Treatment Of Femoral Shaft Fractures Research Articles

Mid-term results from the application of closed antegrade reamed intramedullary nailing for the treatment of femoral shaft fractures

Mid-term results from the application of closed antegrade reamed intramedullary nailing for the treatment of femoral shaft fractures

Early reduction versus skin traction in the orthopaedic treatment of femoral shaft fractures in children under 6 years old

Femoral shaft fractures occur very frequently in children, and their prognosis usually is good. Nonoperative treatment is the gold standard for children under 6 years because of the excellent bony union and the remodelling qualities. The aim of this study was to compare two orthopaedic therapeutic methods: skin traction versus immediate reduction. The study involved 35 children, divided into two groups: in group 1, treatment consisted of skin traction for 21 days followed by hip spica casting; in group 2, an immediate reduction with early hip spica casting was performed. The ranges of motion, the delay before weight bearing, the hospitalisation duration and the required amount of painkillers were recorded. We compared initial shortening, axial, sagittal and rotational alignment, and femoral length discrepancy. We calculated the injured femoral diaphysal overgrowth and correlated it to the fracture type and location and to the initial shortening. Economical variables were also studied. The mean overgrowth was 8.9 mm in group 1 and 8.5 mm in group 2. Three years after the trauma, length discrepancy was 4 mm in group 1 and 1 mm in group 2. Hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration and pain. The cost of treatment with skin traction was four times higher (24,472 euros) than that of immediate reduction (6,384 euros). Our results are in accordance with the literature. The femoral overgrowth was proportional to the initial shortening. Masculine gender, an oblique fracture and injury of the lower third of the femur were associated with the greatest femoral overgrowth. During the first year of follow-up, the femoral length discrepancy hardly varied after immediate reduction (4 mm), whereas the overgrowth reached 6 mm after skin traction. Overall, immediate hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration, complications and costs, while having similar clinical results as traction.

Antegrade Intramedullary Nailing of Pediatric Femoral Fractures Using an Interlocking Pediatric Femoral Nail and a Lateral Trochanteric Entry Point

The treatment of femoral shaft fractures in older children and adolescents using rigid intramedullary (IM) nail fixation offers the advantages of decreased soft tissue stripping, low incidence of malalignment, leg length discrepancy, early ambulation, and decreased hospital stay. Recent reports have described the development of osteonecrosis of the femoral head in children after IM nailing through the piriformis fossa and the tip of the greater trochanter. Others have noted secondary proximal femoral valgus and femoral neck narrowing after antegrade IM nailing. Using the lateral aspect of the greater \trochanter as the starting point avoids the tenuous blood supply of the proximal femur and did not seem to produce avascular necrosis or proximal femoral deformity in early reports. A retrospective clinical and radiographic review of 78 children and adolescents with 80 femoral shaft fractures who underwent IM nail fixation through the lateral aspect of the greater trochanter, with a mean follow-up of 99 weeks, was performed. Twenty-four fractures were observed until skeletal maturity. Final standing anteroposterior radiographs of both lower extremities were used to assess for evidence of osteonecrosis, limb length discrepancy, fracture alignment, and indices around the hips. All patients went on to union in good clinical alignment without loss of reduction. No nonunions, delayed unions, or malunions were observed. Two patients developed infections postoperatively (2.5%). No patient had evidence of osteonecrosis of the femoral head. There was no significant difference in neck-shaft angle, articulotrochanteric distance, or femoral diameter when compared with the nonsurgical, normal side in these patients. Intramedullary nail fixation through the lateral aspect of the greater trochanter in children and adolescents is effective. It does not produce clinically important femoral neck valgus or narrowing. We did not observe osteonecrosis of the femoral head. : Level IV, case series.

