High-energy Femoral Fractures Research Articles

Circular external fixation as definitive treatment for open or comminuted femoral fractures: Radiologic and functional outcomes

IntroductionRing external fixation can be a definitive treatment of high energy femoral fractures. A retrospective analysis of outcomes is presented. Materials and methods23 patients with open or comminuted femoral fractures treated with circular external fixators were included. Mean age was 33 (range, 13–81) years. Lesions were classified according to AO/ASIF. 12 fractures were open. Mean follow up period has been 26.3, (range 20–144) months. The results were assessed according to the modified criteria of Association for the Study and Application of the Method of Ilizarov. Knee functional results were assessed with Hospital for Special Surgery knee scoring system. Results22 fractures united primarily, one showed nonunion. Knee stiffness developed in two patients. No patient had deep pin tract infection. Bone results were quoted as excellent, good, fair and poor in 19, 1, 1 and 2. The functional results were excellent, good, and fair in 16, 6, and 1, on the basis of ASAMI criteria. Mean HSS knee score has been 90.1 (range 60–100). ConclusionCircular external fixation can achieve reliable rates of union and good to excellent functional outcome in open or comminuted femoral fractures. A strict rehabilitation protocol was effective in preserving knee joint function.

Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis

PurposeIn patients following severe trauma sometimes the physiological condition or soft tissue status may not allow definitive fixation of a femoral fracture. In these patients, an external fixator can be placed to temporarily stabilise the fracture, after which definitive fixation can be performed in a second procedure. The aim of this study was to compare the postoperative wound infection and union rates of patients treated with direct intramedullary nailing (IMN) and patients treated with the ‘two-stage treatment’.MethodsAll patients with high-energy femoral fractures treated with IMN between 2000 and 2016 in a single Level 1 trauma centre were eligible. Electronic charts were reviewed for patient and surgical characteristics; furthermore, the development of complications was noted. A propensity score analysis was performed to assess the attributed risk of the external fixator on the development of postoperative wound infections.ResultsA total of 149 patients were included in this study; 93 underwent direct IMN and 56 underwent the two-stage treatment. Patients who underwent two-stage treatment were more severely injured, reflected by lower EMV and higher ISS on admission. Patients in the two-stage treatment group had a significant higher risk of postoperative wound infections (OR: 4.698, 95% CI: 1.203–18.339) but not a higher risk on deep postoperative wound infections (OR 2.345, 95% CI: 0.439–12.540). Union rate did not differ between the two groups (94% vs 94% NS).ConclusionsThe two-stage treatment is a safe treatment option in patients with a high-energy femoral fracture in terms of postoperative wound infections. Union rates are also comparable between the two treatment groups.

Atypical femur fractures: a review.

Bisphosphonates are one of the most commonly prescribed medications for the treatment of osteoporosis. Their use has greatly decreased the number of osteoporosis-related vertebral and nonvertebral fractures. Recently, however, a relationship between long-term bisphosphonate use and subtrochanteric and femoral shaft fractures has been elucidated. These low-energy fractures, termed atypical femur fractures, exhibit unique characteristics in their pathophysiology, presentation, and radiographic appearance compared with more traditional high-energy femur fractures. Here we provide a review based on the most recent literature of the pathophysiology, presentation, evaluation, and management of these fractures. Despite an abundance of literature, atypical femur fractures remain difficult to treat, and surgeons must be aware of the tricks and complications associated with their management.

High-energy Femur Fractures Increase Morbidity but not Mortality in Elderly Patients

