Open interlocking nailing and bone grafting for neglected femoral shaft fractures

Ilizarov Fixator-Assisted Management of Neglected Femur Fractures by Open Intramedullary Nailing: A Case Series

Femoral shaft fractures are major life- and limb-threatening injuries. Such injuries, when neglected for months or years, can lead to a range of debilitating consequences. In the Indian subcontinent, there are multiple such cases that are presented to tertiary care hospitals late due to a lack of awareness and low socioeconomic constraints. These neglected cases on presentation are usually in a state of nonunion or malunion, with gross shortening and deformity affecting adjacent joint mobility. The management of neglected femur shaft fractures (NFFs) demands uphill tasks, such as achieving mechanical stability, restoring length and alignment, and having strong rehabilitation schedules. The functional outcomes of these cases are always not proportional to their radiological counterparts and must be taken care of separately. In this study, intramedullary nailing of the fracture after initial distraction with the Ilizarov fixator aims to reduce deformity and shortening while restoring near-optimal functional life. The study aimed to evaluate the functional and radiological outcomes of NFFs operated with distraction by an Ilizarov fixator followed by intramedullary nailing.

METHODS

Fourteen cases of NFFs presented to Kalinga Institute of Medical Sciences, Bhubaneswar, India, between January 2020 and June 2022 were recruited for the study. After preoperative evaluation and explanation of available treatment options to patients, they were operated on with a two-stage procedure of Ilizarov fixator application, followed by intramedullary interlocking nailing, with a period of gradual distraction in between. They were then followed up for a minimum of 12 months to assess functional and radiological outcomes.

RESULTS

The average time for all of the fractures to heal was 25.2 weeks. The average knee flexion increased from 28.2 degrees before surgery to 87.1 degrees after surgery. All 14 patients could walk with complete weight bearing on the operated limb postoperatively after proper pain control measures were taken. The mean Tegner Lysholm knee score was 77.8. There was residual limping in six of the cases, which could be attributed to muscle atrophy and/or shortening in the affected limbs. In three cases, skin blisters were formed due to the acute nature of the distraction, but they all healed with a scab and scar, otherwise uneventfully. The shortening, in 13 cases, came down to 4 cm or less, which was managed with a shoe raise. The one case with a residual 5 cm shortening had a short, limping gait, and it was attributed to an extremely overriding osteopenic femur preoperatively.

CONCLUSION

A two-stage operation with distraction by an Illizarov fixator followed by an intramedullary fixation provides the basic advantage of not having to excise an excessive amount of bone, which may be required in primary open reduction and intramedullary fixation. It also allows the patient to carry on his daily activities as mobilization is not restricted, which is the case in an individual to whom skeletal traction is applied. Hence, in any NFF case, this algorithm of management can be considered a frontrunner in the comprehensive management of disability and deformity.

One‐Stage Closed Intramedullary Nailing for Delayed Femoral Fracture in Multiple Injured Patients

Objective

To tackle the challengeable dilemma of delayed femoral fracture, a technique of fixator‐assisted closed reduction and intramedullary nailing at one stage was introduced herein and its clinical results were investigated.

Methods

A retrospective study was conducted on delayed femoral shaft fracture between February 2008 and January 2017. The multiple injured patients aged from 18 to 60 years with delayed femoral fracture was included. All patients were treated by one‐stage internal fixation technique and followed up for more than 1 year. Outcome measures including the operation time, intraoperative blood loss and limb alignment, healing time of fracture, visual analog scale (VAS), and range of knee motion were recorded and evaluated.

Results

A total of 13 patients (16 sides) with a mean injury severity score (ISS) of 32.77 ± 9.98 (range, 19 to 52) participated in the investigation. The median length of time‐after‐fracture was 38 days (range, 21 to 110 days). The average shortening distance of the fracture ends was 35.48 ± 19.24 mm (range, 10.00 to 79.00 mm). The average surgery time was 192.19 ± 29.38 min for unilateral femoral fracture, with blood loss of 587.50 ± 232.02 ml. The postoperative discrepancy of lower limb was 3.87 ± 2.52 mm. No patient had vascular and neurologic complications due to the lengthening. All fractures healed successfully with a mean time of 2.98 ± 0.57 months. The mean VAS and maximal knee flexion were 1.63 ± 1.09 and 131.25° ± 5.32° at final follow‐up, respectively.

