Radiographic, Bone Densitometry and Clinic Outcomes Assessments in Femoral Shaft Fractures Fixed by Plating or Locking Retrograde Nail

Which fixation produces the best outcome for distal femoral fractures? Meta-analysis and systematic review of retrograde nailing versus distal femoral plating in 2432 patients and 33 studies

PURPOSE

The distal femur comprises a wide intramedullary cavity and thin cortical bone. Firm internal fixation of comminuted fractures with displacement is challenging. Although many comparative studies have reported retrograde intramedullary nailing (RIN) and distal femoral plating (DFP) as the usual fixation methods for distal femoral fractures, no clear conclusion has been reached. Therefore, a meta-analysis and systematic review of the clinical and radiological results were conducted to determine the appropriate treatment method for distal femoral fractures.

METHODS

A systematic search of the PubMed, Embase, Scopus, and Cochrane Library databases from their inception to December 19, 2022, was performed using predefined criteria. Studies comparing the effects of RIN and DFP were considered. The analyzed outcome measures included duration of surgery, blood loss, time to union, delayed union, nonunion, malalignment, implant failure, infection, reoperation, limb length discrepancy, range of motion, persistent anterior knee pain, knee stiffness, and functional scores. Meta-analysis of pooled data was conducted using a random-effects model to determine the standard mean difference (SMD) or odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Thirty-three studies with 2,432 patients were included. Compared to DFP, RIN was associated with a shorter time to fracture union (SMD, 1.83 months; 95% CI - 2.76 to - 0.90; P < 0.001) and a lower incidence of postoperative infection (OR 0.54; 95% CI 0.31-0.94; P = 0.03). Pooled analysis revealed no significant differences in other outcome measures between the two treatment modalities.

CONCLUSION

In distal femoral fractures, RIN had a shorter bone union time and was more resistant to infection than DFP. However, there were no significant differences in the other clinical parameters. Therefore, the characteristics, strengths, and weaknesses of RIN and DFP should be carefully identified, and appropriate treatment should be provided based on the patient's medical condition and fracture pattern.

Fluoroscopy-free distal screw locking in intramedullary nailing: A retrospective study

Intramedullary nailing is a common orthopedic procedure, but current methods for distal screw locking have several limitations. This study introduces and evaluates a novel technique that aims to overcome these challenges. The findings were statistically significant, with P-values set at .05. Compared to the traditional method, the novel technique demonstrated several advantages. Mean operation times were reduced to 1.2 hours for the new method, in contrast to 1.5 hours for the control group. Hospital stays also favored the new technique, with a mean duration of 2 days, while the control group averaged 3 days. A significant benefit was the marked decrease in radiation exposure, with the new technique eliminating radiation entirely, recording 0.0 mSv compared to the control group's 2.5 mSv. The procedure's success, gauged by the accurate positioning of screws, was higher for the new technique at 92% versus the control's 78%. Furthermore, complication rates were notably lower in the new method, with a 6% incidence compared to 16% in the traditional approach. While the data suggest that the new technique holds promising advantages, such as reduced operation times, decreased radiation exposure, and fewer complications, it is essential to conduct more extensive research for comprehensive validation. Despite the optimistic results, the study acknowledges the need for larger-scale trials to solidify these findings.

Optimal entry point for antegrade and retrograde femoral intramedullary nails

Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.

Resistant distal femoral nonunion treated with combined nail/plate construct and reamer-irrigator-aspirator technique

OBJECTIVE

This study was performed to evaluate the effectiveness of intramedullary nailing and a lateral locking plate combined with the reamer-irrigator-aspirator (RIA) bone grafting technique for resistant distal femoral nonunion.

METHODS

This retrospective observational study was performed from January 2018 to December 2021 and involved five patients who presented with resistant distal femoral nonunion despite undergoing several surgeries. They were treated with intramedullary nailing and a lateral locking plate combined with the RIA bone grafting technique. Postoperative follow-up was performed to observe the healing time, and functional outcomes were evaluated using the Lower Extremity Functional Scale (LEFS).

