Operative management of ipsilateral fractures of the hip and femur

Thirteen patients with ipsilateral hip and femoral shaft fractures are discussed. In nine patients, the femoral shaft fracture was managed by a combination of dynamic compression plating with a medial cancellous bone graft and either multiple cancellous screws or a dynamic hip screw for the proximal fracture (Group I). Four patients had Ender pin fixation (Group II). In Group I, both fractures were united within 16 weeks in all patients, and at least 90% of normal hip and knee motion was regained. Nonunions developed in two of the four Group II patients. Immediate separate fixation of ipsilateral hip and femoral shaft fractures allows definitive management of the proximal fracture and immediate mobilization without external support and provides satisfactory results with a low complication rate.     

两种手术方法治疗股骨干合并同侧股骨颈骨折的疗效比较

目的 比较股骨重建钉与逆行髓内钉加空心钉治疗股骨于合并同侧股骨颈骨折的疗效,探讨各自的手术适应证.方法 回顾性分析2001年1月至2010年5月收治的21例股骨干合并同侧股骨颈骨折患者资料,采用股骨重建钉固定10例(股骨重建钉组),逆行髓内钉加空心钉固定11例(逆行髓内钉加空心钉组).两组患者术前一般资料差异均无统计学意义(P＞0.05),具有可比性.术后1、3、6、9、12个月及以后每年随访1次,通过临床和影像学评估骨折愈合情况和并发症的发生情况.结果 21例患者术后获12 ～48个月(平均27.1个月)随访.两组患者在手术时间、术中出血量、术后引流量、住院时间、股骨干骨折愈合时间、股骨颈骨折愈合时间及Friedman-Wyman功能评定结果等方面差异均无统计学意义(P＞0.05).股骨重建钉组住院费用高于逆行髓内钉加空心钉组,差异有统计学意义(t=16.710,P=0.016).两组股骨干骨折愈合率(9/10 vs.10/11)、股骨颈骨折愈合率(9/10 vs.11/11)差异均无统计学意义(P＞0.05).股骨重建钉组4例发生并发症,逆行髓内钉组7例发生并发症.结论 股骨干合并同侧股骨颈骨折的治疗应采取个体化原则.股骨重建钉更适用于股骨颈基底部骨折合并狭部及狭部以近的股骨干骨折;对于头下型、难复位的股骨颈骨折合并同侧股骨干远端骨折或需要同时处理的膝关节内损伤、关节周围骨折的患者,逆行髓内钉加空心钉更为理想.     

Open intramedullary nailing of neglected femoral shaft fractures: indications and outcome

The management of neglected femoral shaft fractures poses a challenge to the orthopaedic surgeon. We evaluated the outcome of open intramedullary nailing of neglected femoral shaft fractures at our centre. A total of 52 patients with 55 femoral shaft fractures, with a mean age of 39.6 years, were studied. The mean interval from injury to presentation was 24 weeks (range = 4-156). Mean time to achieve fracture union was 20 weeks (range: 14-48). The time to fracture union and weight bearing had a positive correlation with the time interval between injury and fracture fixation, development of deep wound infection and osteomyelitis. There is a need to make orthopaedic and trauma care accessible to underserved communities to avoid the adverse outcome of neglected fractures.     

Reconstruction of distal tibia fractures using a posterolateral approach and a blade plate

OBJECTIVE: The aim of this article is to report a technique for the management of distal tibia fractures with significant anteromedial soft-tissue injury. The patients were initially treated with a spanning external fixator, open reduction and internal fixation (ORIF) of the fibula at the discretion of the surgeon, and soft-tissue management or flap coverage. ORIF of the tibia was performed on a staged basis, using a 90-degree cannulated blade plate and autogenous iliac crest bone graft through a posterolateral approach. DESIGN: Retrospective analysis of a consecutive series of patients. SETTING: Two academic level-1 trauma centers. PATIENTS: Fifteen patients with 15 distal tibia fractures (13 open fractures), Orthopedic Trauma Association (OTA) type 43A3 and 43C1, were definitively treated and followed to union between July 2000 and July 2004. Five patients were referred from outside sources after initial stabilization. INTERVENTION: Initial stabilization in an external fixator and management of the open fracture and soft tissue. Staged ORIF of the tibia with bone graft was performed through a posterolateral approach when the soft tissues allowed. OUTCOME MEASUREMENTS: Radiographic union, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and complications. RESULTS: All 15 fractures were followed to union. Average time to union was 20 (12 to 47) weeks from the time of fixation with blade plate and bone grafting. (AOFAS) ankle-hindfoot score was used to measure outcome. The average score was 81 (60 to 97) out of a possible 100. There were no deep infections. There was one nonunion; the fracture united after revision with a locked plate and bone graft. The average length of follow-up was 14 months (4 to 37). CONCLUSIONS: The staged treatment of high-energy distal tibia fractures with soft-tissue injury can lead to good outcomes and consistent bone union. Our results were obtained by the combination of the posterolateral approach, careful soft-tissue management, and stable internal fixation.     

