Antegrade nailing in femoral shaft fracture patients - comparison of outcomes of isolated fractures, multiple fractures and severely injured patients

Ipsilateral Femoral Neck and Shaft Fractures: Complex Injuries With High Rates of Femoral Shaft Nonunion

OBJECTIVE

To investigate nonunion rates and risk factors in patients with ipsilateral femoral neck and shaft fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Two Level I trauma centers.

PATIENT SELECTION CRITERIA

Two hundred seven patients treated for ipsilateral femoral neck (AO/OTA 31-B) and shaft (AO/OTA 32A-C) fractures from 2013 to 2022. Patients with less than 6 months of follow-up were excluded.

OUTCOME MEASURES AND COMPARISONS

The primary outcome of this study was femoral shaft nonunion. Risk factors for nonunion were evaluated, including smoking, open fracture, delay to full weight-bearing, blood transfusions, and AO/OTA classification.

RESULTS

Two hundred twenty-seven patients were initially identified, but only 154 patients had sufficient follow-up and were included in final analysis. The mean age was 38.9 years (SD = 15.3), and injury severity score was 19.5 (9.7). One hundred ten patients (71%) were male and 69 (45%) required intensive care unit care. Thirty-eight patients (25%) experienced an open fracture, and 44 fractures (29%) were AO/OTA Type C. Thirty patients (20%) underwent initial external fixation, and 88 patients (57%) received a perioperative transfusion. Thirty-four patients (22%) developed a femoral shaft nonunion, and 5 (3%) experienced a surgical site infection. Nonunion was associated with perioperative blood transfusion, AO/OTA Type C fracture, postoperative non-weight-bearing, and delay to full weight-bearing ≥12 weeks. Multivariable regression identified perioperative blood transfusion ≥3 (risk ratio [RR] = 1.91; CI, 1.12-2.72; P = 0.02) and AO/OTA Type C fracture (RR = 2.45; CI, 1.50-3.34; P = 0.001) as independent risk factors.

CONCLUSIONS

Ipsilateral femoral neck and shaft fractures remain difficult injuries to treat. Much attention is given to diagnosis and treatment of the femoral neck component. These results suggest that successful treatment of the femoral shaft component presents its own challenges with high nonunion rates.

LEVEL OF EVIDENCE

Prognostic Level III.

A Scoring System for Predicting Nonunion After Intramedullary Nailing of Femoral Shaft Fractures

INTRODUCTION

Femoral shaft nonunion negatively affects patient quality of life. Although multiple risk factors have been identified for femoral shaft nonunion after intramedullary nail (IMN) fixation, there is no quantitative model for predicting nonunion.

STUDY DESCRIPTION

The study is a retrospective cohort study of patients with femoral shaft fractures treated at two level one trauma centers who were followed to fracture union or nonunion. Patient, injury, and surgical characteristics were analyzed to create a quantitative model for nonunion risk after intramedullary nailing.

METHODS

Eight hundred one patients aged 18 years and older with femoral shaft fractures treated with reamed, locked IMNs were identified. Risk factors including demographics, comorbidities, surgical variables, and injury-related characteristics were evaluated. Multivariate analysis was conducted, and several variables were included in a scoring system to predict nonunion risk.

RESULTS

The overall nonunion rate was 7.62% (61/801). Multivariate analysis showed significant association among pulmonary injury (odds ratio [OR] = 2.19, P = 0.022), open fracture (OR=2.36, P = 0.02), current smoking (OR=3.05, P < 0.001), postoperative infection (OR=12.1, P = 0.007), AO/OTA fracture pattern type A or B (OR=0.43, P = 0.014), and percent cortical contact obtained intraoperatively ≥25% (OR=0.41, P = 0.021) and nonunion. The scoring system created to quantitatively stratify nonunion risk showed that a score of 3 or more yielded an OR of 6.38 for nonunion (c-statistic = 0.693, P < 0.0001).

CONCLUSIONS

Femoral shaft nonunion risk is quantifiable based on several independent injury, patient, and surgical factors. This scoring system is an additional tool for clinical decision making when caring for patients with femoral shaft fractures treated with IMNs.

Analysis of the influence of circumference and displacement of the third fracture fragment on the healing of femoral shaft fractures treated with intramedullary nailing

The effect of circumference and displacement of the third fracture fragment on fracture healing after intramedullary nailing of femoral shaft fractures with a third fracture fragment was investigated. A retrospective cohort study was conducted to analyze the data of 142 patients who suffered femoral shaft fractures with a third fracture fragment and were admitted to the First People's Hospital of Lianyungang from February 2016 to December 2021. According to the circumference of the third fracture fragments, these were divided into three types of type 1: 71 cases; type 2: 52 cases; and type 3: 19 cases. On the basis of the diaphyseal diameter, the degree of displacement of the third fracture fragment was classified into three degrees of degree I: 95 cases; degree II: 31 cases; and degree III: 16 cases. Postoperative follow-up was performed to compare the fracture healing rate, healing time, and the modified Radiographic Union Scale for Tibia (mRUST) at 9th month after surgery in each group. All 142 patients were followed up after operation, with an average of (14.7 ± 4.1) months, and the overall healing rate was 73.4%. When the third fracture fragments were displaced in degree II and III, the mRUST score at 9th month in the type 1 group was higher than that in the type 2 and 3 groups (P = 0.017). Logistic regression analysis showed that greater displacement of third fracture fragments and greater circumference were associated with lower fracture healing rates (P < 0.05). After intramedullary nailing of femoral fractures, the degree of third fragment displacement and circumference affect fracture healing, and the former has a greater impact. When the third fracture fragment is displaced to degree II or III and its circumference is type 2 or type 3, it significantly affects the fracture healing. Intraoperative intervention to reduce the distance of third displacement of the fragment is required to reduce the incidence of non-union.

