Fractures of the ipsilateral femur and tibia: emphasis on intra-articular and soft tissue injury

Twenty-one patients with fractures of the ipsilateral femur and tibia were treated at Boston City Hospital from 1982 through 1987. Fourteen (67%) of the 21 patients sustained a total of 17 open fractures (76% of which were grade II or III wounds). Over 50% of the patients suffered concomitant ipsilateral knee injuries. Associated injuries required 37 nonorthopaedic procedures; 30 orthopaedic procedures were required to stabilize the axial skeleton and the other three extremities. Five patients ultimately required amputation, reflecting the magnitude of the initial high-energy trauma. Superior results were achieved when early rigid intramedullary fixation of the femur and rigid stabilization of the tibia with either an intramedullary nail or an external fixator was undertaken. Patients that underwent initial rigid intramedullary fixation of both the femur and tibia required fewer secondary operative procedures than those treated with primary external fixation. Rigid internal fixation allowed for thorough evaluation and treatment of the ligamentous structures of the knee and facilitated management of the soft tissue trauma.     

Periprothetische Frakturen am Kniegelenk

The demographic developments and an increasing number of total knee replacements will lead to more periprosthetic fractures in the future. These fractures can be classified into intraoperative and postoperative. Revisions in particular are associated with a higher incidence of intra-operative fractures, specifically for the tibia and patella. Most fractures occur in the postoperative period with an average of 2–4 years after the primary procedure. Most commonly the femur is involved. The history and clinical examination as well as imaging are crucial for the treatment as loose components would significantly alter the treatment strategy. In this case a revision has to be carefully planned. In the majority of the cases the prosthesis is well fixed especially at the femur. An open reduction internal fixation (ORIF) can then be carried out. A stable situation must be achieved to provide early post-operative mobilization. Also an anatomic reduction should be achieved with correct alignment especially with respect to varus/valgus and rotation. Modern locked implants can provide this with good success also with the possibility of minimally invasive techniques and polyaxial screw positioning. Retrograde intramedullary devices can be a feasible alternative. Similar principles can be used for the tibia whereas the patella can be stabilized with tension band wiring in the case of good bone stock but still remains a problem in case of bad bone stock.     

交锁髓内钉治疗股胫骨骨折110例分析

目的　探讨交锁髓内钉治疗股、胫骨骨折的疗效 ,分析并发症发生原因 ,提出防治措施。方法　 110例股、胫骨骨折 (闭合骨折 83例 ,开放骨折 2 7例 ) ,除 2例股骨和 5例胫骨闭合复位未扩髓外 ,余均采用开放复位并有限扩髓 ,应用交锁髓内钉固定。随访 3～ 2 4个月 ,平均随访 14个月。结果　 110例骨折全部愈合 ,其中髓内钉折断 5例 ,锁钉折断或松动退出 4例 ,骨折成角畸形 4例 ,骨折延期愈合 8例 (股骨 3例 ,胫骨 5例 ) ,无感染病例。按Johner -Wruh法功能评定 :优 83例 ,良 2 3例 ,中 3例 ,差 1例。结论　只要掌握好手术指征及正确处理所遇问题 ,交锁髓内钉治疗股、胫骨骨折是一种较好的内固定方式     

Ipsilateral open fracture of the femur and tibia treated using the dynamic ASIF-BM tubular external fixator: case reports

Two cases of ipsilateral open fracture of the femur and tibia treated using the dynamic ASIF-BM tubular external fixator are described. Results were very good, with short periods of occupational disability. These cases support primary stable osteosynthesis of these simultaneous fractures and the value of dynamic axial external fixation as a definitive treatment of open fractures of the femur and tibia shaft, either isolated or simultaneous.     

