Early weight-bearing after statically locked reamed intramedullary nailing of comminuted femoral fractures: is it a safe procedure?

Analyzing Gait Dynamics and Recovery Trajectory in Lower Extremity Fractures Using Linear Mixed Models and Gait Analysis Variables

In a prospective study, we examined the recovery trajectory of patients with lower extremity fractures to better understand the healing process in the absence of complications. Using a chest-mounted inertial measurement unit (IMU) device for gait analysis and collecting patient-reported outcome measures, we focused on 12 key gait variables, including Mean Leg Lift Acceleration, Stance Time, and Body Orientation. We employed a linear mixed model (LMM) to analyze these variables over time, incorporating both fixed and random effects to account for individual differences and the time since injury. This model also adjusted for varying intervals between assessments. Our study provided insights into gait recovery across different fracture types using data from 318 patients who experienced no complications or readmissions during their recovery. Through LMM analysis, we found that Tibia-Distal fractures demonstrated the fastest recovery, particularly in terms of mobility and strength. Tibia-Proximal fractures showed balanced improvements in both mobility and stability, suggesting that rehabilitation should target both strength and balance. Femur fractures exhibited varied recovery, with Diaphyseal fractures showing clear improvements in stability, while Distal fractures reflected gains in limb strength but with some variability in stability. To examine patients with readmissions, we conducted a Chi-squared test of independence to determine whether there was a relationship between fracture type and readmission rates, revealing a significant association (p < 0.001). Pelvis fractures had the highest readmission rates, while Tibia-Diaphyseal and Tibia-Distal fractures were more prone to infections, highlighting the need for enhanced infection control strategies. Femur fractures showed moderate readmission and infection rates, indicating a mixed risk profile. In conclusion, our findings emphasize the importance of fracture-specific rehabilitation strategies, focusing on infection prevention and individualized treatment plans to optimize recovery outcomes.

Employing machine learning to enhance fracture recovery insights through gait analysis

This study aimed to explore the potential of gait analysis coupled with supervised machine learning models as a predictive tool for assessing post-injury complications such as infection, malunion, or hardware irritation among individuals with lower extremity fractures. We prospectively identified participants with lower extremity fractures at a tertiary academic center. These participants underwent gait analysis with a chest-mounted inertial measurement unit device. Using customized software, the raw gait data were preprocessed, emphasizing 12 essential gait variables. The data were standardized, and several machine learning models, including XGBoost, logistic regression, support vector machine, LightGBM, and Random Forest, were trained, tested, and evaluated. Special attention was given to class imbalance, addressed using the synthetic minority oversampling technique (SMOTE). Additionally, we introduced a novel methodology to compute the post-injury recovery rate for gait variables, which operates independently of the time difference between the gait analyses of different participants. XGBoost was identified as the optimal model both before and after the application of SMOTE. Before using SMOTE, the model achieved an average test area under the ROC curve (AUC) of 0.90, with a 95% confidence interval (CI) of [0.79, 1.00], and an average test accuracy of 86%, with a 95% CI of [75%, 97%]. Through feature importance analysis, a pivotal role was attributed to the duration between the occurrence of the injury and the initial gait analysis. Data patterns over time revealed early aggressive physiological compensations, followed by stabilization phases, underscoring the importance of prompt gait analysis. χ2 analysis indicated a statistically significant higher readmission rate among participants with underlying medical conditions (p = 0.04). Although the complication rate was also higher in this group, the association did not reach statistical significance (p = 0.06), suggesting a more pronounced impact of medical conditions on readmission rates rather than on complications. This study highlights the transformative potential of integrating advanced machine learning techniques like XGBoost with gait analysis for orthopedic care. The findings underscore a shift toward a data-informed, proactive approach in orthopedics, enhancing patient outcomes through early detection and intervention. The χ2 analysis added crucial insights into the broader clinical implications, advocating for a comprehensive treatment strategy that accounts for the patient's overall health profile. The research paves the way for personalized, predictive medical care in orthopedics, emphasizing the importance of timely and tailored patient assessments.

Is immediate weight bearing safe for subtrochanteric femur fractures in elderly patients treated by cephalomedullary nailing? A multicentric study in one hundred eighty-two patients

PURPOSE

Biomechanical superiority of intramedullary nails over extramedullary implants has been proved for subtrochanteric fractures. Nevertheless, postoperative management of these patients has not changed, with high rates of protected weight-bearing after intramedullary nailing. The purpose of this study is to determine the mechanical complications of immediate postoperative full weigh-bearing for subtrochanteric femur fractures in elderly patients treated with a cephalomedullary nail.

