Alternatives in the treatment of ipsilateral fractures of the hip and femur

Eight cases of ipsilateral femoral neck and shaft fractures were reviewed. The diagnosis of the femoral neck fracture was delayed in two cases. Seven of the femoral shaft fractures were comminuted. In six cases, both fractures were treated with rigid internal fixation. A combination of traction and internal fixation was used in two cases. Two cases of avascular necrosis of the femoral head were observed. The fracture reduction was insufficient in both cases and the diagnosis of femoral neck fracture was delayed in one case. A radiograph of the pelvis is mandatory in high-velocity trauma victims. Ipsilateral fractures of the femoral neck and shaft should be stabilized by internal fixation as early as possible. Intramedullary locked nailing seems to be an attractive alternative in the treatment of the comminuted femoral shaft fracture.     

Ipsilateral fractures of the femoral neck and shaft.

Thirty-three patients with ipsilateral intracapsular femoral neck and shaft fractures were treated with antegrade reamed intramedullary (IM) nails and cancellous screw fixation of the femoral neck. The shaft fractures were fixed prior to definitive neck stabilization. A "reversed" nail construct was used in 13 patients, a conventional interlocked nail was used in 6, and a reconstruction nail was used in the remaining 14. Thirty-one (94%) of the femoral shaft fractures healed primarily. In two patients, the shaft fracture failed to unite and was bone grafted and plated, respectively; the fractures subsequently healed. However, only 27 (82%) of the femoral neck fractures healed after initial fixation. In six patients (18%), a symptomatic varus nonunion developed, requiring a valgus osteotomy. Five of the six femoral neck non-unions and all of the osteotomy sites united; however, two of these patients later developed osteonecrosis of their femoral heads. Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of high rates of varus nonunion of the femoral neck fracture.     

Ipsilateral fractures of femoral neck and shaft

Thirteen cases of ipsilateral intracapsular femoral neck and shaft fractures were seen. All cases occurred in young adults, with the mechanism of injury in all instances being high-energy trauma. The diagnosis of the femoral neck fracture was missed initially in four cases. The patients were divided into four groups according to treatment protocol: group 1 (two cases), both fractures treated nonoperatively; group 2 (four cases), femoral neck fracture treated nonoperatively, open reduction and internal fixation of femoral shaft fracture; group 3 (three cases), McMurray's osteotomy for femoral neck fracture and internal fixation for the femoral shaft fracture; and group 4 (four cases), open reduction and internal fixation of both fractures. The follow-up period ranged from 6 months to 10.1 years. There was a nonunion of one femoral neck fracture, while all shaft fractures united. The best results were seen in group 4 cases. It is also recommended that routine high-quality X-ray films of the hip should be done in all cases of femoral shaft fracture to decrease the high incidence of missed femoral neck fractures in ipsilateral injuries of the femur.     

Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures

A retrospective study of the management of 23 cases of ipsilateral hip and femoral shaft fractures, between January 1998 and December 2001, is presented. All except two cases were managed by a single implant, i.e. reconstruction nail. There was delayed diagnosis of femoral neck fracture in two cases where the "miss a nail" technique was used for fixation of the femoral neck fracture. All patients managed by reconstruction nail were simultaneously operated on for both fractures and operative treatment was executed as early as the general condition of the patient permitted. Delay in treatment was generally because of the associated injuries (head, chest or abdominal). There were 22 males and 1 female patient with an average age of 34.5 years. Average follow-up was 30.9 months. There was one case of non-union of the femoral neck fracture, one case of avascular necrosis and one femoral neck fracture united in varus. There were four cases of non-union and six cases of delayed union of femoral shaft fractures. Mean time for union of the femoral neck fracture was 15 weeks and for the shaft fracture was 22 weeks. In this series femoral shaft fracture determined the total union period. Complications involving the femoral shaft fracture were more common than those related to femoral neck fractures. Shaft complications were more manageable with or without secondary procedures as compared to femoral neck complications, which usually require more extensive procedures. This stresses the need to realise the significance and seriousness of both components of this complex injury, in evaluation, management and post-operative care. We conclude that, though technically demanding, reconstruction nail is an acceptable alternative for management of concomitant fractures of the femoral neck and shaft with acceptable rates of complications and good results.     