External fixation of ipsilateral fractures of the femur and tibia

In five patients with ipsilateral femoral and tibial shaft fractures the Hoffmann apparatus was used to stabilize the fractures of both the femur and tibia. The patients walked early and there were no disturbances of fracture healing. The pin track became infected in three patients. It is suggested that in patients with ipsilateral fractures of the femur and tibia external fixation is indicated for the tibia and that the fracture of the femur should be stabilized by closed medullary nailing. If the patient is critically ill or if there is gross comminution of the femur external fixation is indicated for this fracture as well.     

AO微创内固定系统在股骨远端及胫骨近端粉碎性骨折的应用

目的探讨应用AO微创内固定系统(lessinvasivestabilizationsystems,LISS)治疗下肢股骨远端与胫骨近端粉碎性骨折的临床效果。方法回顾性分析2003年9月~2005年5月采用LISS治疗14例下肢骨折患者,其中男13例,女1例;车祸伤9例,坠落伤3例,摔倒跌伤2例。开放性骨折5例,闭合性骨折9例。骨折部位包括股骨髁上及髁间粉碎性骨折5例,胫骨上段粉碎性骨折9例。骨折按照AO/OTA分类:股骨骨折中,33C2型3例,33C3型2例;胫骨骨折中,41A2型2例,41A3型2例,41B2型3例,41C2型2例。分别应用股骨远端或胫骨近端LISS行内固定手术。术后对其伤口愈合、术前及术后X线片检查及关节功能恢复情况进行观察。结果患者术后切口均期愈合。均获随访1~20个月,平均11个月。12例骨折均在术后3~5个月愈合,另2例经术后2~3个月观察,效果良好。关节功能根据Johner-Wruhs关节功能评定标准:优10例,良3例,可1例;优良率为93%。11例膝关节屈伸范围达110~130°,2例为100°,1例为80°。结论LISS对股骨远端或胫骨近端粉碎性骨折是一种有效的内固定方法,具有创伤小,固定可靠,临床效果良好等优点。     

应用LISS治疗下肢骨不连的初步报告

目的报告应用微创内固定系统(LISS)治疗股骨及胫骨骨不连的初步临床效果。方法自2003年2月～2004午8月间，应用LISS固定与植骨治疗5例股骨下段骨折小连接，4例胫骨上段骨折不愈台；其中内固定失效7例，外固定治疗火败和感染各1例；病程10～111个月，平均29个月。结果个部患随访6～16个月，平均8个月；骨折均住术后4～6个月牢固连接，平均愈合时间4．7个月，无内植入物松动等并发症。结论LISS因其先进的设计，能有效治疗股骨下段和胫骨上段骨折不连接。     

动力髁螺钉内固定并一期植骨治疗股骨远端严重粉碎骨折

目的探讨股骨远端严重粉碎骨折的治疗方法。方法应用动力髁螺钉(dynamic condylar scrow，DCS)内固定并一期植骨治疗股骨远端严重粉碎骨折21例，对术后膝关节功能进行评价。结果21例病人均获随访，膝关节功能：优7例、良9例、可4例、差1例，优良率近80％。结论动力髁螺钉内固定并一期植骨是治疗股骨远端严重粉碎骨折的一种有效方法。     