METHODS

We performed a retrospective case series study from patients treated with a cephalomedullary nail for subtrochanteric fractures (AO/OTA 31A.3 and 32A-32C) over a nine-year period. Patients in the immediate full weight-bearing (IFWB) group received orders for immediate full weight bear as tolerated on postoperative 48 h. Patients in the non- or limited- weight-bearing (NLWB) group received orders not to full weight bear in the immediate postoperative.

RESULTS

There were five (2.7%) cases of implant failure including four cutouts and one nail breakage that needed a reoperation. Of them, one (2.2%) followed the NLWB protocol and four (2.9%) followed the IFWB protocol. Mean length of stay was 7.9 days (median 8, range 3-21) in the NLWB group and 10.7 days (median 8, range 2-60) in the IWBAT group. The NLWB group observed a 2.8-day shorter postoperative length of stay when compared to the IFWB, but the median remained equal.

CONCLUSION

This study suggests that geriatric patients with subtrochanteric fractures treated by intramedullary nailing and in which a good fracture reduction was achieved, may be able to tolerate immediate postoperative full weight-bearing, not increasing reoperation rates due to implant failure.

Rehabilitation effect of standing bed combined with early anti-gravity running table training on ankle fracture

To explore the clinical effect of standing bed combined with early anti-gravity running table training in the healing and functional recovery of anterior rotation external rotation ankle fractures. Fifty-two patients with ankle fractures of degree III or degree IV of PER admitted to Pingle Orthopaedic and Traumatology Hospital of Shenzhen City between September 2021 and January 2023 were selected for observation, and they were divided into 26 cases in each group according to the method of randomised numerical table into the control group and the observation group. The patients in the control group started the routine rehabilitation treatment on the 1st day after operation, and in the 0-2 weeks after operation, the affected limb was elevated and ankle pump training was carried out; in the 3-6 weeks after operation, joint mobility training, strength training and soft tissue release were carried out; and in the 6-8 weeks after operation, weight-bearing training was increased. The observation group added standing bed training on the 7th postoperative day and anti-gravity running table training on the 28th postoperative day on the basis of the treatment protocol of the control group. Bone density, ankle mobility and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores, pain, ankle mobility and swelling evaluations were compared between the 2 groups before and after 8 weeks of treatment, and the quality scores of bone scabs were compared between the 2 groups after 4 weeks of treatment. There was no statistical significance in the comparison of the items between the two groups before treatment (all P > 0.05), and the difference in the bone scab quality score was not statistically significant after 4 weeks of treatment (P > 0.05), and after 8 weeks of treatment, the bone scab quality score, bone mineral density and AOFAS scores, pain, ankle mobility, and evaluations were higher than those of the control group (all P < 0.05), and there was no significant difference in the degree of swelling (P > 0.05). Standing bed combined with early anti-gravity running table training applied to postoperative patients with PER III or IV degree ankle fracture can reduce the degree of pain and improve the ankle joint function.

Biomechanical Behavior of Dynamic vs. Static Distal Locking Intramedullary Nails in Subtrochanteric Femur Fractures

OBJECTIVE

Hip fractures are one of the most frequent fractures presenting to the emergency department and orthopedic trauma teams. The aim of this study was to determine the best indication and therapeutic technique for subtrochanteric fractures and unifying criteria when choosing the most suitable type of nail.

MATERIALS AND METHODS

To analyze the influence of the material and the type of distal locking of intramedullary nails (static or dynamic), a femur model with a fracture in the subtrochanteric region stabilized with a long Gamma intramedullary nail was applied using finite element method (FEM) simulation.

RESULTS

The mechanical study shows that titanium nails allow for greater micromobility at the fracture site, which could act as a stimulus for the formation of callus and consolidation of the fracture. In the mechanical study, the type of distal locking mainly affects mobility at the fracture site and stress in the cortical bone around the distal screws, without in any case exceeding values that may compromise the viability of the assembly or that may result in detrimental effects (in terms of mobility at the fracture site) for the consolidation process.

CONCLUSION

Subtrochanteric fractures treated with titanium nail and static distal locking is safe and does not hinder consolidation.

Effect of Interlocking Mode on the Outcomes of Exchange Nailing for the Treatment of Aseptic Femoral Shaft Nonunion

Background

Exchange nailing is a standard treatment for femoral shaft nonunion after intramedullary nailing. However, substantial uncertainty and controversy remain regarding the mode of interlocking fixation. This study aimed to compare the success rate and time to union of exchange nailing based on interlocking modes.

Methods

We retrospectively analyzed all consecutive patients who underwent exchange nailing for aseptic femoral shaft nonunion between February 2000 and February 2021. Patients who underwent exchange nailing using the dynamically locked mode and statically locked mode constituted the dynamic group and static group, respectively. We compared the success rates of the index surgery and the time to union between the groups and measured the extent of interlocking screw migration on the dynamic oblong hole in the dynamic group.

