Bilateral Femoral Shaft Research Articles

Atypical Bilateral Stress Fractures of the Femoral Shaft Diagnosed by Bone Scintigraphy in a Woman With Osteoporosis

Recent case series have identified the presence of atypical insufficiency fractures at the diaphyseal femur of osteoporotic patients, which are possibly related to the long-term use of biphosphonates. We present images of a 72-year-old woman with a history of colon cancer and osteoporosis referred for bone scintigraphy because of bilateral thigh pain. No trauma or intense exercise was reported. Bone scan revealed bilateral femoral shaft stress fractures, which were confirmed by plain radiographs. In oncologic patients with osteoporosis referred for bone scintigraphy, atypical stress fractures should be included in the differential diagnosis of focal findings in the diaphyseal femur.

Atypical femoral fractures bilaterally in a patient receiving denosumab

We present a case of bilateral low-energy femoral shaft fractures over a 1-year period in a woman after discontinuation of long-term alendronate therapy and initiation of treatment with denosumab. A 73-year-old woman with diabetes mellitus and an 8-year history of post-menopausal osteoporosis presented to the emergency department in June 2011 with a spontaneous left femur fracture. It was 3 weeks after the discontinuation of an 8-year therapy with vitamin D supplement and 70 mg alendronate weekly, and 1 week after the first subcutaneous injection of denosumab. Radiographs revealed a transverse femoral shaft fracture with lateral cortical hypertrophy and medial spiking (Figure 1). Figure 1. The patient’s left femur at the time of the first fracture. A transverse femoral shaft fracture with lateral cortical hypertrophy and medial spiking. The fracture was stabilized with a cephalomedullary nail. Routine blood investigations were within normal range and myeloma was excluded. Bone densitometry revealed an increase in bone density relative to baseline values before the initiation of alendronate therapy, but the T-score of at least 1 site was still in the osteoporotic range (femoral neck T-score: –2.95). 5 months postoperatively, the fracture had healed with callus formation. 1 year after the first fracture, the patient sustained a similar atypical fracture of the right femoral shaft (Figure 2) and she described mild, diffuse pain in the thigh during the previous 6–7 months. She was still on treatment with denosumab 12 months after the first injection (she had received 3 injections of denosumab at 6-month intervals). This fracture was also stabilized with a cephalomedullary nail and a pathological fracture was excluded. Figure 2. Both femurs at the time of the right femoral shaft fracture. This fracture also healed in 5 months with callus formation (Figure 3). In view of reports linking this pattern of femoral shaft fractures to long-term alendronate therapy (Neviaser et al. 2008) and considering the anti-resorptive mechanism of action of the denosumab, treatment with teriparatide (20 µg subcutaneously once a day) and vitamin D was commenced and denosumab was stopped. Figure 3. Anteroposterior radiograph of both femurs 5 months after the second operation, showing healing of the fracture with callus formation.

Atypical forearm fractures associated with long-term use of bisphosphonate

Recent reports on atypical femoral fracture have raised concerns about the long-term use of bisphosphonate. More recent case series focus specifically on the subtrochanteric fractures. But, there is relatively rarity and unawareness of atypical fracture in upper extremity. We report forearm fracture in two women receiving long-term bisphosphonate therapy. First woman presented with pain in the forearm and both thighs and radiographs showed incomplete fractures in a proximal ulnar shaft and bilateral femoral shaft. The other woman had a fracture in the radial shaft. This report suggests atypical fractures associated long-term use of bisphosphonate could occur in bones other than femur. More study is required to identify the magnitude of clinical features of this emerging concern.