股骨重建钉治疗股骨干合并同侧髋部骨折适应证探讨

目的探讨股骨重建钉治疗股骨干合并同侧髋部骨折的手术适应证。方法根据入选标准和排除标准,回顾2001年1月至2011年1月收治的股骨干合并同侧髋部骨折病例15例,其中男14例,女1例;年龄21~64岁,平均35.5岁。通过比较术前、术后即刻、术后1、3、6和12个月的临床和影像学随访结果,评估骨折愈合情况和并发症,分析股骨重建钉治疗股骨干合并同侧髋部骨折的最佳适应证。结果全部病例获得随访,随访时间14~48个月,平均27.8个月。13例股骨干骨折一期获得骨性愈合,愈合时间(6.2±4.1)个月,14例股骨颈骨折一期获得骨性愈合,愈合时间(5.4±2.9)个月。合并症:1例股骨远端骨折由于狭部限制,重建钉过细,局部旋转不稳定,并发肥大性骨不连;1例股骨中段骨折延迟愈合;2例股骨干旋转畸形愈合;1例股骨颈头下型骨折不愈合。末次随访时进行Friedman-Wyman评定,优12例,良2例,差1例,优良率93.3%。结论股骨重建钉适用于绝大部分股骨干骨折合并髋部骨折,尤其是股骨颈基底部骨折合并股骨干近端或狭部骨折。但对于股骨颈头下型、难复位的股骨颈骨折合并股骨干远端骨折,股骨重建钉并非最佳的治疗方案。     

Management von Kombinationsfrakturen des Femurschafts und des proximalen Femurs

Purpose

The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts.

Material and methods

In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study.

Results

Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated.

Conclusion

Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.     

Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures

Introduction Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures. Materials and methods Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture. Results The average time for union of femoral shaft fractures was 27.3 (14–60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8–12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman–Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty. Conclusion Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.This study was conducted at Kyungpook National University Hospital, Daegu, South Korea. The authors have and will not receive any financial benefit in association with the present paper.     

Initial experience with a second generation locking femoral nail: the Russell-Taylor reconstruction nail

A series of 36 patients with 20 subtrochanteric fractures, 12 ipsilateral neck/shaft fractures, and five intertrochanteric fractures with shaft extension underwent closed intramedullary nailing with the Russell-Taylor reconstruction (RECON) nail. The average Injury Severity Score was 16, and seven of the fractures were open. All fractures were acute injuries, and all but one were treated within 24 hours of admission. Follow-up was obtained at three, six, nine, 12, and 24 months or until the fracture healed. The range of follow-up was one to three years. Complete follow-up was obtained in 33 of 36 patients. Union was achieved in all acute fractures. Shortening occurred in two cases and chondrolysis and avascular necrosis occurred in another patient. Excellent hip and knee range of motion were obtained except in a few cases of ipsilateral limb injuries. While many complex femoral shaft fractures can be treated successfully with first generation locking nails, this study demonstrates that second generation locking nails, such as the RECON nail, offer the added strength and design features necessary for more effective treatment of complex proximal and ipsilateral femoral neck/shaft fractures.     

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.     

股骨干骨折合并同侧隐性股骨颈骨折的诊治分析

目的探讨对股骨干骨折合并同侧隐性股骨颈骨折的诊治方法。方法1998年3月至2003年10月我院共收治股骨干合并同侧隐性股骨颈骨折9例。回顾性分析这9例患者的临床资料。9例患者术前CT诊断隐性股骨颈骨折3例,术中诊断5例,术后CT发现合并股骨颈骨折1例。其中5例采用股骨重建髓内针同时固定股骨干和股骨颈骨折;3例患者股骨干采用逆行髓内针固定而股骨颈采用空心钉固定;另1例在顺行完成股骨干固定后用2枚空心钉固定股骨颈。结果所有患者均获得随访,随访时间6～36个月,平均20个月。全部股骨干骨折均在术后6个月内愈合,股骨颈骨折在3个月内愈合。结论股骨干骨折合并同侧隐性股骨颈骨折早期漏诊率高,临床医生通过对患者的受伤机制分析,对高能量损伤患者应考虑隐性股骨颈骨折的可能,术前可用CT获得诊断,行股骨干骨折带锁髓内针时术中和术后密切注意股骨颈骨折是否存在,从而减少股骨颈骨折的漏诊率。采用髓内针固定可获得满意疗效。     

The treatment of nonunions following intramedullary nailing of femoral shaft fractures