弹性髓内钉固定与外固定支架治疗儿童股骨干骨折疗效比较

目的：比较弹性髓内针与外固定支架治疗儿童股骨干骨折的疗效。方法：2002年9月至2008年8月治疗儿童股骨干骨折共67例,使用弹性髓内针治疗儿童股骨干骨折36例,男23例,女13例,年龄5～11岁,平均（7.1±1.6）岁;外固定支架治疗31例,男19例,女12例,年龄3～12岁,平均（6.5±2.3）岁。所有病例均为闭合复位,对两种不同内固定术后骨折愈合时间、术后并发症进行比较分析。结果：全部病例均获随访,时间9～24个月,平均（12±3）个月。弹性随内针组治疗小儿股骨骨折在骨折临床愈合时间和骨性愈合时间均短于外固定支架组（P〈0.05）。外固定支架组,继发钉道感染5例,骨折延迟愈合3例,再骨折2例,螺钉断裂1例;弹性髓内针组钉尾激惹3例。结论：弹性髓内针治疗儿童股骨干骨折有很大优势,而对高能量骨折及多发伤的病例外固定支架则不失为一种良好的选择,股骨近端和远端骨折尽量避免使用弹性髓内针固定。     

A comparison of intramedullary nailing and plate-screw fixation in the treatment for ipsilateral fracture of the hip and femoral shaft

We compared the outcomes of intramedullary nailing with plate-screw fixation in the treatment for ipsilateral fracture of the hip and femoral shaft. A retrospective study. Level 1 Trauma. Forty-one patients (32 males and 9 females; mean age, 34 years; age range, 21–53) with ipsilateral hip and femoral shaft fractures were treated between 1995 and 2005. Eighteen patients were injured in motor vehicle accidents, and 23 fell from a height. All patients were treated by one of the two methods of internal fixation: a screw-plate fixation (n = 24, Group I) or intramedullary nailing (n = 17, Group II). The fracture union time, nonunion, delayed union, implant failure, need of further surgeries, and functional outcomes were investigated and compared. Fisher’s exact test showed that Group I had a significantly higher frequency of nonunion than that of Group II (P = 0.029). Although Group I had more nonunions, delayed unions, and revision operations than Group II, the total union time was similar for both groups. Intramedullary nailing was found to be superior to screw-plate fixation due to improved functional bearing, increased rate of union, stability, and mechanical solidity. The reconstruction nail method is an acceptable alternative treatment for ipsilateral hip and femoral shaft fractures.     

Intramedullary nailing combined with cerclage wiring in the treatment of fractures of the femoral shaft

One hundred sixty-seven femoral shaft fractures were treated with open intramedullary nailing and cerclage wires. Complications requiring surgical reintervention developed in 11 patients (6.6%). Delayed union or nonunion in five patients (3%), deep infection in four patients (2.4%), or unstable fixation in two patients (1.2%) required one or more additional procedures to achieve union. The time to weight-bearing averaged 32 days in patients with isolated injuries and 62 days in patients with associated injuries. One hundred forty-five patients were followed until fracture union occurred. Rotational malalignment in one patient, angulation of 10 degrees or more in two patients, and limb shortening of more than 2 cm in two patients were noted. Loss of hip or knee motion in excess of 20 degrees developed in 15 patients and was always associated with injuries of the pelvis or ipsilateral lower leg. Intramedullary nailing and cerclage wiring significantly expands the indication for intramedullary fixation of fractures of the femoral shaft.     

