bank. J Orthop Trauma 2022; 36:349-354. [PMID: 35727002 DOI: 10.1097/bot.0000000000002322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To document the prevalence of, and the effect on outcomes, operatively treated bilateral femur fractures treated using contemporary treatments. DESIGN A retrospective cohort using data from the National Trauma Data Bank. PARTICIPANTS In total, 119,213 patients in the National Trauma Data Bank between the years 2007 and 2015 who had operatively treated femoral shaft fractures. MAIN OUTCOME MEASUREMENTS Complication rates, hospital length of stay (LOS), days in the intensive care unit (ICU LOS), days on a ventilator, and mortality rates. RESULTS Patients with bilateral femur fractures had increased overall complications (0.74 vs. 0.50, P < 0.0001), a longer LOS (14.3 vs. 9.2, P < 0.0001), an increased ICU LOS (5.3 vs. 2.4, P < 0.0001), and more days on a ventilator (3.1 vs. 1.3, P < 0.0001), when compared with unilateral fractures. Bilateral femoral shaft fractures were independently associated with worse outcomes in all primary domains when adjusted by Injury Severity Score (P < 0.0001), apart from mortality rates. Age-adjusted bilateral injuries were independently associated with worse outcomes in all primary domains (P < 0.0001) except for the overall complication rate. A delay in fracture fixation beyond 24 hours was associated with increased mortality (P < 0.0001) and worse outcomes for all other primary measures (P < 0.0001 to P = 0.0278) for all patients. CONCLUSIONS Bilateral femoral shaft fractures are an independent marker for increased hospital and ICU LOS, number of days on a ventilator, and increased complication rates, when compared with unilateral injuries and adjusted for age and Injury Severity Score. Timely definitive fixation, in a physiologically appropriate patient, is critical because a delay is associated with worse inpatient outcome measures and higher mortality rates. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher T Cosgrove
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Philip R Wolinsky
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA; and
| | - Marschall B Berkes
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Christopher M McAndrew
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Dustin L Stwalley
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
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Fat embolism syndrome in patients with bilateral femur fractures: a systematic review and case comparison. OTA Int 2022; 5:e187. [PMID: 35949269 PMCID: PMC9359015 DOI: 10.1097/oi9.0000000000000187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/09/2021] [Indexed: 11/26/2022]
Abstract
Objectives: Fat embolism and fat embolism syndrome (FES) remain common complications following long bone fractures. Incidence is highest after bilateral femur fractures. We performed a systematic review of FES after bilateral femur fractures and present two cases. Data sources: Systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus, and, Web of Science Library databases was performed in August 2021. Terms used including plural and alternate spellings: “fat embolism,”“fat embolism syndrome,”“fat embolus,” and “bilateral femur fracture.” Articles in German and English were considered. No time frame was applied. Study selection: Original studies, case series and case reports on fat embolism after bilateral femur fracture were included. Insufficient documentation or patients with relevant previous heath conditions were excluded. Data extraction: Abstracts were organized using EndNote X9 by Carivate. Three authors independently screened the abstracts; cross check of the extracted data was performed by the senior author. Data synthesis: Scarcity of articles only allowed for a qualitative synthesis. Data was compared with our cases and situated within the scientific background. Results: Ten articles were included for qualitative synthesis (n = 144 patients). The symptoms were inhomogeneous with neurological deficits being most prominent. Degree of displacement was high, when reported. Although the modes and timing of surgery varied, this appeared unrelated with outcome. Conclusions: FES remains a relevant complication after bilateral femur fractures, despite damage control strategies and improved reaming techniques. Fracture displacement and reduction maneuvers might play a more substantial role in the formation than previously accredited. Level of evidence: 4
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7
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Flagstad IR, Tatman LM, Heare A, Parikh HR, Albersheim M, Atchison J, Breslin M, Davis P, Feinstein S, Hak DJ, Labrum JT, Lufrano RC, Lund EA, Connelly D, Matar RN, Nadeau J, Ries de Chaffin D, Rodriguez-Buitrago AF, Schmidt T, Shaw N, Simske N, Siy AB, Titter J, Vang S, Wagstrom E, Westberg JR, Hahn J, Mauffrey C, Mir HR, O'Toole RV, Obremskey WT, Sanders RW, Schmidt AH, Vallier HA, Whiting PS, Cunningham BP. Single-Stage Versus 2-Stage Bilateral Intramedullary Nail Fixation in Patients With Bilateral Femur Fractures: A Multicenter Retrospective Review. J Orthop Trauma 2021; 35:499-504. [PMID: 33512861 DOI: 10.1097/bot.0000000000002055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures. DESIGN A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. SETTING Ten Level-1 trauma centers. PATIENTS/PARTICIPANTS Two hundred forty-six patients with bilateral femur fractures. INTERVENTIONS Intramedullary nailing. MAIN OUTCOME MEASURES Incidence of complications. RESULTS A total of 246 patients were included, with 188 single-stage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22). CONCLUSIONS This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ilexa R Flagstad
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Austin Heare
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
- Department of Orthopaedics, University of Miami Miller School of Medicine, Miami, FL