OBJECTIVE: To assess the effectiveness of different surgical options in the treatment of nonunion of a femoral shaft fracture after initial intramedullary nailing. DESIGN: Retrospective. SETTING: University hospital. PATIENTS AND METHODS: During a seven-year period a total of 278 skeletally mature patients with 280 fresh femoral shaft fractures were treated by intramedullary nailing. Of these patients, a subgroup of consecutive patients with nonunion of the fracture were subjected to a detailed analysis and were followed until the fracture was united (mean thirty-three months). Injury mechanism, fracture pattern using various established classifications, any possible concomitant injuries, complications, and subsequent surgical interventions were recorded. RESULTS: Of the total of 280 fractures, nonunion was observed in thirty-four patients with thirty-five fractures (12.5 percent). To achieve solid union, one reoperation was sufficient in twenty-five fractures, six fractures had to be operated on twice, and four needed three operations. There were five patients with autogenous bone grafting alone, and all five required a further reoperation for the nonunion. After a dynamization procedure, four of seventeen patients required a further reoperation. After eight exchange nailing procedures, further surgery for nonunion was necessary in only one case. Solid union was achieved within six months after the final successful reoperation. A marked shortening of the femur developed as a local complication in six cases, four of which had undergone dynamization as final treatment before solid union. CONCLUSIONS: Exchange nailing without extracortical bone grafting seems to be the most effective method to treat a disturbed union of a femoral shaft fracture after intramedullary nailing. Autogenous extracortical bone grafting alone proved to be insufficient. Dynamization predisposed to shortening of the bone.     

Treatment of ipsilateral hip and femoral shaft fractures with reconstructive intramedullary interlocking nail

Objective: To evaluate the results of reconstructive intramedullary interlocking nail in the treatment of ipsllateral hip and femoral shaft fractures. Methods: From August 1997 to November 2001, 13 patients were treated with the reconstructive intramedullary interlocking nail. Nine patients were associated with ipsllateral femoral neck fractures, three with ipsilateral intertrochanteric fractures, and one with subtrochanteric fracture. Results: The follow-up time was from 6 to 38 months with an average of 14 months. All the femoral shaft and hip fractures healed up well. There was no nonunion of the femoral neck, and only one varns malunion. No patient had avascular necrosis of the femoral head. The average healing time for femoral neck fracture was 4.6 months and for shaft fracture 5.8 months. The joint movement and other functions were fairly resumed. Conclusions: The reconstructive intramedullary interlocking nail, with less trauma, refiable fixation, and high rate of fracture healing, is an ideal method of choice in the treatment of ipsilateral hip and femoral shaft fractures.     

Hoffa fracture associated with ipsilateral femoral shaft fracture: clinical feature and treatment

Hoffa fracture associated with ipsilateral femoral shaft fracture is very rare.Three cases of this rare type of injury were retrospectively reviewed.The sites of femoral shaft fractures and Hoffa fractures were documented.All femoral shaft fractures were managed with internal fixation.The rate of misdiagnosis for the Hoffa fractures was documented.Functions of the affected knees were evaluated according to the modified Hospital for Special Surgery (HSS) scores at two years follow-up.Femoral fractures were either transverse or composite in all three cases.Ipsilateral Hoffa fractures occurred at medial condyle in two cases,and lateral condyle in one case.Only one Hoffa fracture was identified preoperatively.All the femoral shaft fractures healed uneventfully.In the patient whose Hoffa fracture was correctly diagnosed,the modified HSS score was 94.In another patient,whose Hoffa fracture was treated by a second operation,the modified HSS score was 93.And in the third case,who refused additional operation for the Hoffa fracture,the modified HSS score was only 70.Conclusively femoral shaft fracture can be associated with ipsilateral Hoffa fracture,especially in motorcycle accident.This type of injury is very rare and misdiagnosis is common.     

A preliminary experience with the Russell-Taylor reconstruction nail for complex femoral fractures.

Eleven cases of complex femoral fractures were seen from November 1987 to November 1989; five ipsilateral femoral neck and shaft fractures and six comminuted subtrochanteric fractures. High-energy accidents accounted for most of these injuries. There were numerous associated injuries, many requiring operative procedures. All of the fractures were treated with Russell-Taylor reconstruction nails. All fractures united, but there were two delayed unions. There was no delay in diagnosis of the femoral neck fractures, and all healed without avascular necrosis. Malalignment occurred in one case, shortening of the femur occurred in two cases, and in two cases only one screw could be placed in the femoral head. In three patients technical errors related to nail insertion led to fracture complications. The use of the Russell-Taylor reconstruction nail is technically demanding. However, we conclude that in complex femoral fractures, this device offers superior stabilization over other currently used methods of internal fixation.     

Treatment of ipsilateral femoral neck and shaft fractures

Objective：To investigate the clinical characteristics, treatment options and causes of misdiagnosis of ipsilateral femoral neck and shaft fractures.
Methods： Among 20 patients with ipsilateral femoral neck and shaft fractures, 19 were treated operatively and 1 was treated conservatively. Sixteen cases of femoral shaft fractures were treated by open reduction and internal fixation with compressive plate, and 2 cases were treated with interlocking intramedullary nailing. Eighteen femoral neck fractures were treated with cannulated screws. Another patient was treated with proximal femoral nail to fix both the neck and shaft. Delayed diagnosis for femoral neck frac-tures occurred in 2 cases preoperatively. Results： A total of 19 patients were followed up. The follow up period ranged from 5 to 48 months with an average of 15 months. All the fractures were healed.
Conclusion： For case of femoral shaft fracture caused by high energy injury, an AP pelvic film should be routinely taken. Once the femoral neck fracture is recognized, operative reduction and fixation should be performed in time. Femoral neck and shaft fractures should be fixed separately.     