Antegrade nailing in femoral shaft fracture patients - comparison of outcomes of isolated fractures,multiple fractures and severely injured patients

Introduction: Femoral shaft fractures in adults are high-energy fractures typically accompanied by additional fractures of the upper and lower extremities and brain, thoracic, or abdominal injuries. Intramedullary nailing enables early ambulation with a few complications, but rates of non-union remain high. Therefore, we aimed to compare bone union after femoral shaft fractures in adults (20–65 years old) depending on the injury severity and presence of multiple fractures.Patients and methods: This study retrospectively examined 178 patients (145 male and 33 female) who underwent intramedullary nailing for a femoral shaft fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 32 type) between January 2014 and December 2018 and were followed up for at least 1 year. Patients who underwent intramedullary nailing after the preliminary application of an external fixator were excluded. Patients were divided into groups with isolated femoral shaft fractures (IS group), an injury severity score of ≤14, and multiple fractures of the extremities and the pelvic bone (at least three locations), including a femoral shaft fracture (MU group), and severely injured (injury severity score ≥15) with femoral shaft fractures (SE group). Non-union rate by group and risk factors related to bone union and bone union rate according to time to full weight bearing were analyzed.Results: In total, 29, 54, and 95 patients were assigned to the IS group, MU group, and SE group, respectively. Non-union was observed in two patients in the IS group (6.9%), six patients in the MU group (11.1%), and 11 patients in the SE group (11.6%). There were no significant differences in the bone union rate, according to multiple fractures (p=0.515) and injury severity score (p=0.561). Additionally, no differences in the bone union rate were observed according to the time to full weight bearing. Depending on open fracture (p=0.004) and fracture severity (p=0.011), the non-union rate showed a difference of up to four times or greater.Conclusions: When intramedullary nailing is performed to treat femoral shaft fractures, multiple fractures and severe trauma do not directly affect bone union. However, it should be noted that open fracture and greater fracture severity lead to higher chances of non-union.     

The use of external fixation devices in the management of severe lower-extremity trauma and pelvic injuries in children

Between 1977 and 1982, 17 pediatric patients ranging in age from six to 14 years were treated for injuries that required the application of a total of 20 external fixation devices. The indications for the use of external fixation devices in children include: open fractures with soft-tissue injury, unstable fractures (diaphyseal, epiphyseal, and intra-articular), "polytrauma" patients, and unstable pelvic fractures. All fractures and soft-tissue injuries healed. The usual reported complications of external fixation devices, such as pin tract infections, delayed union, and refracture, were not encountered.     

Ipsilateral femoral shaft and neck fractures: are cephalomedullary nails appropriate?

A retrospective review was conducted to examine rates of malreduction and nonunion in ipsilateral femoral neck and shaft fractures using different fixation strategies. Twenty-two consecutive patients with 23 fractures were identified. Participants were treated with various fixation strategies for ipsilateral femoral neck and shaft fractures. Cephalomedullary devices were used in 13 cases, while cannulated screws and a retrograde femoral nail were used in nine cases. One patient was treated with cannulated screws and external fixation of the femoral shaft. Radiographic assessment of the quality of reduction and union of both fractures was evaluated. Clinical and radiographic follow-up was available in 20 fractures (87%) with a mean of 12 months (range 3-50). Two femoral neck nonunions occurred; both had fair reductions of the fractures obtained by closed maneuvers, and two-device fixation was used in each. One femoral shaft nonunion occurred in a fracture treated with a cephalomedullary nail. All three united after revision surgery. No cases of osteonecrosis or conversion to hip arthroplasty were noted. A combination of retrograde femoral nailing and screw fixation of the femoral neck or placement of a cephalomedullary nail can provide excellent reduction and rate of union in the treatment of this injury pattern. Excellent reduction of the femoral neck fracture is key to preventing femoral neck nonunion.     

扩髓带锁髓内钉治疗股骨、胫骨干骨折不愈合、延迟愈合

目的　总结使用扩髓带锁髓内钉治疗股骨、胫骨干骨骨折不愈合、延迟愈合的临床经验。方法　回顾自 1999年 4月～2 0 0 1年 6月使用扩髓带锁髓内钉治疗股骨干、胫骨干骨折不愈合、延迟愈合病人 2 1例 ,其中股骨 8例 ,胫骨 13例 ,钢板固定术后 ,股骨 3例 ,胫骨 6例。普通髓内针股骨 5例。外固定架胫骨 2例。石膏固定胫骨 3例 ,骨牵引股骨 2例。均采用有限切口切开复位顺行扩髓 ,静力锁定加植骨术。结果　随访半年以上 18例 ,骨折均愈合 ,临近关节功能达正常。无感染、断钉等并发症。结论　采用有限切口切开复位、扩髓、静力锁定治疗股骨、胫骨干骨折不愈合、延迟愈合 ,具有骨折稳定性可靠、有利于骨折愈合和早期关节活动的优点 ,是治疗股骨、胫骨干骨折不愈合、延迟愈合的有效方法之一。     

