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PubMed2004

Rotational malalignment after intramedullary nailing of femoral fractures.

OBJECTIVES: Intramedullary nailing has been accepted as the treatment of choice for femoral shaft fractures. The aim of our study was to determine the incidence and implications of rotational malalignment after intramedullary nailing using computed tomography measurements. DESIGN: Cohort study. SETTING: Patients who postoperatively visited the orthopaedic outpatient and radiology clinics. PATIENTS: Seventy-six patients, 59 men and 17 women, with a mean age of 28.4 years (15-88). INTERVENTION: Patients treated on a fracture table with an antegrade reamed AO nail (n = 46) or Grosse Kempf nail (n = 30) for a unilateral femoral shaft fracture between 1988 and 1998 were included in the study. MAIN OUTCOME MEASUREMENTS: Patients filled out a questionnaire concerning pain, daily activities, and sport. Oxford, Western Ontario and McMaster University osteoarthritis index, and Harris Hip and Knee Society scores were obtained. Physical exams and computed tomography measurements were established. RESULTS: Twenty-one patients (28%) were found to have a rotational malalignment of 15degrees or more. There was no significant difference in rotational deformity with either the AO or Grosse Kempf nail. The incidence of malrotation was independent of the fracture level. Patients with a torsional deformity had difficulties with more demanding activities like running, sports, and climbing stairs. Patients with an external rotational malalignment (n = 12) have more functional problems than patients with an internal rotational malalignment (n = 9). Clinically determined rotation differences are not accurate (+/-20degrees) compared with the established computed tomography measurements. CONCLUSIONS: Rotational malalignment after intramedullary nailing for femoral fractures is found in 28% of the patients in this study. These patients have difficulties with more demanding activities, especially when they have an external torsional deformity.

Adolescent↗
PubMed2006

Retrograde nailing versus fixed-angle blade plating for supracondylar femoral fractures: a randomized controlled trial.

BACKGROUND: A variety of devices have been used in the treatment of supracondylar femoral fractures. The condylar blade plate relies on the principles of open reduction, absolute stability and interfragmentary compression to achieve union. The technique of retrograde nailing uses indirect reduction of the metaphyseal fracture component, offering relative stability and a less invasive approach. Randomized comparison of these common methods of fixation has not been reported. METHODS: Twenty-two patients with 23 supracondylar femur fractures were recruited from two regional trauma centres over a 26-month period and randomized to receive either a retrograde intramedullary nail fixation (IM group, 12 fractures) or a fixed-angle blade plate fixation (BP group, 11 fractures). The groups were followed for 12-36 months. The primary outcome measures were revision surgery and general health. RESULTS: Three patients in the IM group required revision surgery for the removal of implant components. No reoperations occurred in the BP group. There was a trend towards greater pain in the IM group, although there was no statistically significant difference in the scores for any of the SF-36 domains. CONCLUSION: Both distal femoral nailing and blade plating give good outcomes. There is a trend for patients undergoing retrograde nailing to complain of more pain and to require revision surgery for removal of implants.

Aged↗
PubMed1997

Secular trends in proximal femoral fracture, Oxford record linkage study area and England 1968-86.