Results

The dynamic group and static group comprised 17 patients and 18 patients, respectively. All patients in the dynamic group achieved bone union, whereas 5 patients in the static group did not and underwent additional intervention. The success rate of the index surgery was significantly higher in the dynamic group than in the static group (100% vs. 72.2%, p = 0.045). Four of the 5 failed unions in the static group achieved bone union after dynamization. The median time to union was significantly shorter in the dynamic group than in the static group (6.0 months [range, 4.0-6.0] vs. 12.0 months [range, 3.7-21.7], p = 0.035). In the dynamic group, 3 of 17 patients exhibited interlocking screw migration ranging from 1.1 to 4.1 mm.

Conclusions

Exchange nailing with dynamic mode yields a higher success rate and shorter time to union in aseptic femoral shaft nonunion than that with static mode, without the risk of excessive shortening.

Effects of Early Weight-Bearing Treadmill Training Combined with Pre-Emptive Analgesia on Femoral Fracture Recovery

Background

The effect of pre-emptive analgesia plus early weight-bearing treadmill training (EWBTT) on healing and motor function recovery of femoral shaft fracture is not clear.

Methods

A total of 60 SD male rats were randomly allocated into 4 groups: group A (pre-emptive analgesia with EWBTT), group B (pre-emptive analgesia with delayed weight-bearing treadmill training, DWBTT), group C (pre-emptive analgesia with no weight-bearing), and group D (EWBTT with no pre-emptive analgesia). All rats were molded by internal fixation with Kirschner wire after right femoral shaft fracture. In groups A, B, and C, tramadol was intramuscularly injected 15 minutes before surgery. EWBTT was performed at day 1 postoperatively in groups A and D, and DWBTT was performed at day 14 postoperatively in group B. Oblique plate test was accomplished to assess hindlimb motor function recovery of rats in each group. Status of fracture healing was assessed through digital radiography (DR). Hematoxylin-eosin (HE) staining and immunohistochemistry of bone morphogenetic protein-2 (MBP-2) and vascular endothelial growth factor (VEGF) in callus were performed to explore fracture healing. The expression of BMP-2 and VEGF protein in quadriceps femoris muscle was detected by Western blot technique and mRNA expression of BMP-2 and VEGF in callus ascertained via reverse transcription-polymerase chain reaction (RT-PCR) technique.

Results

For oblique plate test, rats in group A outperformed those in groups B and C at all time points after operation. DR image revealed that large numbers of callus growth, blurred fracture line, and obvious continuous callus passing through the fracture line can be found in group A at day 28 postoperatively, which is the best healing status among all groups. HE staining of callus confirmed the optimal effect of healing for rats in group A. VEGF and BMP-2 expression by immunohistochemistry showed a significantly higher positive score for callus in group A while those in group C being the lowest at all time points postoperatively. Significantly higher expression level of VEGF and BMP-2 protein was detected in quadriceps femoris muscle from group A, which exceeded those in all other groups at all time points. RT-PCR testing proved the highest expression of BMP-2 and VEGF mRNA in callus of rats from group A, significantly higher than those of other groups.

Conclusions

Both pre-emptive analgesia and EWBTT can effectively invoke the expression of VEGF and BMP-2 and promote recovery of hindlimb locomotor function in rats with femoral fracture, and the combination of them leads to more superior results.

RADIOGRAPHIC EVALUATION OF IMMEDIATE LOADING SAFETY AFTER SURGICAL REDUCTION IN ACETABULAR FRACTURES: A COMPARATIVE-RETROSPECTIVE STUDY

Objective

Radiographically evaluate the quality of reduction over six weeks of follow-up in patients with surgically treated deviated acetabular fractures who underwent rehabilitation with immediate loading as tolerated and compare this with the results of the unloaded protocol.

Methods

We retrospectively evaluated the records of 137 patients with deviated acetabular fractures treated with open reduction and internal fixation. Sixty-six (48.2%) patients underwent postoperative rehabilitation with immediate loading as tolerated, while 71 (51.8%) patients completed rehabilitation using a no-load protocol. The quality of the reduction was assessed radiographically by measuring the fracturing step and gap on radiographs taken immediately after surgery and three and six weeks after surgery.