小腿严重开放性骨折伴软组织缺损的治疗

目的 探讨小腿严重开放性骨折伴软组织缺损(Gustilo ⅢB型或ⅢC型)的治疗方法.方法 1990年1月至2008年12月,收治开放性胫腓骨骨折53例,其中Gustilo ⅢB型45例,ⅢC型8例.软组织缺损面积为6 cm×4 cm～18 cm×8 cm,8例伴骨缺损.急诊行骨折复位同定和血管修复,二期对软组织或骨缺损采用13种53块组织瓣移位或移植修复.骨折外固定支架固定35例,内固定16例,骨牵引及石膏固定2例.皮瓣或肌皮瓣47例,骨皮瓣6例.结果 51例获得随访,时间8个月～9年(平均18个月).骨折顺利愈合44例,愈合时间3.5～9.5个月,平均6.5个月.骨延迟愈合4例,骨不愈合3例,经手术植骨(5例)或骨外固定支架加压同定治疗(2例)均治愈.组织瓣移植53块,成活51块,坏死2块,成活率为96.2%.无截肢病例.结论 Gustilo ⅢB型或ⅢC型小腿严重开放性骨折,初期清创并采用以骨外支架为主的方法固定骨折,二期采用适当组织瓣移植修复软组织或骨缺损,是安全有效的治疗策略.     

A comparative study of ipsilateral intertrochanteric and femoral shaft fractures treated with long proximal femoral nail antirotation or plate combinations

Objective: To compare the results of long proximal femoral nail antirotation (PFNA‐long) and plate combinations in the treatment of ipsilateral intertrochanteric and femoral shaft fractures. Methods: Between March 2004 and April 2009, 23 patients with ipsilateral intertrochanteric and femoral shaft fractures were treated with PFNA‐long or plate combinations. The patients were divided into two groups. Group I contained 13 patients who were treated with dynamic hip screws (DHS) combined with compression plate fixation. The 10 patients in Group II were treated with PFNA‐long. Results: The average follow‐up was 17.8 and 16.8 months for Groups I and II, respectively. The average union time for intertrochanteric fractures was 17.4 and 16.6 weeks in Groups I and II, respectively, and for femoral shaft fracture 22.2 and 21.5 weeks, respectively. There were nine good, two fair, and two poor functional results in Group I, and eight good, one fair, and one poor in Group II. There was nonunion of two femoral shaft fractures in Group I and one in Group II. There were no significant differences between the two groups in functional outcomes or major complications. Conclusion: Both treatment methods achieve satisfactory functional outcomes in patients with ipsilateral intertrochanteric and femoral shaft fractures. PFNA‐long is the better choice for the treatment of complex fractures, having the advantages of minimal exposure, reduced perioperative blood loss, and achievement of biological fixation of both fractures with a single implant.     

Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients

BACKGROUND: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. METHODS: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). CONCLUSIONS: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.     

Intramedullary nailing of femoral shaft fractures. Part II: Fracture-healing with static interlocking fixation

A consecutive, prospective series of ninety-seven patients who had 100 fractures of the femoral shaft that were treated with static interlocking nailing was analyzed to determine the incidence of union of the fracture without planned conversion from static to dynamic intramedullary fixation as a technique to stimulate healing of the fracture. Eighty-four patients (eighty-seven fractures) were studied through union of the fracture (average follow-up, fourteen months). Eighty-five (98 per cent) of the eighty-seven fractures healed with static interlocking fixation. Two patients needed conversion from static to dynamic interlocking fixation because of inadequate fracture-healing; both progressed to uneventful union. The time to full weight-bearing (average, eleven weeks) was individualized for each patient and depended on the cortical contact of the major fragments, the presence of bridging callus as seen on radiographs, and the extent of other injuries of the ipsilateral lower extremity. No deformation or failure of the static interlocking device developed after early walking with weight-bearing, but fatigue failure of one nail occurred in a non-ambulatory patient who had an intracranial injury. Pain related to soft-tissue irritation by the prominent heads of the interlocking screws, clinically presenting as bursitis or snapping of the iliotibial band, was severe enough in six patients to necessitate removal of either the proximal or the distal screw after union of the fracture. We concluded that static interlocking of intramedullary nails in femoral shaft fractures does not appreciably inhibit the process of healing of the fracture, and that routine conversion to dynamic intramedullary fixation, although occasionally necessary, need not be performed.     