The imbalance between regulatory and IL-17-secreting CD4+T cells in multiple-trauma rat

BackgroundIt has been well recognised that a deficit of numbers and function of CD4+CD25+Foxp3+cells (Treg) is attributed to the development of auto-immune diseases, inflammatory diseases, tumour and rejection of transplanted tissue; however, there are controversial data regarding the suppressive effect of Treg cells on the T-cell response in auto-immune diseases. Additionally, interleukin-17 (IL-17)-producing cells (Th17) have a pro-inflammatory role. The balance between Th17 and Treg may be essential for maintaining immune homeostasis and has long been thought as one of the important factors in the development/prevention of auto-immune diseases, inflammatory diseases, tumour and rejection of transplanted tissue, but their role in multiple trauma remains unclear. ObjectiveThis study aims to investigate whether an imbalance of Treg and Th17 effector cells is characteristic of rats suffering from multiple trauma. Methods and subjectiveSixty Sprague-Dawley (SD) rats were randomly divided into three groups. The control group (n=20, group I) no received procedures (normal). The sham group (n=20, group II) only received anaesthesia, cannulation and observation. The bilateral femoral shaft fractures with haemorrhagic shock groups (n=20, group III). Rats in groups II and III were killed at the end of 4h after models were established. Peripheral blood samples were collected for assessment of Treg cells, Th17 cells and cytokines (IL-17, IL-6, IL-2, transforming growth factor beta (TGF-β)) and intestine tissue was collected for intestine histological analysis. ResultsWe observed decreased Treg/Th17 ratios in CD4+T cells in rats with multiple trauma and a strong inverse correlation with disease activity (intestinal histological scores). ConclusionWe suggest a role for immune imbalance in the pathogenesis and development of multiple trauma. The alteration of the index of Treg/Th17 cells likely indicates the therapeutic response and progress in the clinic.

Impact of Bilateral Femoral Shaft Fracture on Morbidity and Mortality

Impact of Bilateral Femoral Shaft Fracture on Morbidity and Mortality

Bilateral low-energy sequential femoral shaft fractures in patients on long-term bisphosphonate therapy

The aim of this study was to evaluate the demographic characteristics of patients with bilateral bisphosphonate-related low-energy femoral shaft fractures. The clinical registry was reviewed for patients with bisphosphonate-related low-energy fractures localized at femoral shaft between January 2008 and January 2012. Patients with a diagnosis of postmenopausal osteoporosis, bisphosphonate usage of at least 5 years and prodromal pain prior to fracture were included the study. Five women met the inclusion criteria. All patients had bilateral low-energy sequential femoral shaft fractures. Fracture patterns were similar and atypical (transverse-short oblique fractures with lateral cortical thickening). Mean period of bisphosphonate treatment was 8.6 years. Mean patient age was 76.2 years. Union time of three patients was between 20 and 28 weeks. The remaining two fractures were revised for delayed union or nonunion. Long-term (over 5 years) use of bisphosphonates may cause insufficiency fractures due to increased fragility and brittleness which have a close relationship with depressed bone remodeling. While there is still no causal relationship between bisphosphonates and atypical, low-energy femoral shaft fractures, we have some concerns about the optimal usage time and long-term safety of bisphosphonate drugs.

Increased morbidity and mortality after bilateral femoral shaft fractures: Myth or reality in the era of damage control?

IntroductionBilateral femoral shaft fractures have been reported to be an independent risk factor for morbidity and mortality; however, the value of these studies is limited due to small sample sizes and the timing of these studies before the establishment of damage control orthopaedics. The objective of this study was to compare the incidence of morbidity and mortality in patients with bilateral vs. unilateral femoral shaft fractures in the era of damage control orthopaedics. MethodsRetrospective analysis of the TraumaRegister DGU from 2002 to 2005. Inclusion criteria were uni- or bilateral femoral shaft fractures and complete demographic data documentation. Univariate data analysis and logistic regression analysis were performed with SPSS. ResultsBetween 2002 and 2005, 776 patients with unilateral and 118 patients with bilateral femoral shaft fractures were identified. Patients with bilateral femoral shaft fractures had a significantly higher Injury Severity Score (ISS) (29.5 vs. 25.7 points), a significantly higher incidence of pulmonary (34.7% vs. 20.6%) and multiple organ failure (25.0% vs. 14.6%) as well as a significantly higher mortality rate (16.9% vs. 9.4%). In the overall patient population, early total care (ETC) was significantly more often performed in patients with unilateral femoral shaft fractures (50.9% vs. 33.6%). Logistic regression analysis revealed no significant association between bilateral femoral shaft fractures and multiple organ failure or mortality; however, bilateral femoral shaft fractures are an independent risk factor for pulmonary failure. Subgroup analysis revealed that the impact of the bilateral femoral shaft fracture was especially pronounced in patients with an ISS<25 points. DiscussionBilateral femoral shaft fractures are an independent risk factor for pulmonary failure but not for multiple organ failure or mortality. The impact of the additional femoral shaft fracture for pulmonary failure appears to be especially pronounced in the less severely injured patients, whose injuries are often underestimated when stratified with the ISS. Patients with bilateral femoral shaft fractures have significantly more often severe abdominal injuries as well as severe blood loss which may account for the increased mortality rate. Therefore, the presence of bilateral femoral shaft fractures should be recognised as an increased risk for systemic complications.

