Noncontiguous fractures of the femoral neck,femoral shaft,and distal femur

BACKGROUND: Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale. METHODS: This was a retrospective study conducted at a Level I trauma center. RESULTS: Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures. CONCLUSION: This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.     

Ipsilateral hip and distal femoral fractures

We tried to find the trauma mechanism and treatment rationale of ipsilateral concomitant hip and distal femoral fractures involving the articular surface. Between 1988 and 1995, 15 cases of ipsilateral hip (confined to neck or trochanteric areas of the femur) and distal (confined to supra- and intercondylar area of the femur) femoral articular fractures were collected. The hip fractures consisted of 10 trochanteric fractures and five neck fractures, which were managed with reduction and fixation in 14 (Knowles' pin in eight, DHS in four and standard Gamma nail in two), and primary bipolar hemiarthroplastry in one. The distal femoral articular fractures were open in 11; these were managed with radical debridement, implantation of Septopal chains and immediate internal fixation, followed by prophylactic autogenous bone grafting 6 weeks later in the recent six cases (five Judet plates, four dynamic condylar screws and two condylar plates). The other four closed distal femoral fractures were managed with early reduction and internal fixation (two Judet plate, one dynamic condylar screw and one condylar plate). The union time was 20.3 (12-48) weeks for proximal fractures and 23.7 (12-36) weeks for distal fractures. Early infection developed in three cases. Nonunion of a femoral neck fracture developed in one case. The other complications were implant failure in one, coxa vara in one, refracture in one, delayed union in one and knee stiffness in one.     

Retention of distal femoral osteotomy fixed with a AO condylar plate and Grosse-Kempf locked nail in relation to bone mineral in cadavers

On the basis of previous studies showing good correlations between the structural strength of the femur and bone mass as assessed by single energy quantitative computed tomography, this study was scheduled to analyze the mode of failure of an oblique osteotomy in the distal femur in geriatric cadavers stabilized by an AO condylar plate and Grosse-Kempf locked intramedullary nail in axial eccentric loads and to relate the mode of failure to bone mineral content. A pilot study of two pairs of osteotomized, internally fixed femora were loaded axially and the loads correlated with bone mineral content. These correlations were used to calculate estimated failure load in 12 pairs of osteotomized femora (12 plated and 12 nailed specimens) which then were sustained to a cyclic eccentric axial load of 50% of the estimated failure load. The failure patterns in the two groups were different. Fixation failure occurred in all specimens in the plated group at the site of the osteotomy, while in the nailed group the fixation failures in 50% of the specimens were unrelated to the site of the osteotomy. The study suggests that locked intramedullary nailing of a distal femoral fracture in osteoporotic bone gives more secure fracture retention than fixation with a 95° AO/ASIF condylar plate. Furthermore, it shows that bone mineral assessment by densitometric methods can be used to predict the mechanical strength of a bone/implant construct.     

Minimally invasive plate fixation in femoral shaft fractures

Bridge-plating with its advantages in terms of vascularity and bone healing is a well established procedure today in the treatment of comminuted femoral fractures. Bridge-plating means that the fracture site is not interfered with during the operative procedure. This paper introduces a surgical technique in which the plate is inserted through isolated proximal and distal incisions only, behind the vastus lateralis. Alignment is secured by the plates, the fracture site remains untouched, fixation and screw insertion is restricted to the proximal and distal main fragments. Longitudinal femoral fractures extending right into the trochanteric and or condylar areas are the main indication for minimally invasive plate fixations with angled blade plates or condylar screws since fractures which are restricted to the diaphyseal area are mostly treated by nailing today. The surgical trauma resulting from plating by proximal and distal incisions only is less than that associated with conventional techniques. Indirect reduction of femoral fragments is much easier since the integrity of the surrounding muscles and soft tissue is preserved, the fragments often being reduced simply by traction. Adjustment of rotation is an essential aspect requiring careful attention. For special indications, namely comminuted fractures affecting a large part of the femur and extending into the trochanteric or condylar areas, insertion of the plate via proximal and distal incisions only is a further development in bridge-plating which minimizes surgical trauma and operation time.     