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Jared Atchison
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Mary Breslin
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Patrick Davis
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Shawn Feinstein
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - David J Hak
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Joseph T Labrum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Reuben C Lufrano
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Erik A Lund
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Daniel Connelly
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Robert N Matar
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, OH
| | - Jason Nadeau
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | | | | | - Tegan Schmidt
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Nichole Shaw
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Natasha Simske
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Alexander B Siy
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Julie Titter
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Emily Wagstrom
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Jerald R Westberg
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Jesse Hahn
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Hassan R Mir
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Robert V O'Toole
- Department of Orthopaedics, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Roy W Sanders
- Department of Orthopaedics, Florida Orthopaedic Institute, Tampa, FL
| | - Andrew H Schmidt
- Department of Orthopaedics, Hennepin County Medical Center, Minneapolis, MN
| | - Heather A Vallier
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO
| | - Paul S Whiting
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN
- Department of Orhopaedics, TRIA Orthopaedics Center, Bloomington, MN; and
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN
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8
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Flagstad IR, Tatman LM, Albersheim M, Heare A, Parikh HR, Vang S, Westberg JR, de Chaffin DR, Schmidt T, Breslin M, Simske N, Siy AB, Lufrano RC, Rodriguez-Buitrago AF, Labrum JT, Shaw N, Only AJ, Nadeau J, Davis P, Steverson B, Lund EA, Connelly D, Atchison J, Mauffrey C, Hak DJ, Titter J, Feinstein S, Hahn J, Sagi C, Whiting PS, Mir HR, Schmidt AH, Wagstrom E, Obremskey WT, O'Toole RV, Vallier HA, Cunningham B. Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation. Injury 2021; 52:2395-2402. [PMID: 33712297 DOI: 10.1016/j.injury.2021.02.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/16/2021] [Accepted: 02/28/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries. METHODS Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit. RESULTS Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X2 statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94). CONCLUSION In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ilexa R Flagstad
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Austin Heare
- Department of Orthopaedic Surgery, University of Miami Hospital Ortho Clinic, 1400 N.W. 12th Avenue, Suite 2, Miami, FL 33136, USA
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street R200, Minneapolis, MN 55455, USA
| | - Sandy Vang
- Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101, USA
| | - Jerald R Westberg
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Danielle Ries de Chaffin
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Tegan Schmidt
- Department of Orthopaedic Surgery, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Mary Breslin
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Natasha Simske
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Alexander B Siy
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Reuben C Lufrano
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Andres F Rodriguez-Buitrago
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Joseph T Labrum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Nichole Shaw
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Arthur J Only
- Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN 55426, USA
| | - Jason Nadeau
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - Patrick Davis
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Barbara Steverson
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Erik A Lund
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Daniel Connelly
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Jared Atchison
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Cyril Mauffrey
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - David J Hak
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - Julie Titter
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Shawn Feinstein
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Jesse Hahn
- Department of Orthopaedic Surgery, University of North Carolina, 130 Mason Farm Road CB# 7055 UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Claude Sagi
- Department of Orthopaedic Surgery, University of Cincinnati, Medical Sciences Building Room 3109 231 Albert Sabin Way, PO Box 670531, Cincinnati, OH 45267, USA
| | - Paul S Whiting
- Department of Orthopaedic Surgery, University of Wisconsin Hospital and Clinic, 1685 Highland Ave, Madison, WI 53705, USA
| | - Hassan R Mir
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 909 North Dale Mabry Highway, Tampa, FL 33609, USA
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - Emily Wagstrom
- Department of Orthopaedic Surgery, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN 55415, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South MCE South Tower, Suite 4200, Nashville, TN 37232, USA
| | - Robert V O'Toole
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Brian Cunningham
- Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, St. Louis Park, MN 55426, USA.