Atypical bilateral femoral shaft fracture in patient treated with bisphosphonates

We report a patient with previous history of long-term bisphosphonate intake who suffered the fracture of both femurs consecutively. The radiological characteristics of both fractures allowed to catalog a posteriori of atypical fractures associated with the prolonged treatment with bisphosphonates. Atypical fractures represent an entity of recent definition that in the last years have attracted considerable attention due to the publication of an increasing number of cases. The aim of this paper is to emphasize the importance of its clinical suspicion before they appear and the characteristics of this type of fractures to provide the most appropriate clinical and surgical treatment.

Tempo de radiação emitida por fluoroscopia em cirurgias ortopédicas

OBJECTIVE: To ascertain the mean length of radiation emission from fluoroscopic devices during several types of orthopedic surgery and which of these required greater use of radiation. METHODS: The times taken to perform sixteen different types of surgery (total of 80 procedures) were measured. At the end of each procedure, the length of time for which fluoroscopy was used directly from the image intensifier was ascertained. RESULTS: The mean time required for fluoroscopy per operation was 61 seconds. The procedures that demanded greatest mean duration of radiation use were bilateral proximal femoral epiphysiodesis (5.1 minutes) and femoral shaft osteosynthesis using a locked intramedullary nail (3.33 min). CONCLUSION: The mean duration of fluoroscopy use in orthopedic operations was 61 seconds. The procedures using an intramedullary device were the ones that required greatest radiation emission.

FLUOROSCOPY DURATION IN ORTHOPEDIC SURGERY

Objective: To ascertain the mean length of radiation emission from fluoroscopic devices during several types of orthopedic surgery and which of these required greater use of radiation. Methods: The times taken to perform sixteen different types of surgery (total of 80 procedures) were measured. At the end of each procedure, the length of time for which fluoroscopy was used directly from the image intensifier was ascertained. Results: The mean time required for fluoroscopy per operation was 61 seconds. The procedures that demanded greatest mean duration of radiation use were bilateral proximal femoral epiphysiodesis (5.1 minutes) and femoral shaft osteosynthesis using a locked intramedullary nail (3.33 min). Conclusion: The mean duration of fluoroscopy use in orthopedic operations was 61 seconds. The procedures using an intramedullary device were the ones that required greatest radiation emission.

Femoral malrotation following intramedullary nailing in bilateral femoral shaft fractures

This study was designed to evaluate the incidence of femoral malrotation in bilateral femoral shaft fractures. All closed bilateral femoral shaft fractures in patients aged 18 or over treated between April 2000 and December 2009 were included in the current study. All patients received a postoperative CT-scan to estimate femoral antetorsion and leg length. All bilateral fractures were treated with intramedullary nailing on a radiolucent table. Retrospectively, all patients were analyzed according to the following parameters: (1) femoral antetorsion of both limbs and antetorsion difference in degrees, (2) femoral length discrepancy (cm), (3) incidence of femoral malrotation >15°, (4) revision rate due to femoral malrotation. A total of 24 patients (11 [45.8%] female; 13 [52.8%] male) with bilateral femoral shaft fractures were included in this study of average age 38 years (median 38 years, range 18-74 years). Clinically relevant malrotation (greater than 15°) was found in 10 cases (41.2%), whereas in 4 cases (40%) a revision surgery was required. Bilateral femoral shaft fractures are associated with a high incidence of clinically relevant femoral malrotation over 15°. Measurement of intraoperative femoral antetorsion in bilateral femoral shaft fractures is quite difficult and currently only feasible postoperatively.