Retrograde fixation of distal femoral fractures: results using a new nail system

OBJECTIVES: To investigate the management and outcome of distal femur fractures treated with retrograde nailing. DESIGN: Prospective. SETTING: Unfallkrankenhaus Berlin, level I trauma center. PATIENTS: A consecutive series of 47 patients with 48 fractures of the distal femur (37 fractures AO type A and 11 fractures type C) operated on between May 1999 and June 2000. OUTCOME MEASURES: Outcome was assessed by using standard radiographic criteria of time to union, incidence of infection, malunion, and knee function (Leung score). RESULTS: After an average time of 33 months (range 12-37 months), 44 patients were reexamined. Three patients were lost to follow-up. The average age was 44 years (range 17-92 years). Of patients, 19 sustained polytrauma, and 10 had associated soft tissue damage. A total of 34 patients underwent primary definitive osteosynthesis within 12 hours after trauma. All fractures healed after an average of 12.6 weeks (range 9-17 weeks). Seven complications were noted-three related to severity of injury (one deep venous thrombosis, two leg length shortenings of 1.5 cm and 2.5 cm) and four related to the operation (insufficient counterboring of the nail in two patients, one malreduction, one iatrogenic fracture of femur shaft). There was no relevant difference between type A and type C fractures in functional, clinical, or radiographic outcomes. CONCLUSIONS: Retrograde nailing is recommended as an alternative method to plate osteosynthesis in stabilizing distal femoral fractures, particularly in type C fractures.     

Interlocking intramedullary nailing for ipsilateral fractures of the femoral shaft and distal part of the femur.

A review of the data on 684 fractures of the femur that had been treated with intramedullary nailing led to the identification of twenty-three patients who had had a fracture of the shaft of the femur with an accompanying ipsilateral supracondylar fracture (twelve patients, group I) or a concomitant ipsilateral intercondylar fracture (eleven patients, group II). The group-I fractures had been treated with interlocking nailing without supplemental fixation. In group II, ten fractures were stabilized with interlocking nailing and supplemental screw fixation and one, with interlocking nailing and a supplemental plate and screws. The average time to union for all fractures was nineteen weeks (range, twelve to thirty-six weeks), and the average duration of clinical and radiographic follow-up was thirty months (range, nine to fifty-nine months). In group I, alignment of the femur was within 5 degrees of normal in ten of the twelve fractures. In group II, seven intra-articular fractures healed in anatomical alignment, three had slight articular displacement (1.0 to 3.0 millimeters), and one had displacement of more than 3.0 millimeters. The average range of motion of the knee at the most recent follow-up was 0 to 120 degrees in group I and 0 to 115 degrees in group II. Two patients (both in group II) needed a reoperation for a previously unrecognized fracture of a femoral condyle in the coronal plane; post-traumatic arthritis developed in both. No patient in either group had loss of fixation or failure of the implant. We concluded that ipsilateral diaphyseal, supracondylar, and intercondylar fractures of the femur can be adequately stabilized with interlocking nailing and supplemental intercondylar screw fixation. The presence of a fracture in the coronal plane of a femoral condyle (AO type-B3 and type-C3 injuries) is a relative contraindication to the use of this technique.     

Calcaneal plate fixation of distal femoral fractures

Open reduction and internal fixation constitute the standard of care for management of displaced distal femoral condylar fractures. The techniques most commonly used include conventional and locked plating with the primary goal of articular surface congruency. However, a specific implant for the isolated medial femoral condyle fracture is lacking. We report the use of a calcaneal plate as a novel technique for managing medial and lateral femoral condylar fractures.     

Fresh femoral shaft fractures treated with un-reamed intramedullary nail: 203 cases

OBJECTIVE: To discuss the experience treating fresh femoral shaft fractures with un-reamed intramedullary nail. METHODS: 203 cases of fresh femoral shaft fractures who had been treated with un-reamed intramedullary nail from November. 1995 to January. 1999 were analyzed retrospectively. 18 cases were open, classified as Gustilo I, and. 185 cases were closed. Traction table and image intensifier were used during operation. Closed reduction, un-reamed and free hand distal locking technique were used. Active movements of nearby joints were encouraged and partial weight bearing of 10 - 15 kg were allowed right after operation. RESULTS: All 203 cases of fresh femoral shaft fractures got bone union within 4 - 6 months. No case of delayed union and infection happened. 1 distal locking screw was broken. All patients gained normal extremity functions. CONCLUSION: Un-reamed intramedullary nailing of fresh femoral shaft fracture has less damage to the local soft tissue and blood supply. It has a relative stable fracture fixation, and less interruption to the healing procedure. It is one of the best methods for treating femoral fracture.     