OBJECTIVE: To study hospital admission rates for fractures of the proximal femur over a period when incidence is reported to have increased, compensating for known lack of precision in coding, excluding nonemergency admissions and transfers, and modelling for age, period, and cohort effects. DESIGN: Validation of coding of a sample of hospital admissions followed by study of two sets of routinely collected statistical abstracts of hospital records; graphical analysis and statistical modelling were used to search for period and cohort effects. SETTING: Oxfordshire and west Berkshire in 1968-86, covered by the Oxford record linkage study (ORLS), and ENGLAND in 1968-85, covered by the hospital inpatient enquiry (HIPE). The ORLS and HIPE datasets are almost independent (ORLS contributed about 1.8% of the HIPE data). SUBJECTS: Records of patients aged 65 and over. OUTCOME MEASURES: Admission rates for fractured neck of femur and fracture of other and unspecified parts of femur (N820 and N821), and evidence of period and cohort effects. RESULTS: The validation study indicated that it was important to combine the codes 820 and 821 in this age group. Admission rates increased over the period studied in both HIPE and ORLS datasets. In HIPE the pattern was of two plateaux separated by a period of rapid rise in the late 1970s. In the ORLS data there was a more steady rise. Statistical analysis showed significant period and cohort effects but much of this was attributable to the component of the model common to both period and cohort effects (termed "drift"). CONCLUSIONS: The finding that admission rates increased in both datasets, combining relevant codings and restricting analysis to emergency admissions, strongly suggests that the rise was real. At least part of the period effect in the HIPE data, however, might be attributable to a sampling artefact. The cohort effect in incidence rates of femoral fracture has not been previously shown and would be compatible with a number of aetiological hypotheses.

Aged↗
PubMed1998

Dietary protein supplementation and recovery from femoral fracture.

A recent randomized, double-blind, placebo-controlled trial found that protein supplementation improved recovery from femoral fractures in an elderly population. A 6-month course of protein supplementation (20 g/day, 5 days/week) improved serum prealbumin and insulin-like growth factor I (IGF-I) concentrations, minimized bone loss, and decreased length of stay in rehabilitation facilities.

Aged↗
PubMed2002

Femoral fracture repair and postoperative management in new zealand white rabbits.

Low bone density and large muscle mass predispose rabbits to femoral fractures. However, there are few reports describing treatment and prognosis. Two New Zealand White rabbits presented with unilateral left rear limb abduction and lateral rotation of the distal left rear limb 2 and 17 days after experimental surgery to create a "stair step" in the patellar groove of the left medial femoral chondyle. This procedure was performed after approval by the Institutional Animal Care and Use Committee. Radiography revealed a spiral oblique mid-shaft fracture of the left femur in both rabbits. Open fracture reduction was undertaken. Because of the presence of screws and Kirschner-wires in the medial femoral condyle, a lateral approach to surgical correction was chosen. Intramedullary fixation was used to reduce and stabilize the fractures. A 0.062" Kirschner wire was selected for the intramedullary device, because it was sufficiently flexible to allow easy passage into the femoral canal while being sufficiently stiff to promote reduction of the fracture. In addition, the ends of the fracture were secured with a 0.032" Kirschner cerclage wire to provide additional control of rotation and angulation. Then we assessed the range of motion of the knee joint to determine fracture stability and ensure that the hardware did not impinge on soft-tissue elements. After closure and application of sterile dressing, the hind legs were hobbled proximal to the hock by using elastic veterinary wrap in a figure-eight pattern to maintain limb alignment and prevent formation of pressure ulcers. Intraoperative fluoroscopic evaluation and postoperative radiographs confirmed fracture reduction. Bruising and seroma formation occurred at the surgical site, and transient anorexia developed. Rabbits were treated with fluids, analgesics, antibiotics, and fitted with Elizabethan collars. They were housed in isolation to limit excessive environmental stimulation, which could alarm them and provoke "thumping" of the rear legs. Muscular weakness and atrophy developed in the affected legs, but the fractures remained immobilized. Radiographs obtained 21 days after surgery confirmed marked callus formation and integrity of the implanted hardware. Four weeks after surgical fixation, both rabbits showed increased muscle development in the repaired leg and were ambulating normally. The long-term prognosis was excellent. These cases demonstrate that repair of femoral fractures in rabbits can be achieved by using basic orthopedic techniques and diligent post-operative management.

Animals↗
PubMed1996

11 femoral fractures with vascular injury: good outcome with early vascular repair and internal fixation.