RESULTS

After the patients had been monitored for a mean of 17.9 months, complete bone healing was observed in every patient (mean healing time of 4.8 months). Postoperative wound failure in an older patient was successfully treated with resuturing and nutritional assistance. At the last follow-up, the mean LEFS score was 71.2/80 and the mean knee flexion was 109 degrees.

CONCLUSIONS

Our study demonstrates that combining intramedullary nailing and a lateral locking plate with the RIA bone grafting technique enhances biological properties, provides good structural support, and achieves good union and functional results in the management of resistant nonunion of the distal femur.

Comparison of outcomes of retrograde intramedullary nailing versus locking plate fixation in distal femur fractures: A Systematic Review and Meta-analysis of 936 patients in 16 studies

Background

The surgical treatment for distal femur fractures has evolved over time, and it depends upon certain factors; open or closed fracture type, the pattern of fracture, presence of metaphyseal comminution, intra-articular extension, and the bone quality are some of the crucial ones. Both retrograde intramedullary nails (RIMN) and locking plates (LP) can be used for the fixation of these fractures. However, the optimal method among the two devices is still a topic of debate, the superiority of one over the other being unclear. Hence, this systematic review and meta-analysis was conceptualized to compare the outcomes of RIMN with distal femur LP.

Methods

The primary electronic search was conducted on Medline (PubMed), Scopus, Embase, Cinahl, and Cochrane Library databases for the published literature from the inception to 25th February 2022. The studies compared outcomes of RIMN versus LP fixation of the acute supracondylar or distal femur fracture (AO/OTA type-33A, B, and C) and reported at least one primary (mean fracture union time, complications, implant-related complications, and re-operation rate) or secondary outcome (duration of surgery, intra-operative blood loss, and knee range of motion), were included.

Results

Six randomized control trials, 2 prospective and 8 retrospective studies with 936 patients with 8 bilateral cases (467: RIMN; 477: LP) were included. Our analysis demonstrated no statistically significant difference in terms of mean fracture union time, overall complications, implant-related complications, re-operation rates, and duration of surgeries. Although a better knee range of motion was seen in the LP group, however, it also showed more nonunion and infection than the RIMN group.

Conclusion

The present review shows that there are significantly lesser nonunions and infections, in the RIMN group as compared to LP for distal femur fractures, although a better postoperative knee range of motion was seen in the latter. However, in terms of fracture union time, the overall rate of complications, re-operation rates, and duration of surgeries, there is no difference between the two surgical options.

Management of Infected Non-union Following Femoral Shaft Fracture in a Patient with Klippel-Trenaunay Syndrome: A Case Report

Introduction

The etiology of Klippel-Trenaunay syndrome (KTS) has a significant impact on the management of patient requiring surgical interventions. We report the strategies employed to address an infected non-union in a patient with KTS.

Case Report

The patient was transported to an initial treating hospital with femoral shaft fracture after experiencing a fall. The patient was diagnosed with KTS due to vascular malformations identified after severe intraoperative hemorrhaging. An open reduction and internal fixation was performed to stabilize the bone. Nine months after surgery, the patient was transferred to our hospital due to lack of healing with infected non-union. We prioritized treating the infection and plate displacement, and subsequently performed intramedullary nailing. Infection and intraoperative hemorrhaging were successfully controlled and bone union was confirmed 6 months after surgery.

Conclusion

The key factors to minimize procedural complications are sufficient preoperative evaluation and planning, surgical skill, and perioperative resource management.

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.

Intramedullary nail holes laser indicator, a non-invasive technique for interlocking of intramedullary nails

Interlocking of intramedullary nails is a challenging procedure in orthopedic trauma surgery. Numerous methods have been described to facilitate this process. But they are exposed patient and surgical team to X-rays or involves trial and error. An accurate and non-invasive method has been provided to easily interlocking intramedullary nails. By transferring a safe visible light inside the nail, a drilling position appears which use to drilling bone toward the nail hole. The wavelength of this light was obtained from ex-vivo spectroscopy on biological tissues which has optimal transmission, reflectance, and absorption properties. Moreover, animal and human experiments were performed to evaluate performance of the proposed system. Ex-vivo performance experiments were performed successfully on two groups of cow and sheep samples. Output parameters were procedure time and drilling quality which there were significant differences between the two groups in procedure time (P < 0.05). But no significant differences were observed in drilling quality (P > 0.05). Moreover, an In-vivo performance experiment was performed successfully on a middle-aged man. To compare the provided method, targeting-arm, and free-hand techniques, two human experiments were performed on a middle-aged and a young man. The results indicate the advantage of the proposed technique in the procedure time (P < 0.05), while the drilling quality is equal to the free-hand technique (P = 0.05). Intramedullary nail holes laser indicator is a safe and accurate method that reduced surgical time and simplifies the process. This new technology makes it easier to interlocking the intramedullary nail which can have good clinical applications.

