Stabilization Of Femoral Fractures Research Articles

A open reduction and intramedullary pinning for diaphyseal femoral fracture stabilization in a canine patient

A open reduction and intramedullary pinning for diaphyseal femoral fracture stabilization in a canine patient

Physical therapy after femur fracture in elderly patients at the long-term rehabilitation stage

Femoral neck fractures are the leading cause of disability among the elderly. Rehabilitation is fundamental to restore functionality that was before the fracture. Aim. To conduct an observational cohort study to compare the effectiveness of rehabilitation programs in different therapeutic settings. Materials and methods. Elderly patients who underwent surgical stabilization of femur fracture were included in the study. The participants were divided into 3 groups: group 1 – outpatient rehabilitation; group 2 – inpatient rehabilitation; group 3 – rehabilitation at home. Rehabilitation results were determined at the initial stage, 3 and 6 months after the fracture. The Barthel index, passive and active range of motion in hip flexion and extension, and the muscle strength in flexion, extension, and extension of the knee joint were assessed. Results. In 6 months, all three groups showed statistically significant improvement (p < 0.05) in all indices compared to baseline. Considering the intergroup analysis, the final Barthel index score was significantly higher in patients who were treated as outpatients (88.00 ± 9.6) than inpatients (68.57 ± 11.7), but no statistical difference was found between patients who were treated as outpatients and at home (82.5 ± 10.4). In general, patients who were treated in outpatient settings showed better functional outcomes, while patients who were rehabilitated in inpatient settings had worse outcomes. Patients treated at home showed intermediate final functional outcomes more similar to outpatients. Patients with hip fracture undergoing outpatient rehabilitation were more likely to have better long-term effects of the rehabilitation protocol regarding the functional status, muscle strength in hip flexion, hip extension, and knee extension. Patients referred to home rehabilitation showed intermediate results, closer to outpatients, although they started rehabilitation treatment faster after the hospital discharge. Conclusions. The data obtained indicate that rehabilitation leads to significant functional recovery after femur fracture in elderly patients. Both outpatient and home-based rehabilitation are acceptable rehabilitation options for femoral fractures.

Heterotopic Ossifications Following Intramedullary Stabilization of Femoral Fractures in Polytraumatized Patients.

Heterotopic ossifications (HOs) are a well-known complication following total hip arthroplasty. Yet only little is known about the development of HOs following a femoral fracture and intramedullary stabilization in polytraumatized patients. Thus, the present study aimed to investigate whether the development of HOs is being observed more frequently in patients suffering polytrauma compared to those with single-extremity trauma. The retrospective outcome study was conducted at our level I trauma center. All patients admitted from 2010 to 2020 were included if they (1) presented with multiple injuries (≥2 body regions), (2) had an Injury Severity Score ≥16, (3) suffered a femoral fracture, and (4) were treated with intramedullary stabilization. Furthermore, a control group was established to match the polytrauma group (sex, age), who were suffering from single-extremity trauma (femoral fracture) which was treated with intramedullary stabilization. Subsequently, X-rays of the hip were performed and evaluated for up to one-year post-trauma. Our study group consisted of 36 patients in total (91.7% male; mean age 39.4 ± 17.4 years, range: 18-82 years). The polytrauma (PT) group included 12 patients (mean age 39.5 years, median ISS 28), whereas the control group (single-extremity-trauma) included 24 patients (mean age 39.3 years). We documented HOs in nine (75%) patients in the PT group vs. five (20.8%) patients in the single-extremity group (p = 0.03). In this study, we were able to demonstrate that heterotopic ossifications are being observed significantly more frequently in patients suffering from polytrauma in comparison to patients with single-extremity trauma following intramedullary stabilization after a femoral fracture.