Results

Comparing the joint step, group 1 had an average of 0.44 ± 1.4 mm, 0.47 ± 1.5 mm, and 0.51 ± 1.6 mm immediately, three and six weeks after surgery, respectively. Group 2 had a mean step of 0.24 ± 0.8 mm, 0.27 ± 0.9 mm, and 0.37 ± 1.2 mm immediately, three, and six weeks after surgery. No statistically significant differences were observed between the groups. With a joint gap, group 1 had a mean of 1.89 ± 1.7 mm, 2.12 ± 1.8 mm, and 2.36 ± 2.1 mm; and group 2 had a mean of 2.16 ± 2.4 mm, 2.47 ± 2.6 mm, and 2.67 ± 2.8 mm in the immediate postoperative period, three, and six weeks, respectively. There was also no statistical difference between groups in these measurements.

Conclusion

Immediate loading after surgical treatment of deviated acetabular fracture had no negative impact on radiographic reduction parameters and had similar results to the protocol without weight bearing. Level of evidence III; Therapeutic Retrospective Cohort Study .

Evaluation of bone healing process after intramedullary nailing for femoral shaft fracture by quantitative computed tomography-based finite element analysis

BACKGROUND

There is no proven method for quantitative evaluation of bone healing progress or decision to remove the nail after intramedullary nailing for femoral shaft fractures. Finite element analysis has become commonly utilized in bone analysis, but it may also be used to evaluate callus. The goal of this study was to use quantitative CT-based finite element analysis to assess the bone healing process and predict bone strength with the nail removed.

METHODS

Quantitative CT-based finite element analysis was conducted on CT images from patients who had intramedullary nailing after a femoral shaft fracture at 6, 12, and 15 months postoperatively. The failure risk of the callus was evaluated with maximal load throughout the gait cycle. The tensile failure ratio was calculated using the volume ratio of the callus element with a tensile failure risk ≥100%. A virtual model with the nail removed was built for bone strength study, and the strength was calculated using the displacement-load curve.

FINDINGS

The tensile failure ratio reduced with time, reaching 11.6%, 2.6%, and 0.5% at 6, 12, and 15 months postoperatively, respectively, consistent with bone healing inferred from imaging results. At 15 months, the bone strength at nail removal grew to 212, 2670, and 3385 N, surpassing the healthy side's 2766 N.

INTERPRETATION

Quantitative CT-based finite element analysis enables mechanical assessment during the bone healing process and is expected to be applied to the selection of revision surgery. It is also applicable to the nail removal decision.

Removing a bent femoral nail - man versus metal: A case report

Introduction

Intramedullary nailing is the treatment of choice for femoral shaft fractures in adults with excellent clinical results and low complication rates reported in the literature. However, in situ bending of a femoral nail is a rare complication that merits special attention. While there are several extraction techniques and algorithms the scientific evidence to support these decision-making tools is unconvincing.

Presentation of case

A 26-year old man presented to the Accident and Emergency Department with a deformed thigh following a low-energy injury. Radiographs showed a bent femoral nail in situ and the patient disclosed that he had surgery four weeks earlier for a fractured femur sustained in a motor vehicle accident. A treatment algorithm was followed in planning the surgical strategy, but ultimately a simple hacksaw blade was used to cut and remove the nail. The fracture which was stabilised by exchange nailing went on to uncomplicated union and the patient recovered fully.

Discussion

Non-invasive methods of removing a bent femoral nail are often unsuccessful and may result in iatrogenic injuries. Surgeons should assess the available local resources and first consider using simple open methods when attempting to remove a bent femoral nail.

Conclusion

Open extraction methods often disregard the low-resource environment in which many surgeons work. We describe a simple and economical technique that uses a regular hacksaw blade to cut and remove a bent femoral nail.

•

Using modern implants, insitu bending of a femoral nail is a rare occurrence.

•

Closed extraction methods are often unsuccessful and may lead to iatrogenic injuries.

•

An open technique using a simple hacksaw can be used in low-resource settings without access to sophisticated extraction tools.

Does nail size or difference between canal and nail diameter influence likelihood of union or time to union of femoral shaft fractures treated with intramedullary nailing? A retrospective cohort study

Background

This study aims to determine whether nail size or the difference between canal and nail diameter (CN difference) affects the union rate and time of femoral shaft fracture treated with an interlocking intramedullary nail (IMN).

Methods

This was a retrospective review of 257 patients with femoral shaft fractures treated with IMN at a tertiary trauma medical center. All the IMN inserted were the same (Stryker T2 Femoral Nail). The patients were divided into groups based on nail size (10-, 11-, 12-, or 13-mm) and CN difference (< 1, 1–2, or > 2 mm), and union rate and time to union were compared.

Results

The 10-, 11-, 12-, and 13-mm groups based on nail size had 113, 74, 54, and 16 patients, respectively. The overall union rate was 97% (257/265). No significant differences in union rate or time to union were observed among these 4 groups. The groups based on CN differences of < 1-, 1 to 2, and > 2 mm comprised 143, 79, and 35 patients, respectively. Again, no significant differences were noted in union rate or mean time to union among the groups.