Percutaneous/Minimally Invasive Techniques in Treatment of Femoral Shaft Fractures With an Intramedullary Nail

Intramedullary nailing of the femur is often the treatment of choice in isolated fractures of the femoral shaft. Some surgeons are reticent to use intramedullary nailing for proximal and distal femoral fractures. However, indications for femoral nailing can be appropriately extended to highly comminuted fractures as well as distal and proximal fractures when the correct technique and reduction maneuvers are utilized. Implementation of these techniques will also respect the critical soft tissue envelope that is so important in fracture healing. Deforming forces of the muscles of the hip, knee and thigh are neutralized with reduction tools applied percutaneously, blocking screws and Schanz pins. Mastery of these techniques and appropriate reduction are incumbent on the orthopaedic surgeon treating femoral shaft fractures.

Femoral shaft fractures treated with stainless steel flexible nails in children aged between 5 and 12 years at the HUSVP: A two-year follow-up

The purpose of this study is to show our experience with stainless steel flexible nails in the treatment of femoral shaft fractures in children aged between 5 and 12 years and to observe if the type of material used for nails affects the results. A prospective, descriptive study of a series of cases was performed to evaluate patients treated at the Hospital Universitario San Vicente de Paúl (HUSVP) who had been followed up for at least 24 months. The study group was composed of 48 patients, with an average age of 8.6 years. According to the AO classification, the most common type of fracture was 32A3.2 (61%). The average follow-up period was 43 months. The alterations observed were six cases of clinical length discrepancy, two cases of overgrowing, four cases of shortening, and two malunions in valgus. These alterations had no repercussion in the children's function. The follow-up is the main strength of this study, as it demonstrated that, 2 years after surgery. The results with stainless steel nails are as good as those with titanium nails with a shorter follow-up as reported in the literature. Given the high costs of osteosynthesis material in our country, the results of this study provide a less expensive alternative. Level of evidence IV, case series.

Retrograde Intramedullary Nailing or the Treatment of Segmental Femoral Shaft Fracture Including Distal Part

145 통신저자:진 진 우 경남 마산시 회원구 합성 2동 50번지 성균관대학교 의과대학 마산삼성병원 정형외과학교실 Tel:055-290-6030ᆞFax:055-290-6888 E-mail:ortho_ss@yahoo.co.kr *본 논문의 요지는 2008년도 대한정형외과학회 추계학술대회에서 발 표되었음. 접수: 2008. 11. 7 심사 (수정): 2009. 1. 1 게재확정: 2009. 4. 22 Address reprint requests to:Jin-Woo Jin, M.D. Department of Orthopedic Surgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine, 50, Hapsung 2-dong, Hoewon-gu, Masan 630-520, Korea Tel:82-55-290-6030ᆞFax:82-55-290-6888 E-mail:ortho_ss@yahoo.co.kr 대퇴골 원위부를 포함한 간부 분절 골절에서 역행성 골수정을 이용한 치료

The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures

Introduction Stabilisation of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults. To ream or not to ream is still debated. The primary objective of this study was to determine the incidence of non-union following unreamed intramedullary stabilisation of femoral fractures. Secondary objectives were intra- and postoperative complications and implant failure. Methods Between March 1995 and June 2005, 125 patients with 129 traumatic femoral shaft fractures were treated with as unreamed femoral nail. From this retrospective single centre study, 18 patients were excluded due to insufficient follow up data, including 1 patient who died within 2 days after severe head injury. Sixty-six patients had suffered multiple injuries. 21 fractures were open. According to the AO classification, there were 54 type A, 42 type B, and 14 type C fractures. Dynamic proximal locking was performed in 44 cases (36 type A and 8 type B fractures). Results Non-union occurred in two patients (1.9%; one type B and one type C fractures). Intra-operative complications were seen in three patients (2.8%). Postoperative in-hospital complications occurred in 29 patients (27%). Local superficial infection occurred in two patients (1.9%), there were no cases of deep infection. Implant failure occurred in three patients (2.8%): nail breakage was seen in two patients. Conclusion In this study, the incidence of non-union following unreamed intramedullary nailing is low (1.9%) and comparable with the best results of reamed nailing in the literature.