Long proximal femoral nail in ipsilateral fractures proximal femur and shaft of femur

Background:

Ipsilateral fractures of the proximal femur and femoral shaft are extremely uncommon injuries which occur in young adults who sustain a high energy trauma. A variety of management modalities have been tried to treat this complex fracture pattern ranging from conservative approach to recently introduced reconstruction nails. All these approaches have their own difficulties. We studied the outcome of long proximal femoral nail (LPFN) in the management of concomitant ipsilateral fracture of the proximal femur and femoral shaft.

Materials and Methods:

We analysed the prospective data of 36 consecutive patients who had sustained a high energy trauma (30 closed fractures and 6 open shaft fractures) who had concomitant ipsilateral fractures of the femoral shaft associated with proximal femur fractures treated with LPFN between December 2005 and December 2011. The mean age was 39 years (range 28-64 years). Twenty nine males and seven females were enrolled for this study.

Results:

The patients were followed up at three, six, twelve, and eighteen months. The mean healing time for the neck fractures was 4.8 months and for the shaft fractures was 6.2 months. The greater trochanter was splintered and widened in two cases which eventually consolidated. Two patients had superficial infection, two patients had lateral migration of the screws with coxa vara which was due to severe osteoporosis detected during the followup. We had two cases of nonunion of shaft fracture and one case of nonunion of neck fracture. Two cases of avascular necrosis of femoral head were detected after 2 years of followup. No cases of implant failure were noted. Limb shortening of less than 2 cms was noted in four of our patients. The functional assessment system of Friedman and Wyman was used for evaluating the results. In our series 59.9% (n = 23) were rated as good, 30.6% (n = 11) as fair, and 5.5% (n = 2) as poor.

Conclusion:

Long PFN is a reliable option for concomitant ipsilateral diaphyseal and proximal femur fractures.     

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。     

The treatment of femoral fractures by cast-brace and early walking: a review of seventy-nine patients.

Seventy-nine cases of fracture of the femoral shaft treated by cast-brace and early walking have been reviewed. Discrepancy in femoral length was assessed by scanogram. The cases were analysed to relate the incidence of shortening greater than 2 centimetres to the type and site of the fracture, and the time which elapsed from injury until the cast-brace was applied. Such shortening was encountered most frequently when the cast-brace was applied within the first two weeks from injury or after six weeks and in those patients with comminuted fractures of the middle third of the femoral shaft.     

Distal locking of femoral nails under direct vision through a cortical window

We present a salvage technique for distal femoral interlocking under direct vision through a window in the anterior femoral cortex in a subgroup of six patients, among those presented to our institution during the last 10 years with a femoral shaft fracture treated with reamed, locked intramedullary nailing. The common characteristic of these patients was the performance of distal locking under direct vision through a small window in the anterior femoral cortex because of intraoperative dysfunction of the image intensifier. Screw insertion was successful in all cases. All fractures and all cortical windows healed uneventfully. No postoperative fractures occurred through the cortical defect. This technique, despite being a salvage one, has proven a safe alternative to the common distal targeting techniques. It can be used when an image intensifier is unavailable without jeopardizing the excellent clinical and radiographic outcome of reamed locked nailing of femoral shaft fractures.     

Ipsilateral fractures of the femoral neck and shaft

Ipsilateral femoral shaft and neck fractures are difficult to treat. From 1989 to 1998, we treated 18 patients with these complex fractures. There were 14 male and 4 female with an average age of 40 years. Most resulted from high-energy trauma. The average follow-up period is 41 months. All but one of the fractures united well. The mean time to union is 5.2+/-2.3 months in the diaphysis and 4.16+/-2 months in the neck. No cases of the femoral neck fracture or osteonecrosis of the femoral head were observed during the follow-up period. Fourteen cases were treated with a standard protocol of plates for diaphyseal fractures and lag screws or dynamic hip screws (DHS) fixations for the femoral neck fractures. There were 13 good and 1 fair functional results. Two neglected neck fractures were treated with interlocking nailing for diaphyseal fracture with fair results. We conclude that a plate on the shaft and sliding hip screws or separate screws in the hip is a reliable method for ipsilateral femoral neck and shaft fractures.