Functional Outcome of Shaft of Femur Fracture Fixation with Elastic Nail in Children Between 05 to 10 Years of Age

Introduction: Femoral fractures are one of the most common issues in the childrens population. Between 6-16 age, there's no strong agreement as to the favored therapy. The therapy of femoral fractures in children has progressively changed towards a more operative tactic within the past two decades. This is because healthcare criteria demand more rapid mobilisation , early discharge and return to family with normal activity. Operative treatment results in short hospitalization and early mobilization, which has psychological, social, educational and economic advantages over conservative treatment. Aims & Objectives: The aim of our study is to determine the frequency of functional outcome with Flynn’s criteria in shaft of femur fracture stabilization with elastic nails in pediatric population between 5 to 10 years of age presenting in a tertiary care hospital. Place and Duration of Study: We conducted ‘Descriptive case series’, in the unit of Orthopedic Surgery, Services Hospital, Lahore from 01-09-2021 to 01-03-2022. Material & Methods: Sixty patients ranging from 5-10 yrs of age, fulfilling the selection criteria were enrolled after the informed consent in the study through the emergency of the Department of Orthopedic Surgery, Services Hospital, Lahore. Surgery for femoral fracture was performed in these patients under general anesthesia by a single surgical team with the assistance of the researcher. The children were followed up at 1, 2, 3, and 6 months. After 6 months, patients were evaluated according to Flynn’s criteria for femoral fracture outcomes with nailing and results were noted as excellent, satisfactory and poor. All the information was recorded in proforma. Data was entered and analyzed using SPSS version. 25.P-value ?0.05 was taken as significant. Results: Out of 60 patients, 23.3 % ( n=14) were in age group of 5-7 years and 76.7 %( n=46) were in age group of 8- 10years and mean age was 8.17±1.01years. 65.0 %( n=39) were male and 35.0 %( n=21) were females. Out of 60 patients, 21.7 % ( n=13) had road traffic accident, 63.3 %( n=38) had history of fall and 15.0 %( n=9) had miscellaneous cause of injury. The frequency of functional outcome according to flynn’s criteria was excellent in 51.7 %( n=31). Conclusion: We concluded that elastic nail is moderately simple to utilize and an compelling treatment for fractures of femoral shaft in legitimately chosen children by applying Flynn's criteria for functional outcome and can further be compared with other treatment modalities.

Repair of a Comminuted Femur Fracture in a Komodo Dragon (Varanus komodoensis) Using a Double Plating Technique

This report describes double locking compression plate fixation of a moderately comminuted mid-diaphyseal right femur fracture in a Komodo dragon (Varanus komodoensis). The animal was restrained for a routine examination, during which the dragon struggled to escape restraint. When returned to the exhibit, the dragon did not use the right pelvic limb to walk. A right-sided, closed, mid-diaphyseal comminuted (type C3) femur fracture was diagnosed using palpation and radiographs, and the animal was transported to a specialty clinic within a few hours for fracture repair. Two locking compression plates (LCPs) were applied in bridging fashion for fracture repair. Radiographs performed at the four-month post-operative recheck revealed a healed fracture with significant callus formation and stable implants. The dragon was transitioned from cage rest in a restricted space to his normal large exhibit after healing was confirmed, no lameness was observed, and normal limb use was noted. After almost three years, he is still ambulating normally and without lameness. This is the first report of successful femur fracture stabilization using bone plate fixation in a Komodo dragon.

Total Hip Arthroplasty for Failed Osteosynthesis of Proximal Femoral Fractures: Clinical Outcomes from a Low- and Middle-Income Country