Bilateral Simultaneous Femoral Diaphyseal Fractures in a Patient with Long-Term Ibandronate Use

Bisphosphonates are the most common medication used to treat patients with documented osteoporosis. Recently, reports have associated long-term bisphosphonate use with low-energy femur fractures. While no definitive mechanism has been associated, bisphosphonate use has been strongly implicated. This article presents the case of a 65-year-old woman with a 2-year history of ibandronate use presenting with simultaneous low-energy femoral shaft fractures. The patient reported prodromal bilateral thigh pain and was seen by a spine surgeon. A review of the literature implicates long-term ibandronate use in low-energy femur fractures. With most of the basic science studies demonstrating suppressed bone turnover after 5 years of treatment with alendronate, the significance of the present case also lies in the relatively short duration of time the patient was on ibandronate before suffering the bilateral femoral shaft fractures. Possible pathophysiology for the fractures includes suppressed bone turnover that may allow microcracks to propagate in cortical bone, which can weaken the bone and possibly predispose it to fractures. Patients who have been on bisphosphonates long term should be questioned about thigh pain and have radiographs of their femurs obtained if pain exists. Furthermore, if a patient presents with a single subtrochanteric or diaphyseal low-energy femur fracture after long-term bisphosphonate use, a radiograph of the contralateral femur should be obtained to assess for a cortical stress reaction.

Risk of Mortality: The Relationship With Associated Injuries and Fracture Treatment Methods in Patients With Unilateral or Bilateral Femoral Shaft Fractures

The aim of the study was to determine the relative contributions to mortality of a unilateral or a bilateral femoral fracture in patients with or without injuries to other body regions. An observational cohort study of the prospectively recorded England and Wales Trauma Registry data (Trauma Audit Research Network) from 1989 to 2003. Patients were divided into the following groups: UFi (isolated unilateral femur injury), BFi (isolated bilateral femur injury), and UFa and BFa, if an associated injury was present. Injury and treatment data were collected for each patient. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. Patients in group BFa had an increased mortality rate (31.6% vs. 9.8%) than patients in isolated bilateral femur injury group. Group BFa patients had an increased number of associated injuries (80%) than group UFa patients. Bilateral fracture, even in isolation, significantly increased the odds of mortality by 3.07. Intramedullary nailing was the method of fracture fixation associated with the lowest patient mortality overall. When assessing patient mortality in the BFa group with an New Injury Severity Score of >40, seven other fracture fixation regimens were associated with a lower mortality. The increase in mortality with BFs is more closely associated with the presence of associated injuries and poor physiologic parameters than with the presence of the BF alone. The presence of BFs should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential. Damage control fixation options should be considered in the subgroup with a very high New Injury Severity Score.

Insufficient bilateral femoral subtrochanteric fractures in a patient receiving imatinib mesylate

We present a case of insufficient bilateral femoral subtrochanteric fractures in a patient who was treated with imatinib mesylate, an anticancer drug, for 1year after a diagnosis of chronic myelogenous leukemia (CML). A 60-year-old woman presented with bilateral thigh pain for 6months. A plain radiograph revealed bilateral progressive insufficient fractures on the subtrochanteric areas of the femurs. MRI of the femurs revealed incomplete stress fractures and no evidence of bone metastasis on either femur. Bone densitometry showed normal T-scores around the hip joint and spine. The patient had normal serum levels of calcium, vitamin D derivatives, and thyroid hormones. Serum phosphate levels were decreased, and parathyroid hormone levels were increased. Serum osteocalcin and urinary N-telopeptide of collagen cross-links (NTx) were both decreased. A bone biopsy demonstrated normocellular marrow without leukemic cells. A histomorphometric evaluation of her bones revealed reduced bone turnover despite secondary hyperparathyroidism. The serum markers for bone metabolism and histomorphometric evaluations in this patient suggest that the drug may have an effect on bone metabolism. These effects could be seen for both bone formation and resorption: this could result in impaired bone mineralization, a severely suppressed bone turnover rate, insufficient fractures, and bone necrosis, which are sometimes seen with long-term use of bisphosphonates. To our knowledge, this is the first case of an insufficient bilateral femoral shaft fracture that is potentially related to the use of imatinib mesylate in a patient with CML. Careful examination of bone metabolism should be performed in patients with CML because imatinib mesylate treatment is a lifelong process.