Retrograde femoral interlocking nail in complex fractures

Retrograde interlocking nail was used as the method of fixation in 35 different cases of combination of complex femoral fractures. We performed this procedure in fractures of femoral shaft associated with fracture neck femur, pathological fractures of proximal third of femur with trochanteric pathology, ipsilateral fracture of femur and tibia in polytrauma cases with multiple other injuries, in highly obese patients with fracture shaft femur. This technique was also used in cases of pregnancy with fracture shaft femur and in unstable pelvic fracture or dislocation hip associated with fracture shaft femur. Operative technique involved with retrograde insertion of un-reamed, non-cannulated custom made nail through entrance portal in intercondylar notch was applied for fixation of the shaft femur fracture. The other associated fracture around hip was stabilized separately using suitable implant according to type of fracture. In cases of ipsilateral fracture of femur and tibia, femur was stabilized by retrograde interlocking nail and tibia was stabilized by antigrade interlocking nail through same incision at the same sitting. The case was followed up for three years; the average union time was 12 to 18 weeks. Out of 35 cases, 31 cases regained full knee movement. Out of the remaining 4 cases, 2 cases could regain up to 90 degrees of movement, these were old fractures and non-cooperative patients. In one case, patellofemoral arthritis was developed because of an operative error where a nail was not put inside the articular surface. Mal-union was observed in an early case of the series and implant failure was nil. Retrograde interlocking nail was used as the method of fixation in complex fracture problems. Multiple fractures of long bones can be stabilized in one stage, preventing multiple operations at different stages in polytraumatized patients. This resulted in early recovery, lesser hospital stay, and early rehabilitation of patient with good results and is economical also.     

Vacuum-assisted-closure-Therapie

This article reports the case of a 23-year-old woman who sustained severe soft tissue injuries with open fractures of the left distal femur, the left proximal tibia, a subtotal amputation of the left foot with injuries to the anterior and posterior tibial artery due to a bomb blast. When the patient was transferred to our hospital 17 days after the trauma, all primarily closed wounds were severely infected. The fractures were treated by external fixateur and k-wire fixation. After debridement and initiation of negative pressure therapy the anterior tibial artery was reconstructed after 3 days and partial wound closure by a rectus abdominis muscle flap was achieved after 19 days. After almost total wound closure was accomplished open reduction internal fixation (ORIF) was performed for the distal femur fracture and a modification of the external fixateur for the tibial and foot fractures. The negative pressure therapy is an important component for treatment of complex soft tissue injuries and open fractures; however, it must be embedded in an interdisciplinary treatment plan with well-defined treatment goals.     

Ipsilateral fracture of the femur and tibia treated in a quadrilateral cast brace.

In 15 patients traction followed by cast brace was an acceptable method of treatment for ipsilateral fractures of the tibia and femur. Prolonged healing times and limited range of motion of the knee were not significant problems. This method of treatment is especially indicated in patients with severe open injuries or comminution of femoral shaft fractures which do not safely lend themselves to rigid internal fixation. The hospitalization time, 5 weeks, is considerably less than for spica cast treatment of femoral shaft fractures and is comparable to that reported for open reduction and rigid fixation of femoral shaft fractures.     

Fratture esposte meta-epifisarie distali di femore e meta-epifisarie prossimali di tibia

Open fractures around knee are difficult to treat because of the high rates of early and late complications such as wound healing or deep infection. Open reduction and early internal stabilisation remain controversial. Early wound closure, huge washing, large debridements, antibiotic prophylaxis reduce the rate of infection. Temporary external fixation is mandatory in comminuted unstable open fractures with soft tissue damage and allows for the management of polytraumatised patients in keeping with the orthopedic damage control principles. To avoid further complications of definitive internal fixation, knee bridging frames of external fixation should be used. The aim of this article was to summarise the management of open proximal tibia and distal femur fractures since the admission in emergency room to the definitive treatment.     

U形外固定架结合有限内固定治疗干骺端粉碎性骨折

目的 介绍用U形外固定架治疗长骨干骺端经关节面的粉碎性骨折的疗效。方法 2000年2月～2002年9月对8例患者分别采用切开复位少量螺丝钉内固定及U形骨外固定架固定。结果 全部病例均得到随访,随访时间平均11个月。外固定架术后使用时间平均为3.5个月,骨折愈合时间平均为4.5个月,所有骨折均愈合。无骨不连等发生。终末随访时膝关节活动度平均屈95°,伸180°。踝关节平均背伸10°,跖屈28°。结论 外固定架结合有限内固定治疗经关节面的干骺端粉碎性骨折,可避免伤口并发症和骨不连的发生,即能维持骨折对位恢复关节面的解剖关系,又不妨碍关节活动,是治疗长骨干骺端经关节面粉碎性骨折的较好方法。     

Indications and technic of external fixation in acute management of polytrauma

The application of external fixation in the multiple injured patient permits rapid stabilisation of fractures and excellent preservation of soft tissue without an additional systemic load after traumatic shock. Acute fixation in the primary care is achieved by particular constructions for the pelvis and femur and modifications of standard-techniques for the tibia and joint-transfixation. In most cases secondary completions or alterations in the method of treatment are necessary.     