Cephalomedullary fixation for femoral neck/intertrochanteric and ipsilateral shaft fractures: surgical tips and pitfalls

Objective:Surgical management options for femoral shaft fracture and ipsilateral proximal femur fracture vary from single-implant to double-implant fixation.Cephalomedullary fixation in such fractures ...     

Multidimensional revision osteotomy of the distal femur using the retrograde femoral nail

We report the case of a 62-year-old woman with marked valgus and limitation of extension of the right knee joint as the result of a supracondylar fracture of the femur, originally treated by internal fixation with a dynamic condylar screw. Two years later, revision osteotomy with retrograde femoral nailing was carried out to achieve variation and improve extension. Within a week of operation the patient's right leg was fully weight bearing with normal axial positioning. A retrograde locking nail provides satisfactory and stable internal fixation in cases of revision.     

Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: a randomized controlled trial

BACKGROUND: A variety of devices have been used in the treatment of supracondylar femoral fractures. The condylar blade plate relies on the principles of open reduction, absolute stability and interfragmentary compression to achieve union. The technique of retrograde nailing uses indirect reduction of the metaphyseal fracture component, offering relative stability and a less invasive approach. Randomized comparison of these common methods of fixation has not been reported. METHODS: Twenty-two patients with 23 supracondylar femur fractures were recruited from two regional trauma centres over a 26-month period and randomized to receive either a retrograde intramedullary nail fixation (IM group, 12 fractures) or a fixed-angle blade plate fixation (BP group, 11 fractures). The groups were followed for 12-36 months. The primary outcome measures were revision surgery and general health. RESULTS: Three patients in the IM group required revision surgery for the removal of implant components. No reoperations occurred in the BP group. There was a trend towards greater pain in the IM group, although there was no statistically significant difference in the scores for any of the SF-36 domains. CONCLUSION: Both distal femoral nailing and blade plating give good outcomes. There is a trend for patients undergoing retrograde nailing to complain of more pain and to require revision surgery for removal of implants.     

Delayed pseudoaneurysm caused by distal locking screw of a femoral intramedullary nail: a case report

Interlocked intramedullary nailing is an accepted technique in the management of closed femoral shaft fractures. If this technique is used in patients who are skeletally immature, the position of locking screws relative to soft tissues can alter with time. We present a case of an 11-year-old male who developed a delayed pseudoaneurysm 4 years after intramedullary nailing that was most likely produced by movement of the distal locking screws of his femoral nail in relation to the surrounding vascular structures.     

Transient retrograde interfragmentary compression technique in AO/OTA type 33-C distal femur fractures: A surgical technique and short-term radiographic follow up results

Surgical treatment of AO/OTA type 33-C fractures is a therapeutic challenge despite advances in surgical instruments and techniques. We introduce a novel surgical technique named transient retrograde interfragmentary compression (TRIC) to help intraarticular fragment reduction in AO/OTA type 33-C fracture. We inserted a partial threaded 7.0-cannulated screw with a washer along the transepicondylar axis from the medial femoral epicondyle during the articular block reduction process of AO/OTA type 33-C fractures to strengthen the compressive force between the condylar fragments and to enhance the handling of the articular block fragment in the alignmental correction stage. Following the provisional reduction and fixation using lateral distal femur locking compression plate, TRIC screw was removed. Fifteen AO/OTA type 33-C distal femoral intraarticular fractures of thirteen patients were surgically treated using the TRIC technique. We analyzed the radiographic result of the patients by measuring the horizontal gap and vertical step-off in the postoperative radiographs. Mean horizontal fracture gap was 0.34 mm and mean vertical step-off between bicondylar fragments was 0.63 mm. The median value of the horizontal fracture gap and vertical step off was 0 and 0.46 mm, respectively. Mean time to union in the bicondylar fracture fragment was 9 week. TRIC is considered to be a valuable surgical reduction technique in the treatment of the AO/OTA 33-C type fractures.     