Conclusions

Similar union rate and time to union were observed, regardless of nail size or CN difference. This finding indicates that most simple femoral shaft fractures can be treated with a standard, reamed 10-mm IMN. A larger nail insertion is unnecessary and presents more risks; comparatively, the use of a small nail with less reaming is simpler, requires shorter operative times, results in less blood loss, and is less expensive.

Weight Bearing as Tolerated After Intramedullary Nailing of the Femur: A Retrospective Analysis of Clinical and Radiographic Outcomes

Intramedullary nailing of femur fractures has become the standard of care, with high union rates. Few high-level studies have discussed the effect that early weight bearing has on the healing of these fractures, regardless of nail size or fracture pattern. The goal of this study was to determine the clinical and radiographic outcomes of femoral shaft fractures for patients allowed immediate weight bearing after intramedullary nailing. We performed a retrospective review of 341 femoral shaft fractures, with 131 allowed immediate weight bearing, 99 allowed partial weight bearing, and 111 kept non-weight bearing. Demographic, intraoperative, and postoperative variables were collected and analyzed. Increased fracture complexity was associated with higher likelihood of delayed weight bearing. No significant difference was found for nail size or rate of failure with different nail sizes. A total of 50 nonunions were noted (14.7%), with no difference in nonunion rates between weight bearing cohorts. The only significant predictor of nonunion was Orthopaedic Trauma Association (OTA) classification of OTA32B fractures (P=.02), which were 2 times and 4 times as likely to occur compared with OTA32A and OTA32C fractures, respectively. Failure of interlocking screws occurred among 15 patients (4.4%) and was more common with older patients, osteoporotic bone, and larger diameter nails. In summary, unilateral intramedullary nailing of adult femoral shaft fractures does not show a difference in fracture union rates or implant failure with unrestricted, immediate weight bearing, regardless of nail characteristics. [Orthopedics. 2022;45(3):e148-e153.].

Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis

PURPOSE

Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing.

METHOD

This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis.

RESULTS

Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion.

CONCLUSION

The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.

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

INTRODUCTION

Femoral shaft fractures in adults are high-energy fractures typically accompanied by additional fractures of the upper and lower extremities and brain, thoracic, or abdominal injuries. Intramedullary nailing enables early ambulation with a few complications, but rates of non-union remain high. Therefore, we aimed to compare bone union after femoral shaft fractures in adults (20-65 years old) depending on the injury severity and presence of multiple fractures.

PATIENTS AND METHODS

This study retrospectively examined 178 patients (145 male and 33 female) who underwent intramedullary nailing for a femoral shaft fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 32 type) between January 2014 and December 2018 and were followed up for at least 1 year. Patients who underwent intramedullary nailing after the preliminary application of an external fixator were excluded. Patients were divided into groups with isolated femoral shaft fractures (IS group), an injury severity score of ≤14, and multiple fractures of the extremities and the pelvic bone (at least three locations), including a femoral shaft fracture (MU group), and severely injured (injury severity score ≥15) with femoral shaft fractures (SE group). Non-union rate by group and risk factors related to bone union and bone union rate according to time to full weight bearing were analyzed.

RESULTS

In total, 29, 54, and 95 patients were assigned to the IS group, MU group, and SE group, respectively. Non-union was observed in two patients in the IS group (6.9%), six patients in the MU group (11.1%), and 11 patients in the SE group (11.6%). There were no significant differences in the bone union rate, according to multiple fractures (p=0.515) and injury severity score (p=0.561). Additionally, no differences in the bone union rate were observed according to the time to full weight bearing. Depending on open fracture (p=0.004) and fracture severity (p=0.011), the non-union rate showed a difference of up to four times or greater.

CONCLUSIONS

When intramedullary nailing is performed to treat femoral shaft fractures, multiple fractures and severe trauma do not directly affect bone union. However, it should be noted that open fracture and greater fracture severity lead to higher chances of non-union.

Intramedular fixation after breaking of the femoral plate

Any fracture of the femoral shaft presents a challenge to the orthopedic surgeon. Femoral fractures most often occur within polytrauma, by forces of high intensity as is the case with traffic accidents. There are two methods to treat with internal fracture fixation, intra and extra medullary fixation. Both treatments have their advantages and disadvantages and it is necessary to make a good preoperative plan. We present the case of a 23-year-old man who suffered a femoral shaft fracture as a driver in a car accident. He was initially surgically treated with orthopedic repositioning and internal, extramedullary fixation. After 18 months, bending of the osteosynthetic material and dislocation of the fragments with varus and recurvatum were verified. Oligotrophic pseudoarthrosis was also present. Reintervention and fixation with interlocking nail was performed. The weight bearing is allowed after two weeks. After 3 months, patient has full range of motion and there is no palpatory painful sensitivity. Intramedullary fixation is the method of choice for fractures of the femur, especially when there is no comminution and in cases of open fractures of the first and second degree. Rotation of fragments is locked, physical rehabilitation is faster and there is less risk of mal union.

Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study

BACKGROUND

Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation.

METHODS

This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS).

RESULTS

Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7 days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT.

CONCLUSION

An immediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails.

LEVEL OF EVIDENCE

Therapeutic Level III.

Impact of Surrounding Canal Size on Time to Union After Intramedullary Nailing of Femur Fractures: Are 10-mm Nails All We Need?

OBJECTIVE

To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures.

DESIGN

Retrospective review.

SETTING

Two Level 1 and 1 Level 2 trauma centers.

PATIENTS

Two hundred eighty-seven patients met the criteria and were included in the study.

INTERVENTION

Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm.

MAIN OUTCOME MEASUREMENTS

Nonunion rates, mean time to union.

RESULTS

Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups.

CONCLUSION

Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Definitive Treatment of Femoral Shaft Fractures: Comparison between Anterograde Intramedullary Nailing and Monoaxial External Fixation

Background: Femoral shaft fractures result from high-energy trauma. Despite intramedullary nailing (IMN) representing the gold standard option of treatment, external fixation (EF) can be used temporarily for damage control or definitively. The purpose of this study is to compare two different options, anterograde IMN and monoaxial EF, for the treatment of femoral shaft fractures. Methods: Between January 2005 and December 2014, patients with femoral shaft fractures operated on in two centers were retrospectively evaluated and divided into two groups: the IMN group (n = 74), and the EF group (n = 73). For each group, sex; laterality; age; and AO classification type mean follow-up, mean union time, and complications were reported. Results: Both groups were found to have no statistical differences (p > 0.05) in sex, laterality, age, and AO classification types. In the IMN group the average surgery duration was 79.7 minutes (range 45–130). The average time for bone union was 26.9 weeks. Major complications occurred in 4 (5.4%) patients. In the EF group the average follow-up duration was 59.8 months (range 28–160). The average time for bone union was 24.0 weeks. Major complications occurred in 16 (21.9%) patients. Conclusions: IMN is the gold standard for definitive treatment of femoral shaft fractures. In patients with severe associated injuries, EF should be a good alternative.

Definitive Treatment of Femoral Shaft Fractures: Comparison between Anterograde Intramedullary Nailing and Monoaxial External Fixation

BACKGROUND

Femoral shaft fractures result from high-energy trauma. Despite intramedullary nailing (IMN) representing the gold standard option of treatment, external fixation (EF) can be used temporarily for damage control or definitively. The purpose of this study is to compare two different options, anterograde IMN and monoaxial EF, for the treatment of femoral shaft fractures.

METHODS

Between January 2005 and December 2014, patients with femoral shaft fractures operated on in two centers were retrospectively evaluated and divided into two groups: the IMN group (n = 74), and the EF group (n = 73). For each group, sex; laterality; age; and AO classification type mean follow-up, mean union time, and complications were reported.

RESULTS

Both groups were found to have no statistical differences (p > 0.05) in sex, laterality, age, and AO classification types. In the IMN group the average surgery duration was 79.7 minutes (range 45-130). The average time for bone union was 26.9 weeks. Major complications occurred in 4 (5.4%) patients. In the EF group the average follow-up duration was 59.8 months (range 28-160). The average time for bone union was 24.0 weeks. Major complications occurred in 16 (21.9%) patients.

CONCLUSIONS

IMN is the gold standard for definitive treatment of femoral shaft fractures. In patients with severe associated injuries, EF should be a good alternative.

Rehabilitation after plate fixation of upper and lower extremity fractures

Post-operative rehabilitation and weight-bearing protocols are important to fracture fixation outcomes, yet there is a dearth in the literature concerning universal treatment guidelines following plate fixation of extremity fractures. There are controversies regarding time to allow weight-bearing and range of motion for most fractures of the upper and lower extremity. This lack of a consensus has led to varying practice guidelines and differing anecdotal protocols between treating surgeons. This review attempts to establish consensus guidelines for the post-operative rehabilitation required for patients following plate fixation of common upper and lower extremity fractures.

The cost of screening radiographs after stable fracture fixation

BACKGROUND

Currently up to 58% of Canadian surgeons would forego screening radiographs after stable fracture fixation. It is therefore expected that reducing screening radiographs will be well accepted, provided that patient safety is not compromised, resulting in a cost reduction. The study objective was to measure the savings of a simplified radiographic protocol for well-fixed fractures and establish feasibility for a noninferiority trial that proves patient safety.