We reviewed 11 consecutive cases with combined femoral fracture and vascular injury presenting with acute ischemia. 6 cases had ischemia exceeding 8 hours and 4 of them developed massive muscle necrosis in the lower leg. 5 cases with ischemia less than 8 hours had no muscle necrosis. Vascular repair preceded fracture stabilization in 5 cases; there were no vascular complications during the subsequent fracture stabilization. 6 fractures treated with internal fixation had uneventful fracture-healing, whereas the 4 which were treated with external fixation needed later reoperations to obtain fracture-healing. We conclude that the limb must be reperfused within 6-8 hours. Vascular repair should be the first procedure, and fracture fixation by internal fixation is then preferred.

Adolescent↗
PubMed1985

Preliminary study of ethylene oxide sterilization of full-thickness cortical allografts used in segmental femoral fracture repair.

Full-thickness canine cortical allografts were cleanly harvested, sterilized with ethylene oxide, and stored at room temperature. The allografts were incorporated into canine segmental femoral fracture repairs and compared clinically, radiographically, and morphologically with control femoral cortical autografts for function of the limb, graft acceptance, and bone union. Sterility was maintained and the cortical allografts were well accepted by the host animals, resulting in full use of the limb which was subjected to surgical operation. The allografts showed healing patterns similar to those of the autografts, as determined by radiographic, gross, and histologic evaluation of the proximal and distal host-graft interfaces. Evaluations were made monthly. The host-graft interfaces of the allografts and autograft were filled with woven bone with adjacent vascular invasion and remodeling of the graft at the final 4th-month evaluation.

Animals↗
PubMedDate not supplied

Mechanical study of the safe distance between distal femoral fracture site and distal locking screws in antegrade intramedullary nailing.

OBJECTIVE: To determine the safe distance for distal femoral fractures relative to the distal locking screws in antegrade intramedullary femoral nailing using a currently available titanium alloy nail design. DESIGN: Cyclic (fatigue) mechanical testing study. SETTING: Biomechanics laboratory. INTERVENTION: Intramedullary nailing of left synthetic fiberglass composite femora with type 32/33-C fractures at 1, 2, 3, and 4 cm from the more proximal of the distal locking screws. MAIN OUTCOME MEASUREMENT: The number of loading cycles to failure of the nail. RESULTS: A load level of 700 N through the femoral mechanical axis was validated as adequate to cause fatigue failure within 200,000 cycles in slotted stainless- steel nails. In the nonslotted titanium alloy nails, this load level caused failure in only 1 of 3 nails with a fracture at 2 cm from the more proximal of the 2 distal locking screws and in 2 of 3 nails with a fracture at 1 cm from the more proximal of the 2 distal locking screws. All of the other nails did not fail >1 million cycles. CONCLUSIONS: Under laboratory conditions, it is safe to assume that an antegrade titanium alloy nail will survive 1 million compression/bending cycles when the fracture is > or = 3 cm from the more proximal of the 2 distal locking screws.

Biomechanical Phenomena↗
PubMed2006

Flexible intramedullary nailing versus external fixation of paediatric femoral fractures.

Treatment outcomes were compared in two groups of children with femoral diaphyseal fractures which were treated with external fixation (20 fractures) or flexible intramedullary nailing (20 fractures). These 40 children were between 5.4 to 14.1 years of age. The duration of the operation averaged 52 minutes for the external fixator compared with 70 minutes for the flexible nail group. The time taken to gain full weight bearing, full range of movements and return to school was shorter in the flexible intramedullary nail group. There was a higher complication rate in the external fixator group than in the flexible nail group. At final review, three patients in the external fixator group had pain, two had leg-length discrepancy of up to 1 cm, and four had malalignment of 5 degrees -10 degrees. In the nailing group, there were no leg-length discrepancies or malalignments. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft in children which require surgery, and reserve external fixation for open or severely comminuted fractures.

Adolescent↗
PubMed1999

A biomechanical comparison of the antegrade inserted universal femoral nail with the retrograde inserted universal tibial nail for use in femoral shaft fractures.