Trauma centers are projected to have an increase in the number of elderly patients with high-energy femur fractures. Greater morbidity and mortality have been observed in these patients. Further clarification regarding the impact of high-energy femur fractures is necessary in this population. Our purpose was to assess the influence of high-energy femur fractures on mortality and morbidity in patients 60years and older. Specifically, we asked (1) if the presence of a high-energy femur fracture increases in-hospital, 6-month, and 1-year mortality in patients 60years and older, and (2) if there is a difference in morbidity (number of complications, intensive care unit [ICU] and total hospital length of stay, discharge disposition, accompanying fractures, and surgical intervention) between patients 60years and older with and without high-energy femur fractures. A retrospective review of 242 patients was performed. Patients with traumatic brain injury or spine injury with a neurologic deficit were excluded. A control group, including patients admitted secondary to high-energy trauma without femur fractures, was matched by gender and Injury Severity Score (ISS). In-hospital mortality, 6-month and 1-year mortality, complications, ICU and total hospital length of stay, discharge disposition, accompanying fractures, surgical intervention, and covariates were recorded. Statistical analyses using Fisher's exact test, ANOVA, Kaplan-Meier estimates, and Cox regression models were performed to show differences in mortality (in-hospital, 6-month, 1-year), complications, length of ICU and total hospital stay, discharge disposition, surgical intervention, and accompanying fractures between elderly patients with and without femur fractures. The average ages of the patients were 72.8years (±9years) in the femur fracture group and 71.8years (±9years) in the control group. Sex, age, ISS, and comorbidities were homogenous between groups. In-hospital (p=0.45), 6-month (p=0.79), and 1-year mortality (p=0.55) did not differ in patients with and without high-energy femur fractures. Elderly patients with high-energy femur fractures had an increased number of complications (p=0.029), longer total hospital length of stay (p=0.039), were discharged more commonly to rehabilitation centers (p<0.005), had more accompanying long bone fractures (p=0.002), and were more likely to have surgery (p<0.001). Average ICU length of stay was similar between the two groups (p=0.17). High-energy femur fractures increased morbidity in patients 60years and older; however, no increase in mortality was observed in our patients. Concomitant injuries may play a more critical role in this population. Additional studies are necessary to clarify the role of high-energy femur fracture mortality in this age group. Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

An experimental model of hidden high-energy femoral fractures with disrupted callus formation

Objective To explore ways to prevent lack of callus formation by establishing an experimental model of hidden high-energy femoral fractures with disrupted callus formation.Methods Twenty adult dogs were randomly divided into 2 equal groups to create models of closed transverse or short oblique fracture at the left hind legs after anaesthetized.The periosteum and muscles surrounding the fracture ends were stabbed by the ends longitudinally 10 times till the ends overlapped 1.5 cm.Group A was subjected to immediate open reduction and internal fixation with an 8-hole plate while group B to manual reduction and temporary fixation with a fine percutaneous Kirschner wire to stabilize the bone ends through the greater trochanter for 10 days followed by delayed open reduction and internal fixation with an 8-hole plate.At 2,4,6,8 and 12 weeks post-treatment,2 dogs in each group were sacrificed to harvest fracture specimens to observe callus growth by gross and histological examinations.Results In group A,a necrotic exudate cavity appeared around the fracture at 2 weeks,the exudate cavity narrowed and whitish bone ends were covered by no tissue at 4 weeks,the exudate disappeared and the bone ends were absorbed at 6 weeks,and no internal or external callus growth was observed at 8 to 12 weeks and the bone ends were further absorbed,indicating an experimental model of lack of femoral callus formation was successfully created.In group B,lateral callus sprouting was observed at 2 weeks,direct callus sprouting began at 4 weeks,callus formation at both ends was observed to meet each other at 6 weeks,and the callus growth bridged the fracture gap at 8 to 12 weeks.X-rays showed widened fracture gaps due to absorbed bone ends in group A and steady bridging of the gaps by callus growth in group B.Conclusions The present experiment successfully established an experimental model of hidden high-energy femoral fracture with disrupted callus formation caused by early open reduction and internal fixation.Delayed surgery may prevent lack of callus formation. Key words: Femoral fractures; Bony callus; Models, animal; Delayed operation

The Stress Response to Bilateral Femoral Fractures: A Comparison of Primary Intramedullary Nailing and External Fixation

Concern has recently been expressed with regard to the physiologic effects of primary intramedullary femoral nailing in seriously injured patients. "Damage control orthopaedics" techniques have been proposed, which comprise principally the use of primary external fixation. The aim of this study was to compare the physiologic effects of external femoral fixation with those of intramedullary stabilization over the first 24 hours after femoral fracture using an established large animal (ovine) trauma model. Under terminal anesthesia, bilateral high-energy femoral fractures and hypovolemic shock were produced using a pneumatic actuator. Twenty-four sheep were randomized into 4 groups and monitored for 24 hours. Group 1--control, group 2--trauma only, group 3--trauma and external fixation, and group 4--trauma and reamed intramedullary nailing. Outcome measures included the following: pulmonary embolic load (transesophageal echocardiography), metabolic base excess, plasma coagulation markers, and polymorphonuclear cell counts obtained from bronchoalveolar lavage samples. The total embolic load was significantly higher (P < 0.001) in the intramedullary nailing group. All trauma groups had a significant increase (P < 0.05) in prothrombin times with a fall in antithrombin III and fibrinogen levels. However, the type of fracture stabilization used did not significantly affect any of the other outcome measurements. A higher pulmonary embolic load can be expected during early intramedullary femoral fracture stabilization compared with primary external fixation. However, the degree of stimulation to systemic coagulation and pulmonary inflammation by each type of surgery was comparable.