METHODS

Patients were randomized after fixation. The control group received screening radiographs immediately after fixation and at 2 weeks. The experimental group received radiographs only when clinically indicated. At 6 weeks all patients received radiographs. The cost of imaging, time spent in clinic and patient satisfaction was measured. A blinded reviewer documented adverse events, either detected or missed.

RESULTS

Of the 90 patients screened, 39 were randomized and 26 had complete follow-up. The mean cost of radiographs over the first 6 weeks was $44.51 (95% confidence interval [CI] 38.64-50.38) per patient in the experimental group, and $129.23 (95% CI 120.23-138.23) in the control group (p < 0.001). The mean time spent in clinic at 2 weeks was 46 min (95% CI 32-60) per patient for the experimental group and 68 min (95% CI 55-81) for the control group (p = 0.018). Two complications occurred in the experimental group. Both were detected clinically and did not qualify as missed events.

CONCLUSION

Implementing a simplified radiography protocol after stable fracture fixation saves time and money. Additionally, no adverse events were missed with the study protocol. Recommendations are made toward a noninferiority trial to establish protocol safety.

A 3 year minimum follow up of Endoprosthetic replacement for distal femoral fractures - An alternative treatment option

INTRODUCTION

Although the use of an endoprosthesis for distal femoral fractures remains a valid treatment option the widespread use is in its infancy.

METHODOLOGY

In this retrospective case series, we review cases of distal femoral fracture treated with endoprosthetic replacement (EPR). The outcomes we assessed were the time to start mobilising, the time to discharge, morbidity and mortality as well as an Oxford knee score to assess pain and function and also the early survivorship. 6 of the 11 from the cohort had existing Total Knee Replacements (TKRs) in situ.

RESULTS

There were 11 knees in our cohort with a mean age of 81.5 years (range 52-102 years). The median time to follow up was 3.5 years (range 1.6 to 5.5 years). The median times to theatre was 3 days and to discharge was 16 days. Oxford functional and pain scores were 32/48.

DISCUSSION

In the appropriate patient and fracture pattern, Endoprosthetic knee replacement is an excellent option in the treatment of distal femoral fractures whether associated with an existing TKR or not. The implant is more costly than traditional open reduction and internal fixation, but the earlier return to full mobility post-operatively may save on hospital/care home stay and free up hospital space and minimise complications.

Can Tibial Shaft Fractures Bear Weight After Intramedullary Nailing? A Randomized Controlled Trial

OBJECTIVE

To examine the potential benefits and risks associated with weight-bearing after intramedullary (IM) nailing of unstable tibial shaft fractures.

DESIGN

Randomized controlled trial.

SETTING

Two New York State level 1 trauma centers, one level 2 trauma center, and 1 tertiary care orthopaedic hospital in a large urban center in New York City.

PATIENTS/PARTICIPANTS

Eighty-eight patients with 90 tibial shaft fractures were enrolled. The following were used as inclusion criteria: (1) skeletally mature adult patients 18 years of age or older, (2) displaced fractures of tibial diaphysis (OTA type 42) treated with operative intervention, and (3) radiographs, including injury, operative, and completion of follow-up. Sixty-eight patients with 70 tibial shaft fractures completed follow-up.

INTERVENTION

All patients were treated with locked IM nailing. Patients were randomized to 1 of 2 groups: immediate weight-bearing-as-tolerated (WBAT) or non-weight-bearing for the first 6 postoperative weeks (NWB).

MAIN OUTCOME MEASURES

Fracture union or treatment failure/revision surgery.

RESULTS

There was no statistical difference in the observed time to union between groups (WBAT = 22.1 ± 11.7 weeks vs. NWB = 21.3 ± 9.9 weeks; P = 0.76). Rates of complications did not statistically differ between groups. No fracture loss of reduction leading to malunion was encountered. Short Musculoskeletal Function Assessment scores for all domains did not statistically differ between groups.

CONCLUSIONS

Immediate weight-bearing after IM nailing of tibial shaft fractures is safe and is not associated with an increase in adverse events or complications. Patients should be allowed to bear weight as tolerated after IM nailing of OTA subtype 42-A and 42-B tibial shaft fractures.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Working toward reducing postoperative fracture radiographs: a survey of Canadian surgeons

BACKGROUND

When fracture management includes operative fixation with a load-sharing construct in good-quality bone, screening for healing problems or hardware failure with radiographs in the first 6 postoperative weeks may be unnecessary. I sought to determine Canadian orthopedic surgeons' current protocol for early postoperative radiographs of stable, internally fixed fractures as well as their willingness to adopt a simplified protocol.