Flexible Interlocked Nailing of Pediatric Femoral Fractures

The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants. Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups. Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN. Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP. Level III, therapeutic study.

Soft tissue anatomy around the hip and its implications for choice of entry point in antegrade femoral nailing

Antegrade intramedullary nailing is an accepted method of treatment for femoral shaft fractures. Entrance of the nail through the trochanteric fossa is currently recommended by some surgeons. This approach results in some cases, however, in loss of abduction strength and persistent pain. Nail insertion at the tip of the greater trochanter may be more favorable. In this study the anatomical relationships of the trochanteric fossa and of the tip of the greater trochanter were explored. Dissection was carried out in 10 fresh human cadaver femurs. The risks and safety of the two entry points with respect to the adjacent soft tissues were assessed. Abductor muscles and tendons, branches of the medial circumflex femoral artery and the hip joint capsule were at risk during nail insertion through the trochanteric fossa. These structures were not endangered during insertion through the trochanteric tip. The reported clinical morbidity after nailing through the trochanteric fossa may result from direct soft tissue injury and may be reduced by choosing the route through the greater trochanter.

Results of Femoral Intramedullary Nailing in Patients Who are Obese Versus Those Who are not Obese: A Prospective Multicenter Comparison Study

Antegrade femoral nailing through a piriformis fossa starting point in patients who are obese has been demonstrated to be problematic. Retrograde femoral nailing therefore has been advocated in this patient population, but little data exist to support such a recommendation. The purpose of this study was to evaluate and compare antegrade and retrograde femoral nailing technique in both patients who are and are not obese. Prospective, multicenter, nonrandomized, internal review board (IRB)-approved study. Four Level 1 trauma centers. Patients (151) with a femoral shaft fracture (OTA 32) treated with intramedullary nailing were studied. Thirty-two with a body mass index (BMI) of >or=30 comprised the obese group (OG), and 119 with a BMI of <30 comprised the nonobese group (NOG). Antegrade nailing was performed in 15 patients from the OG and 84 from the NOG. Retrograde nailing was performed in 17 patients from the OG and 35 from the NOG. Reamed intramedullary nailing of a femoral shaft fracture. Patient and fracture characteristics, operative time, fluoroscopy time, healing, complications, and functional outcome based on the lower extremity measure (LEM) were evaluated. Antegrade technique in the OG was associated with a 52% greater average operative time (94 minutes) compared with antegrade nailing in the NOG (62 minutes; P < 0.003). For retrograde nailing technique, there was no difference in the average operative time between the OG (67 minutes) and NOG (62 minutes; P = 0.51). Antegrade technique in the OG was associated with a 79% greater average radiation exposure time (247 seconds) compared with antegrade nailing in the NOG (135 seconds; P < 0.03). For retrograde nailing technique, average fluoroscopy time was similar between the OG (76 seconds) and the NOG (63 seconds; P = 0.44). Within the OG, antegrade nailing required 40% greater average operative time (94 minutes versus 67 minutes, P < 0.02) and more than 3 times more average fluoroscopy time (242 seconds versus 76 seconds, P < 0.002) than retrograde nailing. Thirty-eight patients from the original cohort were not available for follow-up. Of the 113 patients followed (average 9 months, range: 4 to 25 months), healing complications occurred similarly between the 2 groups, with 1 nonunion and 2 delayed unions in the OG (12%), and 3 nonunions and 9 delayed unions in the NOG (14%). This study provides evidence, in the form of decreased operative and radiation exposure times, to support the use of retrograde nailing technique for the treatment of femoral shaft fractures in patients who are obese. Also, antegrade nailing was found to require significantly more operative and radiation exposure time in the patient who is obese as opposed to the patients who is not obese. Although having similar baseline functional scores, patients who are obese recovered at a slower rate and more incompletely than patients who are not obese.