Comparative study of intertrochanteric fracture fixation using proximal femoral nail with and without distal interlocking screws

BACKGROUNDIntertrochanteric (IT) fracture is one of the most common fractures seen in an orthopaedic practice. Proximal femoral nailing (PFN) is a common modality of fixing IT femur fracture. We retrospectively studied whether a PFN with two proximal lag screws can be done without distal interlocking screws in the 31-A1 and 31-A2 fracture patterns according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) guidelines for IT femur fractures.AIMTo compare the outcomes of IT fractures (AO/OTA 31-A1 and 31-A2) treated by PFN with and without distal interlocking screws.METHODSWe carried out a retrospective study of 140 patients in a tertiary care centre who had AO/OTA type 31-A1 and 31-A2 IT fractures. We divided the patients into two groups, in which one of the groups received distal interlocking screws (group 1) and the other group did not (group 2). The subjects were followed up for a mean period of 14 mo and assessed for radiological union time, fracture site collapse, mechanical stability of implant, and complications associated with the PFN with distal interlocking and without distal interlocking. Then, the results were compared.RESULTSPFN without distal interlocking screws has several advantages and gives better results over PFN with distal interlocking screws in the AO/OTA 31-A2 fracture pattern. However, similar results were observed in both groups with the fracture pattern AO/OTA 31-A1. In patients with fracture pattern AO/OTA 31-A2 treated by PFN without distal interlocking screws, there were minimal proximal lock-related complications and no risk of distal interlock-related complications. The operative time, IITV radiation time and time to radiological union were reduced. These patients also had better rotational alignment of the proximal femur, and the anatomy of the proximal femur was well maintained. It was also noted that in the cases where distal interlocking was performed, there was a gradual decrease in neck shaft angle, which led to varus collapse and failure of bone-implant construct in 21.40%.CONCLUSIONIn fracture pattern AO/OTA 31-A2, PFN without distal interlocking had better results and less complications than PFN with distal interlocking.     

Intramedullary locked nailing for distal femoral fractures

Surgical Principles Distal femoral fractures, supracondylar and condylar fractures which can be successfully reduced by closed methods are treated with a modified method of intramedullary locked nails. Closed reduction is obtained by adducting the distal fragment and by adjusting the degree of knee flexion and extension. Condylar fractures, if present, are reduced closed and fixed with percutaneous lag screws. After preparing the medullary cavity, the distal 15 mm of the locked nail is cut away and the tip of the nail is driven to the subchondral bone of the distal femur. The advantage of this technique is the minimal dissection for these difficult fractures. The splinting effect of the intramedullary nail decreases the incidence of refracture in the geriatric patient in whom refractures are relatively common. However, this technique may not be applicable in very distal fracture and condylar fracture which cannot be reduced by closed methods, and condylar fracture in the sagittal plane.     

股骨远端骨折常见内固定临床应用评价

目的: 评价股骨远端骨折常见内固定临床应用效果。方法: 1998~2003年共收治股骨远端骨折 215例,骨折按AO/ASIF标准分型, A型 112例, B型 20例, C型 83例。分别采用AO角钢板、松质骨拉力螺钉、DCS、GSH及AO股骨髁钢板内固定, 合并股骨内侧骨质压缩粉碎较重者, Ⅰ期大块自体髂骨植骨。结果: 经平均 10 6个月随访, AO角钢板固定组 (12例): 2例内固定折断骨不连, 1例骨畸形愈合; 松质骨拉力螺钉固定组 (20例 ): 骨折全部愈合; DCS固定组 (96例): 2例骨不连, 1例内固定折断; GSH固定组 (20例 ): 1例骨不连、锁钉折断; AO股骨髁钢板固定组 (67例): 2例骨不连。膝关节功能按Merchan评分标准评分, 总优良率 93%。结论: 股骨远端骨折的常见内固定器械, 均不具包容性, 术前应正确判定骨折的类型并选用合适的内固定, 合并股骨内侧骨质压缩粉碎较重者, Ⅰ期大块自体髂骨植骨。这样, 才能有效提高此类骨折的优良率。     