Introduction Total hip arthroplasty (THA) has a demonstrated utility in the surgical management of patients with proximal femoral fractures that fail internal fixation, with good outcomes reported from high-income countries. Given the lack of data from resource-limited settings, this work sought to report the clinical outcomes of THA for failed proximal femoral osteosynthesis from a low- and middle-income country (LMIC). Methods The work was conducted and reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. A retrospective cohort study was carried out on all patients who underwent rescue THA for failed osteosynthesis of proximal femoral fractures, from January 2016 to June 2020, at a tertiary care center in Northern India. Primary study outcomes were functional outcomes as assessed by Harris Hip Score (HHS) at 1-year postoperatively and the frequency of perioperative complication as assessed by Clavien-Dindo-Sink Grading System. Results Twenty-eight patients with mean age of 43.25 ± 10.5 years were included, with 18 males and 10 females. For their femur fracture stabilization, the most common method used had been dynamic hip screw (n = 16, 57.1%), followed by cannulated cancellous screw (n = 6, 21.5%), proximal femoral nail (n = 3, 10.7%), dynamic condylar screw (n = 2, 7.1%), and Schanz Screw (n = 1, 3.6%). Causes of failure had included cut-out of screw (n = 14, 50.0%), avascular necrosis (n = 8, 28.6%), back-out of screw (n = 3, 10.7%), non-union (n = 2, 7.1%), and secondary osteoarthritis (n = 1, 3.6%). THA was carried out after mean 26.64 ± 9.01 months after index procedure. HHS improved significantly from 39.71 ± 10.89 preoperatively to 79.54 ± 4.22 at 1-year follow-up (mean difference 39.82, 95% confidence interval 43.66–35.98, P < 0.001). Perioperative complications occurred in two patients of Clavien-Dindo-Sink Grade III and another of Grade II, with no mortality occurring by 1 year. Conclusions In resource-limited settings like LMICs, THA may be a safe and efficacious surgical modality for failed osteosynthesis of proximal femoral fractures.

Fracture fixation strategy and specific muscle tissue availability of neutrophilic granulocytes following mono- and polytrauma: intramedullary nailing vs. external fixation of femoral fractures

BackgroundIn the stabilization of femoral fractures in mono- and polytrauma, clinical practice has shown better care through intramedullary nailing. However, the reason why this is the case is not fully understood. In addition to concomitant injuries, the immunological aspect is increasingly coming to the fore. Neutrophil granulocytes (PMNL), in particular next to other immunological cell types, seem to be associated with the fracture healing processes. For this reason, the early phase after fracture (up to 72 h after trauma) near the fracture zone in muscle tissue was investigated in a pig model.Material and methodsA mono- and polytrauma pig model (sole femur fracture or blunt thoracic trauma, hemorrhagic shock, liver laceration, and femur fracture) was used to demonstrate the immunological situation through muscle biopsies and their analysis by histology and qRT-PCR during a 72 h follow-up phase. Two stabilization methods were used (intramedullary nail vs. external fixator) and compared with a nontraumatized sham group.ResultsMonotrauma shows higher PMNL numbers in muscle tissue compared with polytrauma (15.52 ± 5.39 mono vs. 8.23 ± 3.36 poly; p = 0.013), regardless of the treatment strategy. In contrast, polytrauma shows a longer lasting invasion of PMNL (24 h vs. 72 h). At 24 h in the case of monotrauma, the fracture treated with external fixation shows more PMNL than the fracture treated with intramedullary nailing (p = 0.026). This difference cannot be determined in polytrauma probably caused by a generalized immune response. Both monotrauma and polytrauma show a delayed PMNL increase in the muscle tissue of the uninjured side. The use of intramedullary nailing in monotrauma resulted in a significant increase in IL-6 (2 h after trauma) and IL-8 (24 and 48 h after trauma) transcription.ConclusionThe reduction of PMNL invasion into the nearby muscle tissue of a monotrauma femur fracture stabilized by intramedullary nailing supports the advantages found in everyday clinical practice and therefore underlines the usage of nailing. For the polytrauma situation, the fixation seems to play a minor role, possibly due to a generalized immune reaction.

Use of String of Pearls Locking Plate System For Stabilization of Femoral Fractures in Canines

Use of String of Pearls Locking Plate System For Stabilization of Femoral Fractures in Canines

Elastic Stable Intramedullary Nailing for Treatment ofPediatric Femoral Fractures; A 15-Year Single Centre Experience.