Is Damage Control Orthopedics Essential for the Management of Bilateral Femoral Fractures Associated or Complicated With Shock? An Animal Study

The maximum score of a single anatomic system, the Injury Severity Score, may not reflect the overall damage inflicted by bilateral femoral fractures and justify the strategy of damage control orthopedics (DCO). It is necessary to investigate effects of various therapeutic procedures on such fractures with or without shock to facilitate correct decision making on DCO. A model of bilateral femoral fractures was made in 36 of 48 male New Zealand White rabbits. A model of bilateral femoral shaft fractures associated with shock was made. After resuscitation, a reamed intramedullary nailing fixation was performed in the first group (IM group), and an external fixation device applied in the second group (EF group), and the fractures in the third group (control group) were supported with splints only. They were divided into four groups: shock with IM nailing (shock-IM), shock with external fixation (shock-EF), shock with conservative method (shock-Cons), and intramedullary nailing without shock (nonshock-IM). Vital signs and inflammatory reactions were recorded. Thirty-six hours after the therapeutic procedures in four groups, the animals were killed for histologic evaluation. The changes of vital signs were most significant in shock-IM group (p < 0.05). The exaggerated levels of interleukin-6, Interleukin-10, and tumor necrosis factor alpha concentrations demonstrated a significant difference between all the groups-shock-IM and other groups (p < 0.05). As to histologic appearances, the statistical difference varies from organ to organ. There is highly significant difference when the IM group is compared with the other two groups as far as lungs are concerned. As to the liver, there is only significant difference between the IM group and the control group. In terms of kidney and heart, there is no significant difference cross the groups. As to histologic appearances, there is highly significant difference in lungs between shock-IM group and other three groups. There is significant difference in liver between the shock-IM group and the shock-Cons group (p < 0.05). Kidneys and heart were less affected cross the groups. In this study, an early reamed intramedullary nailing fixation procedure resulted in more adverse effects on system stress, inflammatory response, and multiple organs. The injuries also cause histologic damages to lungs and liver. Therefore, early reamed intramedullary nailing fixation may pose a potential risk of developing complications and adopting the DCO strategy may be more preferable. Shock and IM combined cause most severe damages, followed by IM without shock, shock plus EF, and shock plus conservative procedure in that order. If IM must be used for some reasons, it is desirable be delayed until shock has been fully controlled and vasculorespiratory stability restored.

Resuscitation Before Stabilization of Femoral Fractures Limits Acute Respiratory Distress Syndrome in Patients With Multiple Traumatic Injuries Despite Low Use of Damage Control Orthopedics