Conclusions

Our findings indicated that fixator‐assisted closed reduction and intramedullary nailing at one stage is an effective treatment for delayed femoral fracture with satisfactory functional recovery.

Neglected infected floating knee injury: evaluation of closed reduction techniques

PURPOSE

Floating knee injury is uncommon yet challenging problem. The situation is more complicated by presence of infection, open comminuted fractures, and late presentation. The aim of this study was to evaluate the closed reduction techniques by circular external fixation in a single stage to treat patients having infected neglected floating knee injuries.

METHODS

This retrospective study included 19 patients with a mean age of 34.4 years. The average duration from trauma to surgery was 51.1 days. All patients had at least one infected open fracture. According to Fraser's classification, ten injuries were type I, one case was type IIa, four were type IIb, and four were type IIc. Patients were treated by closed reduction techniques using the Ilizarov principles. Orthoplastic procedures were done in four cases in the same surgical setting.

RESULTS

Closed reduction and union were achieved in all cases with control of infection in 17 cases. The follow-up period averaged 41 months. The mean knee flexion was 97.4°. The complications included 5° extension lag (two cases), malunion (three cases), refracture (two cases), and DVT (four cases). The bone results were excellent (12 cases), good (5 cases), and poor (2 cases). The functional results were excellent (two cases), good (seven cases), acceptable (seven cases), and poor (three cases).

CONCLUSIONS

Closed reduction techniques using a circular frame provided a valid treatment option for infected neglected floating knee injuries in one stage without bone grafting. However, the high rate of complications and the diminished knee range of motion should be considered.

Healing of bisphosphonate-associated atypical femoral fractures in patients with osteoporosis: a comparison between treatment with and without teriparatide

Atypical femoral fracture (AFF) often appears with bisphosphonate use. Teriparatide (TPTD) treatment may promote AFF healing, but few controlled or comparative studies have examined the effects of TPTD on healing of bisphosphonate-associated AFF. We retrospectively reviewed the medical records of 45 consecutive AFFs in 34 Japanese patients who had received oral bisphosphonates (alendronate or risedronate) for osteoporosis before AFF and had been followed for ≥12 months (range, 12-90 months). Thirty-seven complete or incomplete AFFs (82 %) were treated surgically and eight incomplete AFFs (18 %) were treated conservatively. Bisphosphonates were stopped at diagnosis. Based on TPTD use after fracture, AFFs were divided into non-TPTD (n = 24) and TPTD (n = 21) groups. Time to fracture-healing and frequency of delayed healing or non-union were compared between groups. Because fracture type (complete or incomplete) differed significantly between groups, only subanalyses for all surgically treated AFFs (complete and incomplete), surgically treated complete AFFs, and conservatively treated incomplete AFFs were performed. In subanalyses for all AFFs treated surgically, mean (± standard deviation) time to fracture healing was significantly better in the TPTD group (5.4 ± 1.5 months) than in the non-TPTD group (8.6 ± 4.7 months; P = 0.012), and the frequency of delayed healing or non-union was significantly lower in the TPTD group than in the non-TPTD group (P = 0.014). Subanalyses for surgically treated complete AFFs yielded similar results, but subanalyses for incomplete AFFs treated conservatively showed no significant differences between groups. TPTD treatment appears to significantly shorten the postoperative time to fracture healing and reduce rates of delayed healing or non-union after bisphosphonate-associated AFF.

Supracondylar skeletal traction and open interlocking nailing for neglected fracture of the shaft of femur - Retrospective study

BACKGROUND

Neglected trauma is a common problem faced by Orthopaedic surgeons practicing in developing countries. Nothing much in English literature is available regarding the practical difficulties and guidelines for treating neglected trauma of long bones.

METHODS

In our institution from November 2003 to October 2009 we treated 25 cases of neglected fracture of shaft of femur. Patients underwent either of three types of management protocols depending upon the preoperative manual traction radiographs. The fracture was fixed with open interlocking nail. Primary bone grafting and bone shortening procedures were not performed in any of the patient.

RESULTS

The fractures united in all patients at an average duration of 17 weeks. Two patients had limb length discrepancy.

CONCLUSION

Careful preoperative evaluation is mandatory for good results. Preoperative skeletal traction and two stage surgical procedure may be required to avoid limb length discrepancy and neurovascular complication.