Objective:To analyze outcomes of treatment and complications in children treated with elastic stable intramedullary nailing (ESIN) due to femoral fracture.Methods:From May 2002 until May 2018 case records of 103 patients (76 male and 27 female), with median age of 9 (range, 3-17) and follow-up of 92 months, who underwent ESIN because of displaced femoral fracture were retrospectively reviewed. The patient’s information including age, sex, side involved, trauma mechanism, type of fracture, associated injuries, neurovascular status, complications, operation time, duration of hospital stay, time to implant removal were analyzed. The surgical procedure implied a reposition of bone fragments and osteosynthesis with titanium elastic nails introduced through an incision over the lateral and medial border of the distal femoral metaphysis. Results:All patients achieved complete radiographic healing at a mean of 8.5 (range, 5-15) weeks. Nine (8.49%) postoperative complications were recorded: three entry site skin irritation, two cases of valgus angulation and one case of nail protrusion, re-fracture, Varus angulation and delayed union. All complications, except case of re-fracture and one valgus angulation, were treated conservatively, with no long term consequences for the patients. Two patients were re-operated. After removal of nails all patients recovered complete function of the extremity, without long term consequences.Conclusion:The ESIN for treatment of femoral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. Because of the excellent objective and subjective results, the operative stabilization of femoral fractures with ESIN should be recommended to all pediatrics patients

Retrograde nailing versus locked plating for distal femur fractures

Purpose Two major therapeutic principles can be employed for the treatment of distal femoral fractures: Retrograde Intramedullary Nail (RIN) or locked plating (LP). Both operative stabilizing systems follow the principle of biological osteosynthesis. Intramedullary nailing protects the soft tissue envelope owing to its minimally invasive approach and closed reduction techniques better than distal femoral LP. The purpose of this study was to evaluate and compare outcome of distal femur fracture stabilization using RIN or LP techniques. Patients and methods In a prospective study from 2014 to 2015, we analyzed 30 patients with distal femur fracture who had been treated by RIN (15 patients) or LP (15 patients). The patients had a mean age of 49 years (20–85 years). Mechanism of injury was high-energy impact in 66.7% and low-energy injury in 33.3%. Fractures were classified according to Association for Osteosynthesis (AO) classification: there were 17 type A fractures and 13 type C1 fractures. Functional and radiological outcomes were assessed. Results Clinical and radiographic evaluation according to the functional score of Sanders and colleagues demonstrated that, in RIN group, one (6.6%) case was excellent, nine (60%) cases were good, and four (26.8%) cases were fair, whereas in locked compression plates (LCP) group; eight (53.2%) cases were good, four (26.8%) cases were fair, and three (20%) cases were poor. In RIN group, the average time of fracture union was 19.5 weeks, with a range of 12–28 weeks. Of 15 cases, 14 (93.4%) cases progressed to union, and one (6.6%) case had delayed union and need dynamization. In LCP group, average time was 27.65 weeks, with a range of 12–32 weeks. Of 15 cases, 12 (80%) cases progressed to union, one (6.6%) case had nonunion, and two (13.4%) cases had delayed union. Conclusion Both femoral retrograde interlocking nail and LCP of distal femur appear to have statistically insignificant differences regarding knee motion, pain, resuming function, and rate of need of second surgery. However, retrograde nail is preferable to LP in terms of operative time, blood loss, image intensifier exposure time, early appearance of callus, weight bearing, and shorter time required for full union.

A study to evaluate functional outcomes of distal femur fractures

Purpose: Despite advances in techniques and improvements in surgical implants, treatment of distal femoral fractures remains a challenge in many situations. Debate continues around choice of implant for fixation of metaphyseal-diaphyseal fractures. In this prospective study, we had evaluated and compared clinical and radiological outcomes of distal femur fracture stabilization. Study design: We conducted interventional study on adult patients having distal femur fractures. 58 fractures were presented during study period. 12 patients were excluded due to Polytrauma (6), head injuries (2), spine injuries (2) and unwilling to participate (2). Forty six patients were evaluated at the end of study. Demographic variables, fracture pattern, mode of injury, union time, non union, and complications were recorded in proforma evaluated at the end of follow up using Pritchett outcome scores. Results: Mean age was 44.7±18.18 yrs. Fifty percent had AO 3.3C injuries. 47.8% patients underwent distal femoral locked plate fixation. 26% had open fractures. 45.7% fractures united within 6 months of surgical procedure. 32.6% patient had excellent outcome. Loss of fixation was related to pain and tendency to worse outcome according to Pritchett score. Conclusion: Stable fixation and early knee joint mobilization are important factors for good functional outcome of distal femoral fracture.

Feasibility of and Rationale for the Collection of Orthopaedic Trauma Surgery Quality of Care Metrics.