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Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time-A Systematic Review. J Clin Med 2021; 10:jcm10122733. [PMID: 34205701 PMCID: PMC8234368 DOI: 10.3390/jcm10122733] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development. MATERIALS AND METHODS Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019. STUDY SELECTION Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included. DATA EXTRACTION Two authors independently extracted data using a predesigned form. STATISTICS Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960-12 December 1979, Group 2: 1 January 1980-1 December 1999, and Group 3: 1 January 2000-31 December 2019, chi-square test, χ2 test for group comparisons of categorical variables, p-value < 0.05. RESULTS Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001). CONCLUSIONS There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.
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Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis? Orthop Traumatol Surg Res 2021; 107:102864. [PMID: 33621700 DOI: 10.1016/j.otsr.2021.102864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/29/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Whether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles. MATERIALS AND METHODS This retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression. RESULTS Between 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality. DISCUSSION Studies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients. CONCLUSION Bilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management. LEVEL OF EVIDENCE IV; retrospective study.
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Al Maskari S, Muzaffar R, Yaseen A. Retrograde femoral nails for emergency stabilization in multiply injured patients with haemodynamic instability. Trauma Case Rep 2020; 29:100350. [PMID: 32885018 PMCID: PMC7451695 DOI: 10.1016/j.tcr.2020.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction The purpose of this study is to retrospectively evaluate the immediate effect of retrograde intramedullary femoral nail (RIMFN) fixation technique on patient's hemodynamic status as documented by vital signs (blood pressure and pulse) intraoperatively in all patients with femoral shaft fractures with multiple injuries and hemodynamic instability who were treated with RIMFN at our institution on emergency basis as part of damage control orthopaedics. Patients and methods A retrospective review of intra operative vital signs obtained from patient records was completed at a Level 1 trauma center in a university hospital. In all, 11 multiply injured patients with (14) femur fractures with hemodynamic instability were identified. Of those, 3 had bilateral femur fractures. Closed reduction and retrograde femoral nailing without proximal locking was performed to achieve immediate skeletal and haemodynamic stability. Pulse rate and BP measurements were noted for all patients starting from the time patient would enter the operating room till the patient was shifted back to the recovery ward. Results The average cohort age was 28 years (20–36 years). The average Injury Severity Score was 28 (16–50). Statistically significant improvement in pulse rate and blood pressure was noted following femoral fracture fixation with intramedullary nail. No cases of infection or symptomatic fat or pulmonary embolism were encountered. One patient required exchange nailing for non-union and one femur underwent later lengthening. Conclusions Retrograde Intramedullary femoral nail can be an effective alternative to external fixator as damage control device and is associated with immediate improvement in vital signs (pulse and blood pressure) intra operatively. Reversal of shock is important determinant of outcome in multiply injured patients. Retrograde femoral nailing achieves immediate haemodynamic stability. Retrograde nailing as damage control device has low morbidity and mortality. Retrograde nailing without proximal locking is rapid, safe, effective procedure.
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Durigan JR, Silva ACD, Takata P, Zamboni C, Santili C, Mercadante MT. ANTEGRADE X RETROGRADE NAILING IN FEMORAL FRACTURES: A STUDY ON CONSOLIDATION AND INFECTION. ACTA ORTOPEDICA BRASILEIRA 2019; 27:313-316. [PMID: 31798322 PMCID: PMC6870539 DOI: 10.1590/1413-785220192706218655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective: Osteosynthesis with intramedullary nailing is considered the method of choice to treat diaphyseal femur fractures in adults. The objective of this retrospective study was to evaluate the bone healing time and incidence of infection in patients with diaphyseal femur fractures treated surgically with retrograde and antegrade intramedullary nailing. Methods: The medical records of 123 patients from two university hospitals dated 2011-2013 were evaluated, with 126 diaphyseal femur fractures having been found. The most frequent treatment was antegrade intramedullary nailing (51%), of which 38% involved reaming (n=25). Results: We found evidence of 92% healed fractures at 12 months postoperatively. Complications included chronic osteomyelitis in one patient and femoral neck fracture in another patient, both after reamed antegrade nailing. Pyoarthritis of the knee associated with osteomyelitis affected two patients after reamed retrograde nailing and one patient after unreamed retrograde nailing. Conclusion: We did not observe a significant difference in bone healing rates with the use of reamed or unreamed antegrade or retrograde nailing. Complications included the presence of infection with an incidence similar to that reported in the literature, and of particular significance, unrelated to the type of approach. Level of evidence III, Retrospective comparative study.