Development and validation of predictive nomogram for postoperative non-union of closed femoral shaft fracture

Closed femoral shaft fracture is caused by high-energy injuries, and non-union exists after operation, which can significantly damage patients' body and mind. This study aimed to explore the factors influencing postoperative non-union of closed femoral shaft fractures and establish a predictive nomogram. Patients with closed femoral shaft fractures treated at Hebei Medical University Third Hospital between January 2015 and December 2021 were retrospectively enrolled. A total of 729 patients met the inclusion criteria; of them, those treated in 2015-2019 comprised the training cohort (n = 617), while those treated in 2020-2021 comprised the external validation cohort (n = 112). According to multivariate logistic regression analysis, complex fractures, bone defects, smoking, and postoperative infection were independent risk factors. Based on the factors, a predictive nomogram was constructed and validated. The C-indices in training and external validation cohorts were 0.818 and 0.781, respectively; and the C-index of internal validation via bootstrap resampling was 0.804. The Hosmer-Lemeshow test showed good fit of the nomogram (P > 0.05) consistent with the calibration plot results. The clinical effectiveness was best at a threshold probability of 0.10-0.40 in decision curve analysis. The risk prediction for patients with fractures using this nomogram may aid targeted prevention and rehabilitation programs.

Optimal entry point for antegrade and retrograde femoral intramedullary nails

Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.

Aseptic femoral nonunion treated with exchange locked nailing with intramedullary augmentation cancellous bone graft

Background

Closed reamed locked intramedullary nailing has been the treatment of choice for most of femoral shaft fractures. A high union rate with a low complication rate is generally predictable. For an aseptic femoral shaft nonunion with a prior inserted intramedullary nail, exchange nailing is one of favored surgical techniques for treatment. However, a greatly varied success rate of 72–100% has been reported. To improve the success rate of exchange femur nailing, a modified bone grafting technique was developed. The purpose of this retrospective study intended to evaluate outcomes of such a revised technique.

Methods

From July 2011 to March 2019, 48 consecutive adult patients (average, 38 years; range, 19–67 years) with aseptic femoral shaft nonunions after intramedullary nailing treatment were studied. All femoral shaft fractures were initially caused by traffic accidents, which were treated by a closed or open intramedullary nailing technique at various hospitals. The current revision treatment was performed after an average of 2.2 years (range 1.1–6.2 years) from initial injuries. In the surgery, the prior nail was removed and the marrow cavity was reamed widely (at least 2 mm as possible). Sufficient cancellous bone grafts harvested on the trochanteric marrow wall from the inside were placed in the marrow cavity of the junction of nonunion fragments. A new 1-mm smaller size locked intramedullary nail was inserted. Whether the dynamic or static mode of nails were used mainly depended on the nonunion level. Postoperatively, protected weight bearing with crutches was allowed for all patients.

Results

Forty-one patients were followed for an average of 2.8 years (85.4%; range, 1.9–4.5 years) and all fractures healed. The union rate was 100% (41/41, p < 0.001) with a union time of an average of 3.4 months (range, 2.5–5.0 months). There were no complications of deep infection, nonunions, malunions, implant failures or an avulsed trochanter tip fracture. The satisfactory knee function improved from 73.2% (30/41) preoperatively to 92.7% (38/41) at the latest follow-up (p = 0.019).

Conclusions

The described modified bone grafting technique may effectively improve a union rate of exchange femur nailing while the surgical procedure is not complicated. It may therefore be used concomitantly in all aseptic femoral shaft nonunions when exchange nailing is performed.

The characteristics and influence of iatrogenic fracture comminution following antegrade interlocking nailing for simple femoral shaft fractures, a retrospective cohort study

AIM

The incidence and characteristics of iatrogenic comminution (IC) are unknown, and the influence of IC on fracture union is unclear. This study was aimed to investigate the (1) incidence and characteristics of IC and (2) the outcomes of IC following antegrade interlocking nailing of simple femoral shaft fractures.

METHODS

We retrospectively collected data on patients who experienced simple femoral shaft fractures and underwent antegrade interlocking nailing between February 2009 and December 2016. The incidence and characteristics of IC were examined. According to the presence of IC, patients were divided into two groups: an IC group and a non-IC (NIC) group. Demographic information and nonunion rates were compared between the two groups. Potential risk factors for IC (age, gender, body mass index (BMI), nail fit ratio, reduction technique, and greater trochanter nail entry) were analyzed using univariate and multivariate logistic regression. The aforementioned variables, along with IC occurrence, were also assessed as potential risk factors for nonunion at 12 and 24 months after operation using multivariate logistic regression.

RESULTS

Of the 211 total patients, IC occurred in 20.9% (n = 44) of patients. Most ICs were found at the level of the isthmus, and involved the medial cortex. Compared with the NIC group, higher nonunion rates were observed in the IC group at 12 months (31.8% vs. 12.5%, p = 0.002) and 24 months (18% vs. 6.5%, p = 0.017) after surgery. Age older than 35 years old was related with the occurrence of IC in univariate analysis. Multivariate analysis found no risk factor associated with IC. Open reduction technique, IC occurrence and higher BMI were identified as the risk factors of nonunion at 12 months and 24 months after surgery in multivariate analysis.

CONCLUSION

IC is a non-rare complication in antegrade interlocking nailing of simple femoral shaft fractures and was associated with higher nonunion rate. Age older than 35 years old showed a trend toward increasing risk of iatrogenic fracture comminution. In multivariate analysis, open reduction technique, IC occurrence and higher BMI significantly correlated with fracture nonunion.

LEVEL OF EVIDENCE

Level IV.