Reproducible metrics are needed to evaluate the delivery of orthopaedic trauma care, national care, norms, and outliers. The American College of Surgeons (ACS) is uniquely positioned to collect and evaluate the data needed to evaluate orthopaedic trauma care via the Committee on Trauma and the Trauma Quality Improvement Project. We evaluated the first quality metrics the ACS has collected for orthopaedic trauma surgery to determine whether these metrics can be appropriately collected with accuracy and completeness. The metrics include the time to administration of the first dose of antibiotics for open fractures, the time to surgical irrigation and débridement of open tibial fractures, and the percentage of patients who undergo stabilization of femoral fractures at trauma centers nationwide. These metrics were analyzed to evaluate for variances in the delivery of orthopaedic care across the country. The data showed wide variances for all metrics, and many centers had incomplete ability to collect the orthopaedic trauma care metrics. There was a large variability in the results of the metrics collected among different trauma center levels, as well as among centers of a particular level. The ACS has successfully begun tracking orthopaedic trauma care performance measures, which will help inform reevaluation of the goals and continued work on data collection and improvement of patient care. Future areas of research may link these performance measures with patient outcomes, such as long-term tracking, to assess nonunion and function. This information can provide insight into center performance and its effect on patient outcomes. The ACS was able to successfully collect and evaluate the data for three metrics used to assess the quality of orthopaedic trauma care. However, additional research is needed to determine whether these metrics are suitable for evaluating orthopaedic trauma care and cutoff values for each metric.

Metallurgical Failure Analysis of Intramedullary Nail Used for Femoral Fracture Stabilization

Currently orthopedics challenge is the use of intramedullary nails to straighten diaphyseal femoral fractures. In this paper it was conducted a case study on an intramedullary nail used for femoral fracture stabilization, in the case of one young patient. The evolution was unfavorable to the fracture site and the implant failed after three month of first surgical intervention. Intramedullary nail dimensions were 300mm length and 10mm in diameter. The following investigations were made in order to establish the failure causes: determination of the chemical composition through spectral analysis, macrostructural analysis using stereomicroscopy, optical microstructural analysis using optical microscopy, fractographic analysis using scanning electron microscopy. The final conclusions showed that the metallic biomaterial used for manufacturing the intramedullary nail was approximately an austenitic stainless steel AISI 316L, but with major microstructural defects. Macro-structural analysis revealed the presence of two zones of cracking, which are very rare at austenitic stainless steels. Also breaking with a fragile character has radial front tear propagation. In longitudinal section, cracks were evidenced due to the extraction operation and also the presence of corrosion products was shown. From fractographic analysis it was determined that intramedullary nail failure was predominantly through the mechanism of brittle fracture that took place at the point of maximum bending of the implant fragile.

Mechanical rigidity of the Ortho-SUV frame compared to the Ilizarov frame in the correction of femoral deformity.

The Ortho-SUV frame (OSF) is a novel hexapod circular external fixator which draws upon the innovation of the Ilizarov method and the advantages of hexapod construction in the three-dimensional control of bone segments. Stability of fixation is critical to the success or failure of an external circular fixator for fracture or osteotomy healing. In vitro biomechanical modelling study was performed comparing the stability of the OSF under load in both original form and after dynamisation to the Ilizarov fixator in all zones of the femur utilising optimal frame configuration. A superior performance of the OSF in terms of resistance to deforming forces in both original and dynamised forms over that of the original Ilizarov fixator was found. The OSF shows higher rigidity than the Ilizarov in the control of forces acting upon the femur. This suggests better stabilisation of femoral fractures and osteotomies and thus improved healing with a reduced incidence of instability-related bone segment deformity, non-union and delayed union.

Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma.

Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as "low." No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated "low." In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

Surgical Stabilization of Femur Fractures in Post-Traumatic Hypoxemic Patients: When and Why?