组合式桥接内固定系统固定治疗儿童四肢干骺端骨折

目的探讨组合式桥接内固定系统固定治疗儿童四肢干骺端骨折的疗效。方法回顾性分析2015年10月至2018年12月期间南京医科大学附属常州第二人民医院骨科采用组合式桥接内固定系统固定治疗的16例儿童干骺端骨折患者资料。男11例,女5例;年龄为8~14岁,平均11.0岁。骨折部位:肱骨近端4例,股骨远端3例,胫骨近端3例,胫骨远端6例;骨折按Salter-Harris分型:Ⅱ型6例,Ⅲ型5例,Ⅳ型5例。受伤至手术时间为3~8 d,平均5.3 d。记录患者的骨折愈合时间、并发症发生情况(术后感染、内固定失效)及术后功能恢复情况等。结果16例患者术后获12~18个月(平均13个月)随访。16例儿童患者术后均获骨性愈合,骨折愈合时间为2~5个月(平均2.4个月)。末次随访时4例肱骨近端骨折患者根据Neer评分标准评定疗效:均为优;6例股骨远端骨折或胫骨近端骨折患者根据美国特种医院膝关节功能评分标准评定疗效:优5例,良1例;6例胫骨远端骨折患者根据Baird评分标准评定疗效:优5例,良1例。随访过程中无一例患者发生术后感染、断钉、断棒及骨折不愈合等并发症。结论组合式桥接内固定系统固定治疗儿童干骺端骨折具有微创、操作简单、固定可靠及并发症少等优点,是儿童干骺端骨折的一种可选治疗方案。     

Treatment of Lower-extremity Long-bone Fractures in Active, Nonambulatory, Wheelchair-bound Patients

A retrospective review of surgically treated lower-extremity long-bone fractures in wheelchair-bound patients was conducted. Between October 2000 and July 2009, eleven lower-extremity fractures in 9 wheelchair-bound patients underwent surgical fixation. The Short Musculoskeletal Function Assessment, Short Form, and Spinal Cord Injury Quality of Life questionnaires were used to assess functional outcome.Mechanism of injury for all patients was a low-energy fall that occurred while transferring. Four patients who sustained a distal femur fracture, 1 patient who sustained a distal femur fracture and a subsequent proximal tibia fracture, and 1 patient who sustained a proximal third tibia shaft fracture underwent open reduction and internal fixation with plates and screws. Three patients with 4 midshaft tibia fractures underwent intramedullary nailing.At last follow-up, all 9 patients had returned to their baseline preoperative function. Quality of life was significantly higher (P<.01) than the Spinal Cord Injury Quality of Life questionnaire's reference score. Self-reported visual analog scale pain scores improved significantly from time of fracture to last follow-up (P=.02). All fractures achieved complete union, and no complications were reported. This study's findings demonstrate that operative treatment in active, wheelchair-bound patients can provide an improved quality of life postinjury and a rapid return to activities.     