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Affiliation(s)
| | | | - Pedro Takata
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil
| | - Caio Zamboni
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil
| | - Claudio Santili
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil
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Bilateral tibial shaft fractures: a multicenter analysis. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Lane MK, Nahm NJ, Vallier HA. Morbidity and Mortality of Bilateral Femur Fractures. Orthopedics 2015; 38:e588-92. [PMID: 26186320 DOI: 10.3928/01477447-20150701-56] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 10/07/2014] [Indexed: 02/03/2023]
Abstract
Bilateral femur fractures have been associated with frequent morbidity and mortality. Associated injuries and massive hemorrhage contributed to mortality rates that were as high as 27% in previous reports. The goals of this study were to determine the frequency of associated complications, including mortality, and to identify which patient and injury features are associated with increased morbidity and mortality. The authors proposed that some patients with bilateral femur fractures may undergo early definitive fixation with an acceptable rate of complications. Patients who had bilateral femur fractures during the same injury event were retrospectively reviewed. Demographic characteristics, associated injuries, and the type and timing of treatment were determined. Complications were identified. The authors identified 50 men and 22 women, with a mean age of 41.5 years, who had high-energy bilateral femur fractures. These patients accounted for 5.5% of all femur fractures treated at the authors' institution over a period of 11 years. Two patients died before fixation. In addition, 13 other patients (19%) had 21 complications, including pneumonia in 6 (8.6%) and deep venous thrombosis in 7 (10%). No patient had adult respiratory distress syndrome, but 2 died of multiple organ failure. All patients with pulmonary complications had an underlying chest injury (P=.004). The overall mortality rate was 6.9%, and mortality was associated with higher mean age and higher Injury Severity Score (ISS). Of the 60 patients who had definitive fixation within 24 hours of injury, 53 (88%) had no complications. Complication rates were similar to those reported in the literature, with a mortality rate of 6.9%, including 3 patients who died after femoral fixation. Mortality was associated with advanced age and higher ISS. Chest injuries were associated with pulmonary complications. Most patients had early definitive fixation without complications, but it is not possible to predict which patients may be safely treated on an early basis.
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Intramedullary nailing of diaphyseal femur fractures secondary to gunshot wounds: predictors of postoperative malrotation. J Orthop Trauma 2014; 28:711-4. [PMID: 24714402 DOI: 10.1097/bot.0000000000000124] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to determine significant factors that may impact the postoperative differences in femoral version (DFV) and differences in femoral length (DFL) between the fixed and uninjured sides after intramedullary nailing (IMN) secondary to gunshot wounds. DESIGN Retrospective data registry study. SETTING Academic level I trauma center. PATIENTS Over a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (OTA/AO 32A-C). Of these, 57 patients sustained fractures caused by gunshots and had a postoperative computed tomographic scanogram. MAIN OUTCOME MEASURES DFV and DFL. The effect of the following variables on DFV and DFL were determined through univariate and stepwise multivariate regression analyses: age, sex, body mass index, trauma fellowship-trained versus nontrauma surgeon, daytime versus nighttime surgery, antegrade versus retrograde nail insertion, use of traction, type of operating table, and AO and Winquist classifications. RESULTS The mean postoperative DFV for all patients was 8.62 degrees (±6.67 degrees). Postoperative DFV greater than 15 degrees was found in 12.3% of all patients. After IMN, no significant differences in DFV were found with increasing complexity of AO/OTA or Winquist fracture classification. None of the aforementioned independent variables were significantly predictive of postoperative DFV in univariate or multivariate analyses. The mean postoperative DFL for all patients was 5.25 mm (±4.36 mm). In a multivariate model, classification as Winquist type 3 or 4 was weakly (adjusted R = 0.075) but significantly predictive of less DFL than categorization as type 1 or 2 (P = 0.027). CONCLUSIONS Although gunshot-associated femur fractures may present surgical challenges for treatment through IMN, acceptable femoral rotation and length are obtainable regardless of the fracture complexity or a variety of demographic and surgically-related variables. LEVEL OF EVIDENCE Prognostic level II.