Background:Post-traumatic hypoxemia can deteriorate during operative manipulations.Objectives:In the present study, criteria-based approach was applied to determine optimum conditions for femur surgery. The aim of this study was to optimize perioperative management of post-traumatic hypoxemia.Patients and Methods:In this prospective observational study, post-traumatic adults with PaO2 < 70 mmHg in room air were enrolled. Physiological parameters, O2 saturation (SO2), arterial blood gas (ABG) analysis, Schonfeld fat embolism index score (SS), and Murray’s lung injury scores (LIS) were assessed. The management protocol was femur surgery when patient was hemodynamically stable with LIS < 2.5 and PaO2/FiO2 > 200 mmHg (FiO2 < 0.5, PEEP < 8 cm H2O).Results:A total of 31 adults (26 males and 5 females) with LIS of 0.1 to 2.5 (26 patients) and > 2.5 (five patients) at admission were recruited. Sixteen patients were admitted within 24 hours and 15 between 24 and 90 hours after injury. Thirteen patients were operated within 24 hours. Post-operative LIS was improved. No adverse sequels or mortality were seen.Conclusions:Appropriate surgical stabilization can be safely performed during established post-traumatic hypoxemia using a multidisciplinary approach, continuous monitoring, and serial investigations to diagnose fulminant pathology and associated injuries.

Placas ósseas confeccionadas a partir de diáfise cortical equina na osteossíntese femoral em coelhos

A evolução tecnológica tem possibilitado o desenvolvimento e o aperfeiçoamento de novos materiais para implantes. Apesar dos fundamentais benefícios providos pelos dispositivos ortopédicos, complicações decorrentes de corrosão, degradação, infecção, além de outras podem ocorrer. O entendimento das características dos biomateriais é fundamental para a previsibilidade do seu comportamento in vivo, fornecendo subsídios para que o composto mais adequado seja escolhido na reconstrução do defeito ósseo. As placas de origem metálica são as mais utilizadas para o reparo de fraturas de ossos longos, sendo mecanicamente resistentes e biocompatíveis. No entanto, a necessidade de remoção e o enfraquecimento do osso são suas principais desvantagens. Neste trabalho, placas produzidas a partir de osso cortical equino foram empregadas experimentalmente em fêmur osteotomizado de coelhos (Grupo osso-GO), num estudo comparativo com placas de metal (Grupo metal-GM). A avaliação radiográfica foi realizada a cada 30 dias, durante 120 dias, momento em que foi então realizada análise histológica do material em estudo. Não houve diferença estatisticamente significante entre os dois grupos com relação à morfometria do calo ósseo e consolidação óssea em todos os momentos avaliados, sendo que ambas as placas permitiram a consolidação em todos os animais. Entretanto, observou-se que o calo ósseo foi menor no GO, em relação ao GM, em todos os momentos do estudo. Por outro lado, a maior parte dos animais do GO apresentou consolidação completa da fratura aos 90 dias, enquanto que no GM isto ocorreu aos 60 dias. Não foram evidenciadas células do tipo corpo estranho na histopatologia dos animais do GO, mas maior quantidade de tecido fibroso foi identificada, envolvendo este biomaterial. A placa confeccionada com osso equino representa uma alternativa de baixo custo e muito viável, uma vez que permitiu estabilização adequada para consolidação óssea de fratura de fêmur em coelhos. Neste estudo, a menor formação de calo periosteal, associada a um tempo superior para consolidação em GO sugerem maior estabilidade da fratura onde a placa de osso foi utilizada.

Clinical Utility of Intra-Operative 6% Hydroxyethyl Starch (130 / 0.4) Supplementation in Hypoxemic Femur Injury Patients: A Preliminary Report of Twenty Cases