Femoral shaft fractures are associated with acute respiratory distress syndrome (ARDS). The idea that primary intramedullary nailing increases the incidence of ARDS has theoretical support. Our approach to treating femoral fractures in patients with multiple traumatic injuries is to perform reamed nailing after adequate resuscitation has been shown by normalizing lactate plus optimized ventilatory and hemodynamic parameters. Damage control orthopedics (DCO) with primary external fixation usually is reserved for those rare patients who do not respond to resuscitation. Our hypothesis was that this approach yields a low rate of ARDS. A prospective trauma database was searched for all femoral shaft fractures treated at a Level I trauma center during a 3-year period, yielding 582 patients. Exclusion criteria included death before treatment (n = 9), age younger than 16 years (n = 16), age older than 65 years (n = 35), fractures that were not amenable to nail fixation (n = 31), shaft fractures treated with a plate (n = 3), patients with bilateral femoral shaft fractures who had a primary nail placed in one femur and an external fixator on the other limb (n = 1), and patients with an Injury Severity Score (ISS) <or=17 (n = 260), leaving 227 patients in the final study group. We defined ARDS as a mean partial pressure of oxygen/fraction of inspired oxygen <200 for 5 or more consecutive days. We compared our results with the results of a similar design in the literature. Of the 227 patients with ISS >17, only 12% were initially treated with DCO, and 88% were treated with primary reamed nailing. The 227 patients achieved successful early resuscitation as shown by lactate values that decreased significantly on the operative day compared with presenting values (p < 0.05). ARDS rates were low, including rates for the subgroup of patients with lung injury (thoracic Abbreviated Injury Scale score >2, n = 175) who were treated with nailing and had an ARDS rate of 2.0% and a death rate of 2.0%. The ARDS rate for the most severely injured patients who underwent nailing (ISS >28, thoracic Abbreviated Injury Scale score >2, n = 78) was only 3.3%, and 1.7% died. In the context of resuscitation before reamed intramedullary nailing of femoral shaft fractures, our rate of ARDS was lower (p < 0.001) than that of a similar study reported in the literature in which the DCO approach was used in up to 36% of patients (p < 0.001) and was more in keeping with previously reported rates of ARDS. This remained true despite frequent use of early reamed femoral nailing and infrequent use of DCO. An explanation for the discrepancy between the centers might be differences in preoperative resuscitation or medical care provided to treat shock.

Bilateral femoral shaft fractures in an adolescent snowboarder

A 23-year-old male snowboarder suffered bilateral femoral shaft fractures from a jumping accident. On the day following the injury, closed intramedullary nailings with static locking were inserted. Follow-up radiographs revealed that bone unions had formed in the bilateral femurs. The patient was able to walk without the help of a cane, and returned to work. Snowboard injuries most frequently involve the upper extremities, so that there have been no previous reports of bilateral femoral shaft fractures in snowboarders. Generally, femoral shaft fractures result from high-energy injury; however, in this case, the board dug into the ground on landing, and the patient was pitched forward with his lower legs bound to the ground via the board so that the indirect force caused the bilateral femoral shaft fractures. Jumping is becoming the main cause of snowboard injuries. Therefore, in order to decrease the number of snowboard-associated injuries, we should encourage snowboarders to be more cautious about jumping.

Estimation of pretraumatic femoral antetorsion in bilateral femoral shaft fractures

To describe a system for measurement of the pretraumatic femoral antetorsion angle post-bilateral femoral shaft fracture with the use of new imaging software which allows segmentation and three dimensional (3D) reconstruction of DICOM (digital imaging and communications in medicine) images. This case involved a 20-year-old patient with bilateral femoral shaft fractures. Following initial clinical examination, CT scans of both femurs were performed. Subsequently, the DICOM datasets were uploaded to the new software tool. Following segmentation and 3D reconstruction, pretraumatic femoral antetorsion angles were determined. Femoral antetorsion was described and assessed in two ways by referring to the intersection of the posterior condylar plane and (1) a line drawn between the center of the femoral head and femoral neck, (2) a line drawn between the centers of the femoral head and greater trochanter. Using these definitions, values for femoral antetorsion were found to be, respectively, 20 degrees at the right fracture site and 19 degrees on the left site, and 33 degrees bilaterally. The investigators describe in this current technical report the use of new imaging software which enables the calculation of femoral AV following reduction of virtual fracture fragments which are created from standard DICOM images. We believe that this 3D reconstruction method of measuring the antetorsion angle can be integrated into a regular treatment algorithm and may potentially optimize clinical outcomes.

両側大腿骨近位部・骨幹部骨折の１例

両側大腿骨近位部・骨幹部骨折の１例

OPINION: Closed Rigid Locked Intramedullary Nailing

From the Department Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO. Case Profile: A 9-year-old boy who was a restrained passenger in a motor vehicle accident suffered bilateral femoral shaft fractures as isolated injuries. Physical examination revealed deformity in both legs at the level of the midfemur. The patient was neurovascularly intact in both lower extremities. Radiographs revealed bilateral midshaft femur fractures with significant shortening and malrotation.