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Abstract
OBJECTIVES To determine whether previously reported high mortality rates associated with bilateral femoral fractures have decreased over time. DESIGN Retrospective review. SETTING Urban academic trauma center. STUDY GROUP 54 adults with bilateral femoral fractures treated at our center from 2000 to 2006. The 108 fractures were initially treated with external fixation (11%), reamed antegrade nailing (23%), and reamed retrograde nailing (67%). Unilateral control group: 461 patients with unilateral femoral fractures treated at our center from 2002 to 2005. INTERVENTION Univariate analysis compared our results with those of a published historical control group from the same center approximately 15 years ago (study period, 1984-1990). MAIN OUTCOME MEASUREMENTS Mortality rates. RESULTS We noted marked differences between the current mortality rate associated with bilateral femoral fractures and that of the historical control group. The mortality rate decreased over time at our center for both bilateral (26%-7%, P = 0.002) and unilateral (12%-2%, P = 0.0001) fractures. Mortality rates were still significantly higher (P = 0.037) for bilateral (7%) than for unilateral (2%) fractures. CONCLUSIONS Mortality rates and Injury Severity Scores were reduced for bilateral and unilateral femoral fractures compared with data reported 15 years ago from the same center. The improved outcome might be related in part to changes in resuscitation, triage, intensive care, and orthopaedic management of the patients. However, considering that the Injury Severity Score also significantly decreased, the improvement might have occurred because of changes in injury patterns, perhaps secondary to improved safety features in motor vehicles. LEVEL OF EVIDENCE Prognostic level III. See instructions for authors for a complete description of levels of evidence.
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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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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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20
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Husebye EE, Lyberg T, Opdahl H, Aspelin T, Støen RO, Madsen JE, Røise O. Intramedullary nailing of femoral shaft fractures in polytraumatized patients. a longitudinal, prospective and observational study of the procedure-related impact on cardiopulmonary- and inflammatory responses. Scand J Trauma Resusc Emerg Med 2012; 20:2. [PMID: 22221511 PMCID: PMC3285514 DOI: 10.1186/1757-7241-20-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 01/05/2012] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Early intramedullary nailing (IMN) of long bone fractures in severely injured patients has been evaluated as beneficial, but has also been associated with increased inflammation, multi organ failure (MOF) and morbidity. This study was initiated to evaluate the impact of primary femoral IMN on coagulation-, fibrinolysis-, inflammatory- and cardiopulmonary responses in polytraumatized patients. METHODS Twelve adult polytraumatized patients with femoral shaft fractures were included. Serial blood samples were collected to evaluate coagulation-, fibrinolytic-, and cytokine activation in arterial blood. A flow-directed pulmonary artery (PA) catheter was inserted prior to IMN. Cardiopulmonary function parameters were recorded peri- and postoperatively. The clinical course of the patients and complications were monitored and recorded daily. RESULTS Mean Injury Severity Score (ISS) was 31 ± 2.6. No procedure-related effect of the primary IMN on coagulation- and fibrinolysis activation was evident. Tumor necrosis factor alpha (TNF-α) increased significantly from 6 hours post procedure to peak levels on the third postoperative day. Interleukin-6 (IL-6) increased from the first to the third postoperative day. Interleukin-10 (IL-10) peaked on the first postoperative day. A procedure-related transient hemodynamic response was observed on indexed pulmonary vascular resistance (PVRI) two hours post procedure. 11/12 patients developed systemic inflammatory response syndrome (SIRS), 7/12 pneumonia, 3/12 acute lung injury (ALI), 3/12 adult respiratory distress syndrome (ARDS), 3/12 sepsis, 0/12 wound infection. CONCLUSION In the polytraumatized patients with femoral shaft fractures operated with primary IMN we observed a substantial response related to the initial trauma. We could not demonstrate any major additional IMN-related impact on the inflammatory responses or on the cardiopulmonary function parameters. These results have to be interpreted carefully due to the relatively few patients included. TRIAL REGISTRATION ClinicalTrials.gov: NCT00981877.
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Bone LB, Giannoudis P. Femoral shaft fracture fixation and chest injury after polytrauma. J Bone Joint Surg Am 2011; 93:311-7. [PMID: 21266645 DOI: 10.2106/jbjs.j.00334] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Cardiopulmonary Response to Reamed Intramedullary Nailing of the Femur Comparing Traditional Reaming With a One-Step Reamer-Irrigator-Aspirator Reaming System: An Experimental Study in Pigs. ACTA ACUST UNITED AC 2010; 69:E6-14. [DOI: 10.1097/ta.0b013e3181d27928] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
In order to evaluate the impact of simultaneous intramedullary nailing in patients with bilateral femoral fractures on systemic complications a comprehensive review of the literature was performed. Four studies reporting the results of 197 patients following trauma were analysed. The mean Injury Severity Score was 20.6 (range, 9-75). According to the data available, reamed intramedullary nailing was performed in 96% of the cases. The incidence of fat embolism was 4.1%, ARDS 14.6% and pulmonary embolism 6.9%. The overall mortality was 6%. The mean hospital stay was 17.9 days (range, 4-108). Bilateral femoral fractures have a high risk of complications and mortality. Damage control surgery should be considered in these cases where the clinician anticipates the development of systemic complications.
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