Treatment of distal tibial fractures: plate versus nail

A study of 24 patients who sustained an extra-articular fracture of the distal third of the tibial shaft was performed to determine the effect of the type of treatment, open reduction and internal fixation (ORIF) or closed reduction and intramedullary (IM) nailing, on the occurrence of malalignment. All patients were treated in our clinic between 1993 and 2001 for a fracture in the distal third of the tibia. Twelve patients treated with ORIF were matched to 12 patients treated with IM nailing, with regard to gender, age decade, and the AO classification of the fracture. The group treated with IM nailing was assessed after a mean 6.0 years versus ORIF after a mean of 4.5 years. Two patients treated with ORIF versus six patients treated with IM nailing had a malalignment of the tibia. Furthermore, we found no difference with regard to time to union, non-union, hardware failure or deep infections between ORIF and IM nailing. Our results suggest that control of alignment is difficult with IM nailing of distal tibial fractures. For optimal alignment we advise considering the use of ORIF for closed and type I open extra-articular fractures in the distal third of the tibia.     

The condylar plate for treatment of distal femoral fractures: A long-term follow-up study

The aim of this retrospective study was to present the long-term functional and radiological outcomes of indirect reduction techniques and fixation with a condylar plate for treatment of distal femoral supracondylar or intracondylar femoral fractures. The series included 24 men and 17 women, mean age 51 years, between March 1994 and April 1999. All fractures were AO type 33, and eight were open fractures. Primary iliac bone graft was used in five cases. In one case of severe osteoporosis, screw fixation was augmented with cement. There were three delayed unions, one non-union and two infections; four participants required reoperation with bone grafts. Two (5%) participants developed a second varus deformity and three a second valgus deformity; correction osteotomy with bone grafts was necessary in these cases.After a mean follow-up of 9.5 years, the mean Neer score was 82 points and indicated that function was excellent in 16, satisfactory in 9, unsatisfactory in 4 and poor in 2 cases. The mean Neer score in cases of isolated fracture was 89 points and in cases with additional injuries was 72 points. Thus the long-term results of indirect reduction techniques of distal femoral fractures treated with the condylar plate were good to excellent in 82% of cases.     

股骨髁上逆向交锁髓内钉在股骨远端骨折中的应用

介绍用股骨髁上逆向交锁髓内钉治疗股骨远端骨折的方法与优点。方法 应用股骨髁上逆向交锁髓内钉治疗２９例患者（３０个股骨）。结论 股骨髁上逆向交锁钉的应用扩大了髓内钉手术适应证,具有操作简便,固定牢靠,锁钉定位准确等优点,是治疗股骨远端骨折的有效方法。     

Biomechanical analysis of distal femur fracture fixation: fixed-angle screw-plate construct versus condylar blade plate

OBJECTIVE: The objective of this study is to establish the relative strength of fixation of a locking distal femoral plate compared with the condylar blade plate. METHODS: Eight matched pairs of fresh-frozen cadaveric femurs were selected and evaluated for bone density. A gap osteotomy model was used to simulate an OTA/AO A3 comminuted distal femur fracture. One femur of each pair was fixed with the blade plate; the other, with a locking plate. After 100 N preload and 10,000 cycles between 100 N and 1000 N, total displacement of each specimen was assessed. After completion of cyclic loading, maximum load to failure was tested. RESULTS: Significantly greater subsidence (total axial displacement) occurred with the blade plate (1.70 +/- 0.45 mm; range, 1.21-2.48 mm) than with the locking plate fixation (1.04 +/- 0.33 mm; range, 0.67-1.60 mm) after cyclic loading (P = 0.03). In load-to-failure testing, force absorbed by the locking plate before failure (9085 +/- 1585 N; range, 7269-11,850 N) was significantly greater than the load tolerated by the blade plate construct (5591 +/- 945 N; range, 3546-6684 N; P = 0.001). Variability in bone mineral density did not affect the findings (fixed angle distal femoral plate r = 0.1563; condylar blade plate r = 0.0796). CONCLUSIONS: The locking screw-plate construct proved stronger than the blade plate in both cyclic loading and ultimate strength in biomechanical testing of a simulated A3 distal femur fracture. Although differences were small, the biomechanical performance of the locking plate construct over the blade plate may lend credence to use of the locking plate versus the blade plate in the fixation of comminuted distal femur fractures.