Results of operative therapy of periprosthetic femur shaft fractures in total hip endoprostheses

Periprosthetic femoral shaft fracture represents an uncommon but potentially devastating complication associated with total hip arthroplasty. The treatment should result in complete union of the fracture and at the same time guarantee stability of the implant. 15 patients treated between 1992 to 1998 were analysed. Clinical and radiographic follow-up averaged 30 months (6-79 months) in 13 cases. Two patients died regardless of the fracture. The method of treatment depended on the intraoperative stability of the prosthesis and in addition on the fracture type (Bethea). In 5 cases of intraoperative stability of the prosthesis plate fixation was performed. Plate fixation was complicated by fixation failure combined with a recurrent fracture in two cases leading to shift to a long stem prosthesis. Ten cases of fractures associated with loose stems were treated with a new prosthesis using a long stem system. In these cases an uncomplicated healing of the fracture was achieved with adequate stability in radiographic examinations. The average Harris score was 70 (26-93). For fractures near the femoral stem or in case of implant loosening we recommend the shift to a long stem prosthesis. Also in fractures distally from the femoral stem tip we prefer now long stem implants rather than plate fixation to avoid large exposure of the femoral shaft and resultant complications.     

Risk of hip/femur fractures in patients using antipsychotics

The objective of our study was to investigate whether use of antipsychotics is associated with hip/femur fractures and whether pharmacological differences between antipsychotics are related to the occurrence of fractures.

A case-control study was conducted, in which cases were defined as patients with a hip/femur fracture. Each patient was matched to one control patient. The association between use of antipsychotics and the occurrence of hip/femur fractures was evaluated using conditional logistic regression.

The study included 44,500 patients from 683 general practices from different geographical areas in the UK, registered within the General Practice Research Database (GPRD). Exposure to antipsychotics was categorized as “no use”, “current use” and “prior use”.

Both current and prior use of antipsychotics were associated with an approximately two-fold increased risk of fractures. After adjustment for possible confounders, a small significant effect remained (Odds Ratios (OR) of 1.3). We did not find an association between dose of antipsychotics, or between the degree of blockade of the alpha-1 adrenoceptor or histamine-1 receptor and risk of fractures. The total number of days of antipsychotic use was significantly associated with an increased risk of hip/femur fractures.

We conclude that there is a small increased risk of hip/femur fractures associated with the use of antipsychotics. This risk increases with long-term use.     

Bilateral hip and femur fractures

Bilateral hip and femoral fractures are rare. A 26-year-old male with multiple injuries including such fractures was successfully treated with a variety of internal fixation techniques, allowing early mobilization. It is important to consider the possibility of this fracture pattern in high-energy trauma.     

Management of femur shaft fractures in obese patients

Given the ongoing epidemic of obesity, femoral fracture management in the population affected by this condition is likely to become more frequent. Fracture treatment in obese patients poses a special challenge given greater difficulty in establishing an accurate diagnosis and confirming associated injuries. Adequate intraoperative positioning and obtaining accurate reduction and stable fixation may require special considerations. Obese patients have a high predisposition for complications such as compartment syndrome, nerve injuries, and pressure ulcers, and are at increased risk for medical complications given the high prevalence of comorbidities. A thorough understanding of the risks associated with obesity and the diagnostic and therapeutic challenges involved with femoral shaft fractures in this setting is paramount to achieve adequate results.     

重建钉治疗股骨干合并同侧髋部骨折的临床观察

目的：评价股骨重建钉治疗股骨干合并同侧髋部骨折的临床疗效及手术要点。方法：自2002年6月至2008年6月采用重建钉治疗15例股骨干合并同侧髋部骨折患者,全部为男性,年龄34-85岁,平均45岁。股骨干骨折WinquistI型2例,Ⅱ型6例,Ⅲ型2例,Ⅳ型2例,3例多段骨折。髋部骨折包括粗隆间骨折7例,股骨颈骨折8例（根据Garden分型,I型1例,Ⅱ型3例,Ⅲ型2例,Ⅳ型2例）。结果：15例患者均获随访,时间12～55个月,平均30．9个月。股骨颈骨折不愈合1例,内翻畸形1例;14例2-6个月获得髋部骨折愈合,平均4个月。股骨干骨折延迟愈合1例（9个月时愈合）,不愈合2例;13例4～9个月获得股骨干愈合,平均5．5个月。无感染、股骨头坏死及超过2cm的下肢短缩。Friedman—Wyman系统疗效评价：优良13例,一般1例,差1例。结论：股骨重建钉对于股骨干合并同侧髋部骨折固定可靠,并发症少,是一种有效的固定方式。     

Management of pediatric femoral shaft fractures

Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture. Nonsurgical management, usually with early spica cast application, is preferred in younger children. Surgery is common for the school-age child and for patients with high-energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails, and plate fixation have specific indications. The skeletally mature teenager is treated with rigid intramedullary fixation. Potential complications of treatment include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. Risks of surgical management include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation, and soft-tissue irritation caused by the ends of flexible nails.     