骨水泥填充加锁定钢板内固定治疗长骨转移癌伴病理性骨折

[目的]探讨病灶清除后骨水泥填充加锁定钢板内固定治疗长骨转移癌伴病理性骨折的临床疗效。[方法]2005年2月～2008年2月,对本院收治15例骨转移癌伴长骨病理性骨折患者,其中肱骨3例,尺骨2例,桡骨1例,股骨5例,胫骨4例,采用骨水泥填充+锁定钢板内固定进行手术治疗。[结果]所有患者均有随访,随访时间24～46个月,平均35.6个月。术后14例(93.3%)疼痛症状明显减轻,疼痛评分改善率[(手术前评分-手术后评分)/手术前评分]为75%;术后2周Enneking肢体功能评分为优者13例(86.7%),改善率[(手术后评分-手术前评分)/手术后评分]为72%。手术前、后患者生活质量评分有显著统计学意义(P0.05)。本组病例术后6个月生存率为60%,术后2年生存率为26.7%。[结论]对于长骨转移癌伴病理性骨折患者,尤其是近关节部位,骨水泥填充+锁定钢板内固定是一种安全、有效的手术方式,该手术可明显减轻患处疼痛、改善肢体功能、提高患者的生活质量,同时还能方便患者接受护理和进一步综合治疗。手术中骨水泥灌注确实、选择合适锁定钢板,是提高临床效果的有效办法。     

浮动髋的治疗(附11例报告)

浮动髋系同侧骨盆骨折和股骨骨折。我院自1985年以来收治浮动髋11例。按Tile分类,骨盆骨折A_1型1例,A_2型3例,B_1型1例,B_2型2例,C_2型2例,C_3型2例。同侧股骨干骨折8例,股骨粗隆间骨折2例,股骨颈骨折1例。骨盆骨折均给予保守治疗,下肢骨折内固定4例,保守治疗7例。9例获平均4年的随访,结果优6例,良2例,差1例。     

The floating knee in the pediatric patient. Nonoperative versus operative stabilization

The results of nonoperative and operative or rigid stabilization of ipsilateral femur and tibia fractures in children and adolescents were evaluated. Twenty-nine consecutive patients with open physes (30 affected extremities) were reviewed. Their mean followup was 8.6 years (range, 1.1-18.6 years). The nonoperative group consisted of 16 patients and 16 extremities treated by skeletal traction of the femoral fracture, closed reduction and splinting or casting of the tibia fractures, and eventual immobilization in a hip spica cast. The operative group, was comprised of 13 patients and 14 extremities in which one or both fractures were treated by open reduction and internal fixation, intramedullary fixation, or external fixation. Despite higher modified injury severity scores and skeletal injury scores, the patients who were treated operatively had a significantly reduced hospital stay, 20.1 days versus 34.9 days, respectively; decreased time to unsupported weightbearing, 16.8 weeks compared with 22.3 weeks, respectively; and fewer complications. Operative stabilization of the femur had a significant effect on decreasing the length of hospital stay and the time to unassisted weightbearing. The patients also were analyzed according to their age at the time of injury: 9 years of age or younger and 10 years of age and older. The younger children who were treated nonoperatively had an increased rate of lower extremity length discrepancy, angular malunion, and need for a secondary surgical procedure as compared with younger children who were treated operatively with rigid fixation. Based on the results of the current study, operative stabilization of at least the femur fracture and, preferably, both fractures in the treatment of a child with a floating knee is recommended, even for younger children.     

AO微创内固定系统治疗胫骨近端骨折

目的报告AO微创内固定系统（less invasive stabilization system,LISS）治疗胫骨近端骨折短期疗效,结合文献,着重探讨LISS手术相关问题。方法本组4例,左侧2例,右侧2例。骨折AO分型：A型1例,为A3型;B型1例,为B3型;C型2例,其中C2 1例,C3 1例。开放性骨折1例,闭合性骨折3例。受伤至手术时间5～30d。均应用胫骨近端LISS内固定治疗。结果本组4例均得到随访,切口均一期愈合,X线平片复查示骨折对位、对线良好。随访时间6～12个月,平均9个月,膝关节功能按Merchan等评分标准评定。本组优3例,可1例。结论LISS对胫骨近端骨折是一种有效的微创内固定治疗方法,术中不需植骨,术后并发症少。效果确切。