Trochanteric versus Piriformis Entry Portal for the Treatment of Femoral Shaft Fractures

The purpose of this study was to compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa with nails specifically designed for each starting point. Prospective cohort study. Four level 1 trauma centers. One-hundred and eight patients treated by 1 of 4 surgeons for a femoral shaft or subtrochanteric fracture with antegrade nailing between January 2001 and April 2003 were included. Four patients who expired early in the postoperative period and 13 with insufficient follow-up were excluded from analysis. Patients were treated with either nailing through a greater trochanter starting point with the Trigen TAN nail (GT group) (n = 38) or through a piriformis fossa starting point with the Trigen FAN nail (PF group) (n = 53). Operative time, fluoroscopy time, fracture alignment, fracture healing, complications, and functional outcome based on the lower-extremity measure (LEM). Thirty-seven of the 38 fractures from the GT group and 52 of the 53 fractures from the PF group healed after the index procedure. One patient from the GT group had external rotation malalignment of 12 degrees. There were no other malalignments or iatrogenic fracture comminution. There were 2 infectious complications, 1 from each group. The average operative time was 75 minutes for piriformis insertion using the FAN nail and 62 minutes for trochanteric insertion using the TAN nail (P = 0.08). The average fluoroscopy time was 61% greater for the PF group (153 seconds) than for the GT group (95 seconds) (P < 0.05). These differences were magnified in patients who were obese (body mass index > 30) where the operative time was 30% greater (P < 0.05) and the fluoroscopy time was 73% higher in the PF group (P < 0.02). Patients from both groups had a similar initial decline and subsequent improvement in function over time (P > 0.05). A femoral nail specially designed for trochanteric insertion resulted in equally high union rates, equally low complication rates, and functional results similar to conventional antegrade femoral nailing through the piriformis fossa. The greater trochanter entry portal coupled with an appropriately designed nail represents a rational alternative for antegrade femoral nailing with the benefit of decreased fluoroscopy time and decreased operative time in patients who are obese.

A new intramedullary nailing device for the treatment of femoral shaft fractures: A biomechanical study

Background The treatment of choice for early mobilization of femoral fractures is surgery, which traditionally employs plates and screws or intramedullary nails. We examined the biomechanical properties of a new femoral nail system. The new intramedullary propping nailing system, made of a stainless-steel alloy, consists of a nail shaft, inner rod, tensile screw, end cape and two interlocked screws. Methods Intramedullary propping nailing biomechanics was compared with that of the Grosse and Kempf nail when securing transverse fractures in 10 pairs of cadaveric femurs. The axial compressive, bending, torsional stiffness, and strain values were calculated. Findings The intramedullary propping nailing system had torsional stiffness (0.50 Nm/°) and bending stiffness (699.74 and 670.84 N/mm of lateral and frontal bending, respectively) comparable with the Grosse and Kempf nail (0.35 Nm/°, 644.85 and 606.32 N/mm of lateral and frontal bending, respectively). Intramedullary propping nailing system produced a significantly higher compressive stiffness (1.67 and 1.50 × 10 6 N/mm, respectively) than the Grosse and Kempf nail in the medial and anterior aspects (0.86 and 1.32 × 10 6 N/mm, respectively). Although no significance was found in comparison with Grosse and Kempf of the strain of each aspect, intramedullary propping nailing system yielded a significantly better-distributed strain ( F = 1.007, P = 0.401). Interpretation Biomechanically, the intramedullary propping nailing system is safe and able to provide good abutment of the nail to the bone. The intramedullary propping nailing system produces a more extensive and tight contact between the nail and bone than the application of Grosse and Kempf nail.