Femoral shaft fractures with and without bony contact were simulated in cadaver specimens fixed with one of two different types of intramedullary locked nail systems; conventional antegrade nail fixation of the femur with the universal AO femoral nail or retrograde insertion in the femur with the universal tibial nail (a smaller diameter slotted nail) were utilized. Mechanical testing simulated one leg stance, and resultant deformation was measured in bending, torsion, and shortening. In stable fractures, fracture stability was similar to both devices, while in unstable fractures, the larger femoral nail was more stable. Furthermore, the simulation of single leg stance led to a coupled deformation of varus bending, axial shortening, and external rotation, which was dependent on bone geometry.

Adult↗
PubMed2003

[Overgrowth of femoral fractures in childhood].

PURPOSE: The purpose of this work was to define the role of different factors which can accelerate overgrowth of femoral fractures in childhood. MATERIAL AND METHODS: Fifty-one fractures of the femur observed in 28 boys and 23 girls, mean age four years, were treated orthopedically. Twelve fractures involved the upper third of the femur, 34 the middle third and five the lower third. There were 30 transverse, 13 oblique, and eight spiral fractures. Overgrowth (OG) was assessed on x-rays obtained two years after bone healing and defined as the sum of the initial shortening (RI) plus leg length difference (LLD): OG=RI + LLD. RESULTS: OG was 11.3 mm in boys and 7.55 in girls, mean 9.5 mm. OG was greatest between the ages of 3 and 7 years. OG was 18.62 mm in spiral fractures, 9.15 mm in oblique fractures and 7.59 mm in transverse fractures. OG was 12.41, 9.46, and 2.49 mm for the upper, middle, and lower femur. Mean OG was 5.46, 9.43, and 18.09 mm for RI<5 mm, 5 mm 10 mm respectively. There was a linear relationship between RI and OG: OG=0.84 RI + 3.4. DISCUSSION: Taking into account different factors, bony overgrowth can be estimated from the initial shortening in fractures of the femur in children. It is tolerated better in boys, between the age of 3 and 7 years, and for proximal and spiral fractures.

Age Factors↗
PubMed2006

Distal femoral fractures treated by hinged total knee replacement in elderly patients.

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile. Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low. A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

Aged↗
PubMed1992

Treatment of displaced subcapital femoral fractures with total hip replacement.

A series of 46 patients with 46 displaced subcapital femoral fractures were treated with total hip replacements. Indications for treatment were age between 65 and 79 years, a mental test score of greater than 7/13 and mobility sufficient to allow the patient to leave the house at least once a week. The main complication was dislocation (9 per cent), which tended to occur early, and was associated with inexperience of the surgeon. The 6-month mortality was 9 per cent. The mean Harris score of 33 patients reviewed at 3 years was 83. Preoperative mobility was well maintained and there was no evidence of deep sepsis or loosening. We recommend that this method of treatment should be studied further in a prospective comparative fashion.

Aged↗
PubMed1999

[Limb preservation after clostridial myonecrosis following internal fixation of a closed femoral fracture].

A 24-year-old healthy man developed Clostridium perfringens myonecrosis with severe sepsis after plating of a closed femoral fracture. The leg could be preserved by complete resection of the fascia from all muscle compartments of the leg, including the pelvitrochanteric and the iliopsoas muscles, radical removal of necrotic muscle tissue, dissection of the para-aortal infrarenal lymphatics, daily débridements over 2 weeks, and systemic antibiotic therapy. The plate was removed because of a second septic episode followed by temporary stabilization with external fixation. After soft-tissue healing, plate fixation was carried out. The patient developed significant deficit of knee flexion (0 degree/0/20 degrees) due to heterotopic ossification of the quadriceps femoris muscle that could be improved by partial resection of heterotopic bone formation. In the same operation the bony defect of the femur was filled with autologous bone graft. The fracture healed 10 months after the accident. The patient can work full time in his previous profession as a mechanic, but again needs operative mobilization of the knee joint, including open arthrolysis and quadriceps plasty.

Adult↗