Posttraumatic intravasation of fat and debris can lead to a cascade of events. Hydroxyethyl starches (HES) markedly suppress neutrophil influx by decreasing pulmonary capillary permeability and facilitating tissue oxygenation by improving microcirculation. It was hypothesized that in hypoxemic femur injury patients undergoing operative stabilization, HES administration will prevent the deterioration of respiratory variables and facilitates recovery. This prospective, double-blind, randomized preliminary study, enrolled twenty posttraumatic hypoxemic patients (room air PaO2 < 70 mmHg, Schonfeld fat embolism index score (SS) > 5) scheduled for femur fracture stabilization under general anesthesia. Patients were allocated to receive either; 6% HES 130/0.42, 15 mL/kg or 0.9% normal saline (NS) to maintain their central venous pressure (CVP) 12 + 2 mm Hg. Blood was transfused according to the maximum allowable blood loss and by serial hematocrit estimations. Perioperative Glasgow Coma Scale (GCS), physiological variables, arterial oxygen saturation (SpO2), arterial blood gas (ABG), SS and P/F ratios were recorded until recovery. The partial pressure of oxygen in arterial blood / fraction of inspired oxygen ratio (PaO2/FiO2) improved from a preoperative value of 273.33 ± 13.05 to 435.70 in the 6% Hydroxyethyl starch group (HES) and from 275.24 ± 15.34 to 302.25 ± 70.35 in the NS group over a period of six days (P values =0.970, 0.791, 0.345, 0.226, 0.855, 0.083, 0.221). Time taken to achieve a P/F ratio > 300 and for persistent reduction of Murray’s lung injury score (LIS) were comparable (P = 0.755 and 0.348, respectively). The number of ventilator, intensive care unit (ICU) and hospital stay days, did not differ (P value = 0.234, 1.00, 0. 301, respectively). There were no adverse sequelae or mortalities. A trend showing relatively fast improvement in the P/F ratio and an early reduction in LIS values was observed in hypoxemic, femur injury patients receiving intraoperative colloid supplementation.

Early Appropriate Care: Definitive Stabilization of Femoral Fractures Within 24 Hours of Injury Is Safe in Most Patients With Multiple Injuries

Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications. Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury. Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04). Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.

Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis

Background:Two major therapeutic principles can be employed for the treatment of distal femoral fractures: retrograde intramedullary (IM) nailing (RN) or less invasive stabilization on system (LISS). Both operative stabilizing systems follow the principle of biological osteosynthesis. IM nailing protects the soft-tissue envelope due to its minimally invasive approach and closed reduction techniques better than distal femoral locked plating. The purpose of this study was to evaluate and compare outcome of distal femur fracture stabilization using RN or LISS techniques.Materials and Methods:In a retrospective study from 2003 to 2008, we analyzed 115 patients with distal femur fracture who had been treated by retrograde IM nailing (59 patients) or LISS plating (56 patients). In the two cohort groups, mean age was 54 years (17–89 years). Mechanism of injury was high energy impact in 57% (53% RN, 67% LISS) and low-energy injury in 43% (47% RN, 33% LISS), respectively. Fractures were classified according to AO classification: there were 52 type A fractures (RN 31, LISS 21) and 63 type C fractures (RN 28, LISS 35); 32% (RN) and 56% (LISS) were open and 68% (RN) and 44% (LISS) were closed fractures, respectively. Functional and radiological outcome was assessed.Results:Clinical and radiographic evaluation demonstrated osseous healing within 6 months following RN and following LISS plating in over 90% of patients. However, no statistically significant differences were found for the parameters time to osseous healing, rate of nonunion, and postoperative complications. The following complications were treated: hematoma formation (one patient RN and three patients LISS), superficial infection (one patient RN and three patients LISS), deep infection (2 patients LISS). Additional secondary bone grafting for successful healing 3 months after the primary operation was required in four patients in the RN (7% of patients) and six in the LISS group (10% of patients). Accumulative result of functional outcome using the Knee and Osteoarthritis Outcome (KOOS) score demonstrated in type A fractures a score of 263 (RN) and 260 (LISS), and in type C fractures 257 (RN) and 218 (LISS). Differences between groups for type A were statistically insignificant, statistical analysis for type C fractures between the two groups are not possible, since in type C2 and C3 fractures only LISS plating was performed.Conclusion:Both retrograde IM nailing and angular stable plating are adequate treatment options for distal femur fractures. Locked plating can be used for all distal femur fractures including complex type C fractures, periprosthetic fractures, as well as osteoporotic fractures. IM nailing provides favorable stability and can be successfully implanted in bilateral or multisegmental fractures of the lower extremity as well as in extra-articular fractures. However, both systems require precise preoperative planning and advanced surgical experience to reduce the risk of revision surgery. Clinical outcome largely depends on surgical technique rather than on the choice of implant.