Intramedullary Kirschner wire (K-wire) fixation of femoral fracture in children

The aim of this study was to evaluate the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of femoral shaft fracture in children. We report the results of intramedullary K-wires nailing in 178 children with a mean age of 7.7 years (range, 4-14 years) from 2000 to 2005, retrospectively. A total of 184 diaphyseal femoral fractures were treated with both antegrade and retrograde nailing using the same principles of elastic stable intramedullary nailing (ESIN). The patients were followed for 12 months on average (range, 6-24 months). No major complication (limb length discrepancy >15 mm, non-union, avascular necrosis, knee joint stiffness) occurred during the observation period. All fractures healed within 7.1 weeks on average (range, 5-12 weeks). Associated injuries were seen in 16.9% of the cases. All but seven fractures were reduced by closed manipulation. Early mobilization and weight bearing was allowed. Intramedullary K-wires were removed after an average of 4.8 months (range, 3-12 months) without any complications. In children, intramedullary fixation by using standard K-wires provides effective treatment for the diaphyseal femoral fracture that has excellent clinical results. Each intramedullary K-wire costs US $5, which adds a cost effective advantage to this method of treatment.

Plating of Femoral Shaft Fractures: Open Reduction and Internal Fixation Versus Submuscular Fixation

The standard treatment for femoral shaft fractures is intramedullary nailing. However, there are indications for which plating can be performed either openly or in a submuscular manner. Between June 1996 and May 2002, two fellowship-trained orthopedic trauma surgeons treated 40 acute diaphyseal femoral fractures in 37 patients with use of plating techniques. Traditional open plating with emphasis on preservation of soft tissue integrity was performed exclusively before February 1999 (n = 19). After that time point, in all but one case (n = 21) submuscular plating techniques were used. No bone grafting was used for either group. A comparison of reduction quality, union rates, secondary interventions, and infection rates between traditional open reduction and internal fixation and submuscular fixation was performed (retrospective cohort study/evidence-based medicine (EBM)-level III). In assessing reduction quality, there were no malreductions in the traditional plating group and six in the submuscular plating group. There was one infection and one nonunion in the open reduction or internal fixation group. One infection was noted in the submuscular group. A 2.5% incidence of nonunion and a 5% incidence of infection (2 of 40; both in type III open fractures) were seen in this series of 40 femoral shaft fractures treated with plate application. Although the theoretical advantages of submuscular plating are well established, its utilization in the femoral shaft did not have a clear clinical advantage. In addition, its use appears to be more technically challenging, and is associated with a high rate of suboptimal reductions.

Femoral head avascular necrosis after interlocking nail of a femoral shaft fracture in a male adult: a case report

Reamed interlocking nail through the piriformis fossa remains the golden standard for treatment of femoral shaft fracture. Fracture healing rates are 95-99%, and infection rates less than 1% (Clawson et al. in J Bone Joint Surg (Am) 53:681-692, 1971; Winquist et al. in J Bone Joint Surg (Am) 66:529-539, 1984; Brumback et al. in J Bone Joint Surg (Am) 70:1453-1462, 1988). Previous reports recognize avascular necrosis of the femoral head as a complication of antegrade interlocking nail in the adolescent (Beaty et al. in J Pediatr Orthop 14:178-183, 1994; Mileski et al. in J Bone Joint Surg (Am) 76:1706-1708, 1994; O'Malley et al. in J Pediatr Orthop 15:21-23, 1995; Buckaloo et al. in J Southern Orthop Assoc 6(2):97-100, 1997). This report describes a male adult who developed avascular necrosis of the femoral head after an open antegrade interlocking nail of a proximal third femoral shaft fracture. To our knowledge, there is no similar report in the English medical literature.

Current Concepts: Aseptic Nonunion of Femoral Shaft Diaphysis.