Elastic stable intramedullary nailing in pediatric femur and lower leg shaft fractures: intraoperative radiation load

BACKGROUND: Elastic stable intramedullary nailing (ESIN) is currently the therapy of choice in unstable, transverse and short oblique femoral and tibial-fibular shaft fractures in childhood and adolescence. As with every intramedullary technique, it requires a greater intraoperative reliance on radiological imaging. Literature concerning intraoperative radiation load in ESIN is rare, results having a wide range from less than 1 minute to more than 15 minutes. METHODS: We performed a retrospective analysis of 53 femoral and 24 tibial shaft fractures. In addition, image intensifier times of several steps of the operative procedure in 10 femoral shaft fractures were evaluated prospectively. RESULTS: The average radiation time in femoral fractures was 70.3 (range, 12-193) seconds, in tibial shaft fractures, 42.4 (range, 16-108) seconds. The prospective analysis of femur shaft fractures was able to show the most intense use of imaging during fracture passage (43.2%) and placement of the nail tips (26.6%). Image intensifier times in educational operations were not significantly higher than in operations performed by experienced surgeons. CONCLUSIONS: The actual intraoperative radiation load is influenced by bone mass and soft tissue coverage. Surgeons are able to reduce it only by decreasing the fluoroscopy time. According to our results, image intensifier time should not exceed 3 minutes in ESIN of femoral shaft fractures and 2 minutes in ESIN of lower-leg fractures. Low intraoperative radiation times are a mark of quality with respect to the interests of patients, surgeons, and operation theater staff.     

Ipsilateral hip and femoral shaft fractures

Over a 20-year period, 24 patients were treated for ipsilateral hip and femoral shaft fractures. The majority of the hip fractures were extracapsular. All resulted from high-energy impaction injuries (motor vehicle accidents and falls from over 15 feet), with 25% being open. There were numerous associated injuries, many requiring multiple operations. One-third had an associated knee injury, with 75% occurring in those with extracapsular fractures. The diagnosis and treatment of three hip fractures were delayed, but all healed without avascular necrosis. Patients were treated by traction and various internal fixation methods, either alone or in combination. Fifty percent had major complications, predominantly patients treated only in traction. At a mean follow-up examination of 9.5 years, two-thirds had a good result and one-third a fair result. Those with extracapsular fractures had the same result as those with intracapsular fractures. Patients treated by fixation of one or both fractures had a significantly shorter hospital stay than those treated by traction alone. Extracapsular fractures have a high incidence (43%) of associated knee injuries. Treating both fractures with internal fixation allows early mobilization, easier patient care, fewer complications, and a shorter hospital stay. Despite the severity of multiple injuries, and the diversity of treatment with many complications, when stability is achieved the patients generally recover good function.     

Ipsilateral femoral shaft and hip fractures

A midshaft femoral fracture in a high-energy trauma victim should prompt the orthopedist to search carefully for an ipsilateral fracture of the femoral neck. This fracture will be present in 5 per cent of patients, and the incidence may be increasing. Management of the femoral neck fracture should include emergent capsulotomy, anatomic reduction, and rigid fixation with compression. Management of the femoral shaft should not interfere with these goals because of the risk of post-traumatic necrosis of the femoral head. Successful methods of management of the femoral shaft fracture have included compression plating, retrograde Kuntscher nailing, and interlocking nails. Approaches to the treatment of concomitant intertrochanteric and femoral shaft fractures should be selected according to the skill and experience of the surgeon and the availability of equipment.     

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.     

Treatment options in pediatric femoral shaft fractures

Fracture of the femur in a pediatric patient presents special problems, and a variety of treatment options. Child abuse and neglect should be considered and evaluated. Fractures in infants (0-18 months) may be treated successfully in a Pavlik Harness. Spica casting is safe and effective in children up to about 6 years or 100 pounds, although complications can occur and careful attention to technique is important. Surgical treatment is superior in most older or larger children or adolescents, and in cases of multiple trauma, soft tissue injury, obesity or head injury. External fixation is minimally invasive, but carries a risk of malunion and refracture. Rigid antegrade intramedully nailing is possible in adolescents of acceptable size, but has a risk of avascular necrosis. Flexible nailing is minimally invasive and well suited to fractures of the central 2/3 of the diaphysis. In comminuted fractures, it may require supplemental external support. Plate fixation is stable and addresses the entire length of the femur. Soft tissue concerns due to surgical exposure can be minimized by the use of submuscular placement technique.