Evaluation of pediatric lower extremity fractures managed with external fixation: outcomes in a deployed environment

External fixation of pediatric lower extremity fractures is usually reserved for severe, open fractures in polytraumatized patients, but it is often the only available treatment option for deployed military surgeons. We analyzed the outcomes and complications of 17 consecutive pediatric long bone fractures treated with external fixation at a Forward Surgical Team facility in an austere environment during Operation Enduring Freedom in Afghanistan during a 12-month period. Treatment consisted of uniplanar external fixation for 12 femoral shaft fractures (11 closed), 4 tibial shaft fractures (all open), and 1 subtrochanteric fracture (closed) in 14 males and 3 females with an average age of 7.4 years. All 17 fractures went on to union with no incidences of refracture. Complications included 1 broken pin and 3 pin site infections treated with wound care and oral antibiotics. In a deployed environment, external fixation is the treatment method of choice for lower extremity fractures by virtue of patient, environment, equipment, and mission factors. This case series validates the usage of a simple, uniplanar external fixator for a variety of open and closed pediatric long bone fractures as evidenced by the successful union rate and low number of complications.     

Treatment of open tibial fracture with fixateur externe

External fixation with a Hoffmann or an ASIF frame was used in the treatment of 50 severe open lower leg fractures from 1979 to 1987. In 7 cases consolidation was achieved by means of external fixation without changing to any other method. Plaster cast fixation was subsequently performed after soft-tissue healing in 35 patients. Further methods of treatment applied after external fixation were intramedullary nailing in 5 cases, internal stabilization with a plate in 1 case and provision of a surgical support in 1 case. In 1 patient early amputation was necessary. On average, fracture healing took 6.7 (4-15) months, significantly correlating with the severity of soft-tissue lesion. Compound fractures of the proximal tibial shaft turned out to be problem cases, requiring up to 15 months for bone union. Acute infections occurred in 6 cases (12%), despite primary antibiotic prophylaxis. Nonunion was noted in 2 patients. A follow-up examination of 33 patients after a median of 45 months (range 6-99) showed full weight-bearing in all cases. Persistent soft-tissue problems were found in 7 patients, chronic osteitis in 4, and shortening of the extremity by up to 2 cm in 11 cases. One-third of the patients were out of work or had had to change their jobs as a social effect of their severe injuries.     

Experience in the use of the long Gamma nail for 16 femoral shaft fracture that have occurred following initial Asian Pacific Gamma nail fixation for pertrochanteric fractures

From January 1993 to September 2002, 931 patients suffered from intertrochanteric fracture and subrochanteric fracture received open reduction and internal fixation with APGN in our institute. Among these patients, 16 patients (1.7%) developed a femoral shaft fracture after the initial fixation with APGN. Removal of the APGN, closed reduction and fixation with long Gamma nail (LGN) was performed in all the 16 patients. The patients were followed for 12-60 months (average, 39.8 months). The union time of fracture was 12-24 weeks (average, 18.5 weeks) for femoral shaft fractures and 12-20 weeks (average, 16 weeks) for peritrochanteric fractures. Two early complications were noted, including one superficial (6%) infection and one deep (6%) infection. Two malunions (12.5%) developed with no definite functional impairment. The functional results using the Harris hip score were good to excellent. In conclusion, closed reduction and internal fixation with a LGN is very effective in the management of a femoral shaft fracture, a complication of a previous APGN that had been initially used for stabilisation of a pertrochanteric fracture.     

Is external fixation needed for the treatment of tibial fractures with acute compartment syndrome?

Acute compartment syndrome (ACS) after tibial fracture carries a risk of various complications, including infection, delayed union, nonunion, nerve damage, and poor prognosis. For the treatment of fractures with ACS, fasciotomy is conducted, and the method to stabilise the fracture has to be considered. Thirty-five patients who underwent surgery for ACS with tibial shaft fractures were evaluated, and the results of initial internal fixation (Group I, 20 patients) and initial external fixation (Group II, 15 patients) were analysed. The mean age was 41 years. Five patients needed additional surgery for bone union. Complications occurred in 4 cases, but no deep infection was reported. The time to bone union, the need for additional surgery, and the incidence of complications in Group I and Group II were not statistically different. For the treatment of ACS with tibial fracture, immediate internal fixation and changing from external fixation to internal fixation did not affect the clinical course.