In spite of increased understanding of biomechanics and improvements of implant design, nonunion of femoral shaft fractures continues to hinder the treatment of these injuries. Femoral nonunion presents a difficult treatment challenge for the surgeon and a formidable personal and economic hardship for the patient. In most series of femoral fractures treated with intramedullary nailing techniques, the incidence of this complication is estimated to be 1%. A higher frequency has recently been reported due to advances in trauma care leading to increased survivorship among severely injured patients and expanded indications of intramedullary nailing. Whereas the treatment of femoral shaft fractures has been extensively described in the orthopedic literature, the data regarding treatment of femoral shaft nonunions are sparse and conflicting, as most of the reported series consisted of a small number of cases. However, careful review of the existing literature does provide some answers regarding either conservative or operative management. The gold standard for femoral shaft nonunions invariably includes surgical intervention in the form of closed reamed intramedullary nailing or exchange nailing, but several alternative methods have been reported including electromagnetic fields, low-intensity ultrasound, extracorporeal shock wave therapy, external fixators and exchange or indirect plate osteosynthesis. In this paper, a comprehensive review of the current treatment modalities for aseptic midshaft femoral nonunion is presented, after a concise overview of the incidence, definition, classification and risk factors of this complication.

Antegrade Versus Retrograde Locked Intramedullary Nailing for Femoral Fractures: Which Is Better?

Locked intramedullary nailing or interlocking nailing (ILN) is a proven mode of treatment for femoral shaft fractures. It can be inserted via the antegrade or retrograde approach. Retrograde approach is technically less demanding especially if the patient is overweight. But there are concerns with regard to the violation of the knee and its effect on subsequent knee function. We studied consecutive cases of femoral shaft fractures treated with locked intramedullary nailing at the Penang General Hospital, from 1st June 2004 to 1st June 2005. We looked at radiological and clinical union rates, union of fractures, alignment of the operated limb, and the knee function, using the Thoresen scoring system. There were a total of 77 cases of femoral interlocking nails during the study period. Forty-two cases were antegrade nails and 35 cases were retrograde nails. Both groups of patients eventually achieved union of the fracture and retrograde nailing group showed significantly earlier union rate (p = 0.032). There is no significant difference between both groups, in regards to knee pain, swelling, and range of motion as well as postnailing femoral alignment. Both methods of nailing achieved excellent union rates with good alignment of the limb. Contrary to popular belief, we found that retrograde nailing does not give rise to a higher rate of knee complications. Therefore, we strongly recommend this approach of nailing as it is technically less demanding.

X-ray-based machine vision system for distal locking of intramedullary nails

In surgical procedures for femoral shaft fracture treatment, current techniques for locking the distal end of intramedullary nails, using two screws, rely heavily on the use of two-dimensional X-ray images to guide three-dimensional bone drilling processes. Therefore, a large number of X-ray images are required, as the surgeon uses his/her skills and experience to locate the distal hole axes on the intramedullary nail. The long-term effects of X-ray radiation and their relation to different types of cancer still remain uncertain. Therefore, there is a need to develop a surgical technique that can limit the use of X-rays during the distal locking procedure. A robotic-assisted orthopaedic surgery system has been developed at Loughborough University to assist orthopaedic surgeons by reducing the irradiation involved in such operations. The system simplifies the current approach as it uses only two near-orthogonal X-ray images to determine the drilling trajectory of the distal locking holes, thereby considerably reducing irradiation to both the surgeon and patient. Furthermore, the system uses robust machine vision features to reduce the surgeon's interaction with the system, thus reducing the overall operating time. Laboratory test results have shown that the proposed system is very robust in the presence of variable noise and contrast in the X-ray images.

Fractured neck of femur in a child after femoral fracture fixation by intramedullary flexible nails: a case report

Since the introduction of flexible intramedullary nails, the treatment of femoral shaft fractures in adolescents has been revolutionized and this has become the routine treatment in most units, with minimal complications. We report a rare complication of an ipsilateral fractured neck of femur in a fit and healthy 12-year-old girl 6 months after treatment of a traumatic fractured femoral shaft; this was treated effectively with cannulated screws and the patient was successfully discharged without any further complication.

Early active treatment of femoral shaft fractures in children—A proposed protocol

Early active treatment of femoral shaft fractures in children—A proposed protocol