A novel closed reduction technique for treating femoral shaft fractures with intramedullary nails, haemostatic forceps and the lever principle

Background

Faster, easier, more economical and more effective versions of the minimally invasive reduction procedure for femoral shaft fractures need to be developed for use by orthopaedic surgeons. In this study, a fracture table was used to restore limb length, and long, curved haemostatic forceps and the lever principle were utilized to achieve minimally invasive reduction and intramedullary nail fixation of femoral shaft fractures.

Methods

A retrospective analysis involving 20 patients with femoral shaft fractures reduced with a fracture table; long, curved haemostatic forceps; and the lever principle was conducted. The operative effect was evaluated on the basis of the operative time, reduction time, fluoroscopy time, and intraoperative blood loss.

Results

All 20 cases were reduced in a closed fashion, and no conversions to open reduction were needed. The average operative time and fracture reduction time for all patients were 69.1 ± 13.5 min (range, 50–100 min) and 6.7 ± 1.9 min (range, 3–10 min), respectively. The fluoroscopy exposure time during the reduction process was 5–15 s, with an average time of 8.7 ± 2.7 s. The average intraoperative blood loss was 73.5 ± 22.5 mL (range, 50–150 mL). The patients exhibited excellent alignment in the injured limb after intramedullary nailing. Seventeen patients successfully completed a follow-up after fracture healing. The healing time ranged from 4 to 6 months.

Conclusions

Displaced femoral shaft fractures in adults can be treated by a labour-saving lever technique involving fragments, 2 haemostatic forceps and soft tissue envelope-assisted closed reduction and intramedullary nail fixation. This technique is easy to perform; reduces blood loss, the fluoroscopy time and the surgical time for intraoperative reduction; and leads to excellent fracture healing.

Biomechanical evaluation of retrograde docking nailing to a total hip arthroplasty stem in a periprosthetic femur fracture model

INTRODUCTION

Slotted nails allow a connection to a total hip arthroplasty (THA) stem and act as intramedullary load carrier. This study compares construct stiffness, cycles to failure and failure load between a retrograde slotted femur nail construct docked to a THA stem and a lateral locking plate in a human periprosthetic femur fracture model.

MATERIALS AND METHODS

In seven pairs of fresh-frozen human anatomic femora with cemented THA, a transverse osteotomy was set simulating a Vancouver type B1 fracture. The femora were instrumented pairwise with either a retrograde slotted nail coupled to the prosthesis stem, or a locking plate plus a locking attachment plate. Four-point mediolateral bending, torsional and axial bending construct stiffness was investigated via non-destructive tests. Cyclic testing under progressively increasing physiologic loading was performed at 2 Hz until catastrophic construct failure.

RESULTS

Mediolateral bending stiffness did not differ significantly between the two groups (P=0.17) but exhibited a biphasic profile with significantly increased stiffness in both groups (P<0.01). Nail constructs provided a significantly lower torsional stiffness (0.49 ± 0.66 Nm/°) than plate constructs (1.70 ± 0.86 Nm/°), P=0.03. Axial bending stiffness did not differ significantly between the groups (Nail: 605 ± 511 N/mm; Plate: 381 ± 428 N/mm), P=0.61. Cycles to failure and failure load were significantly higher for the plate constructs (25'700 ± 8'341; 3'070 ± 1334 N) compared with the nail constructs (20'729 ± 7'949; 2'573 ± 1295 N), P=0.04.

CONCLUSION

The docking nail construct provides an intramedullary fixation with connection to the prosthesis stem; however, it is biomechanically weaker in stable fractures compared to the plate construct.