METHODS

Members of the Canadian Orthopaedic Association were surveyed electronically. Five examples of surgically treated fractures were chosen to represent the spectrum of load-sharing constructs. The survey collected demographic data and inquired about current postoperative radiograph protocols and consideration of a simplified protocol.

RESULTS

Of the 822 emailed invitations to complete the survey, 400 were opened and 243 surveys were completed. Most participants (91%) practised in Canada and managed some trauma (91%), but were not trauma specialists (82%). Surgeon experience was equally distributed. Sixty-six percent of respondents acquire immediate postoperative radiographs after femur and tibia intramedullary nails, and 62% repeat radiographs at 2-week follow-up. Fifty-one percent of respondents acquire immediate postoperative radiographs after forearm, humerus and ankle internal fixation, and 69% repeat radiographs at 2-week follow-up. Of the respondents who currently acquire radiographs, 33% would consider foregoing immediate postoperative radiographs after intramedullary nailing of femur and tibia fractures, while 25% would forego them at 2-week follow-up. Similarly, 58% would consider foregoing radiographs immediately after internal fixation of forearm, humerus and ankle fractures, while 24% would forego them at 2-week follow-up.

CONCLUSION

Many Canadian orthopedic surgeons do not acquire screening postoperative radiographs after stable fracture fixation, and many more are willing to adopt this practice. These findings support investigating the safety and cost-effectiveness of a simplified postoperative radiographic protocol.

Removal of a bent intramedullary nail with a posttraumatic sagittal plane deformity

High-energy injuries may result in a femur fracture with resultant bending of a previously placed intramedullary femoral nail. A bend of the nail in the sagittal plane presents unique challenges for nail extraction and subsequent exchange nailing. The described surgical technique illustrates a simple method to straighten the sagittal plane bend in situ and performs exchange nailing although maintaining symmetric femoral length and rotation.

Is there a standard rehabilitation protocol after femoral intramedullary nailing?

INTRODUCTION

The purpose of this article was to describe the impairments and functional deficits associated with femoral shaft fractures treated with an intramedullary (IM) nail and to illustrate an evaluation-based rehabilitation program designed to target these functional deficits.

LITERATURE REVIEW

The current literature describing management of diaphyseal femur fractures is replete with evidence regarding surgical management and optimal bone healing. However, a dearth exists with respect to postoperative rehabilitation recommendations, targeting the impairments that often limit return to activity. Current literature suggests that residual impairments after IM rod fixation of a femoral shaft fracture include hip abduction weakness, knee extensor weakness, anterior knee pain, and gait abnormalities. Any combination of these impairments can potentially limit the ability of a patient to return to prior levels of function. A rehabilitation program designed to target these impairments provides the best opportunity for a favorable outcome. REHABILITATION PROTOCOL: An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. Progression through the program is dependent on successful attainment of baseline goals. These goals address weight bearing (WB) status, knee effusion, quadriceps control, and hip abduction strength. The program is a dynamic incorporation of interventions designed to target these known impairments.

CONCLUSIONS

An evaluation-based rehabilitation protocol for femur fractures treated with an IM nail can facilitate restoration of function in a predictable manner and should be considered as a standard for patients with these injuries.

Estimating femoral nail length in bilateral comminuted fractures using fibular and femoral head referencing

OBJECTIVE

Femoral nail length can be estimated preoperatively by several methods, but this usually requires an intact contralateral femur. The aim of this study was to determine an alternative method using fibula and femoral head as references.

MATERIALS AND METHODS

Digital radiographic views of the lower limbs of 102 healthy volunteers were used to compare femoral medullary length with the sum of fibular length and transverse head diameter.

RESULTS

Femoral medullary length and the estimated length were highly correlated (r=0.942, p<0.0001). Paired samples t-testing has produced a high significance (p<0.002).

CONCLUSION

The formula provides a simple and accurate estimation of femoral medullary length, and may be used in nailing, particularly of bilateral comminuted femoral fractures.

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.

The locked flexible intramedullary humerus nail in pediatric femur and tibia shaft fractures: a feasibility study

There are several options for the treatment of long bone fractures in skeletally immature patients. Surgeon experience, type of fracture, and the possibility of damage to the physeal area dictate individual fracture management patterns. Notably, nail devices have not gained popularity in this patient group. Intramedullary locking nails have become the standard of care in adult patients due to decreased morbidity and mortality. A novel nail has been developed for humeral shaft fractures that uses a lateral starting position to avoid damage to the rotator cuff in humeral fracture fixation. This is possible because of the nail's transient flexibility during insertion. This study illustrates that it is feasible to insert this type of nail through multiple entry portals for both tibial and femoral fracture fixation, without damaging the physeal blood supply or growth areas.