Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes

Intramedullary Nailing in Femoral Diaphyseal Fractures: A Retrospective Multicenter Cohort Study

Intramedullary nails (IMNs) are the most frequent surgical fixation method for femur fractures. Although IMNs provide good healing outcomes and low complication rates, concerns persist regarding potential complications such as malunion, nonunion, and infections. This multicenter retrospective study aims to assess the epidemiology and outcomes of IMNs for diaphyseal femoral fractures. Data from 91 patients who underwent IMN fixation at two Brazilian hospitals between 2020 and 2024 were analyzed, with a mean age of 33.3 years (SD ± 12.7) and 76.9%% of male patients. Traffic accidents were the most common mechanism of trauma (84.61%). The bone healing rate was 96.7% within six months, and 98.9% within one year, with a complication rate of 3.26%, including two cases of pseudoarthrosis, one case of pseudoarthrosis and infection, and two reoperations. There was a significant association between previous external fixation and fracture type (open/closed) (χ2(1) = 17.5, pFischer < 0.001). Previous external fixation was also associated with lower consolidation rates six months post-surgery (χ2(1) = 9.83, pFischer = 0.031), but not after one year (χ2(1) = 8.19, pFischer = 0.11). The retrograde approach was associated with a lower consolidation rate after six months (χ2(1) = 6.98, pFischer = 0.027), but no significant association was found after one year (χ2(1) = 2.27, pFischer = 0.308). Only one patient with pseudoarthrosis did not consolidate after one year. The outcomes support the efficacy of IMNs in achieving bone consolidation with low complication rates.

"Terrible Triad" Injury in an Adolescent Patient With a High-Energy Femoral Shaft Fracture: A Case Report

Although femoral shaft fractures are typically treated with intramedullary nailing, alternative fixation methods like plating are required in select cases, particularly when nailing may be contraindicated due to respiratory complications or other patient-specific factors. Currently, there are no established guidelines for the optimal surgical fixation method of femoral shaft fractures in polytrauma patients with respiratory dysfunction. We present the case of a young patient with a diaphyseal femur fracture who underwent multiple surgical interventions within three months due to recurrent injuries and complications, primarily resulting from non-adherence to postoperative guidelines. We describe this sequence as a "terrible triad injury", consisting of primary fixation of the femoral fracture, revision of the first osteosynthesis due to recurrent trauma and implant failure, and a subsequent patellar tendon rupture.

Comparative Study of Exchange Nailing and Augmentative Plating for Treating Aseptic Nonunion of Femoral Shafts Post Intramedullary Nailing: A Single-Blind, Multicentric Randomized Clinical Trial

Background: Aseptic nonunion of femoral shafts after intramedullary nailing (IMN) can be a challenging condition that may lead to long-term disability and the need for multiple surgical procedures. This study compared the clinical and radiological outcomes between exchange nailing and augmentative plating with bone grafting. Methods: In this multicenter, prospective, single-blind, randomized controlled trial, patients with aseptic nonunion of the femoral shaft after IMN were randomly assigned to receive exchange nailing or augmentative plating. The primary outcomes measured were the time to bone union and union rate 12 months after revision surgery. The secondary outcomes included operative time, blood loss, hospitalization duration, pain level using the visual analog scale (VAS), knee range of motion (ROM), and complication rates. Results: The augmentative plating group had a significantly shorter mean time to union (5.39 ± 1.29 months) compared with the exchange nailing group (7.38 ± 1.97 months; p < 0.001). The union rates at 12 months were 100% in the augmentative plating group and 89.65% in the exchange nail group. Augmentative plating resulted in a shorter operation time (99.46 ± 11.08 min vs. 106.45 ± 12.22 min; p = 0.025) and reduced blood loss (514.79 ± 45.87 mL vs. 547.72 ± 54.35 mL; p = 0.016). Significant pain reduction was observed in the augmentative plating group, with preoperative VAS scores decreasing from 6.04 ± 2.28 to 2.64 ± 1.50, compared with a decrease from 5.66 ± 2.21 to 3.66 ± 2.19 in the exchange nailing group (p = 0.047). Knee ROM improved significantly in the augmentative plating group (p = 0.0176). The complication rate was lower in the augmentative plating group (3.57%) than in the exchange nail group (17.24%). Conclusions: Augmentative plating with autologous bone grafting is superior to exchange nailing for treating aseptic nonunion of femoral shafts. It is associated with faster healing, higher union rates, better clinical and functional outcomes, and fewer complications. We recommend this technique as the preferred treatment option for such complex cases.

Incidence and characteristics of ligamentous knee injuries accompanying a femur shaft fracture and their association with injury mechanism and fracture characteristics: A prospective-observational study in a low-middle-income country

Objective

This study aims to elaborate the incidence, types, and characteristics of ligamentous knee injuries accompanying femoral-shaft fractures and their association with demographic data, fracture characteristics, and injury mechanism.

Methods

This multi-center-prospective-observational study examined patients in the Shaheed Mohtarma Benazir Bhutto Institute of Trauma and Civil Hospital orthopedic wards. Using the consecutive sampling technique, 146 patients with femoral-shaft fractures were recruited, and scrutinized to determine the presence of ligamentous knee injury, through an evaluation form encompassing patients' demographic data, fracture characteristics, knee examinations, and confirmed through magnetic resonance imaging. Knee injuries were detected intra-operatively under regional/general anesthesia and post-operatively utilizing diagnostic maneuvers (varus/valgus stress, Lachman, anterior/posterior drawer, external rotation recurvatum, and McMurray tests) by 2-3 surgeons and confirmed through magnetic resonance imaging. Magnetic resonance imaging was exclusively employed in suspected false positive/negative cases, and when a titanium implant was utilized, that is, 131 cases (89.7%). Chi-square test was used to assess the relationship between incidence and type of ligamentous knee injury with demographic data, injury mechanism, and fracture characteristics.

Results

Among the 146 patients with femoral-shaft fractures, 78% and 22% were males and females, with 37% experiencing associated ligamentous knee injury. Medial collateral ligament and anterior cruciate ligament were the commonest types of ligamentous injuries accompanying femoral-shaft fractures, at 44% and 33%. The Chi-square revealed a statistically significant association between the incidence of ligamentous knee injury accompanying femoral-shaft fracture with demographic data, injury mechanism, and fracture characteristics (p-value < 0.05), and was noted to be higher among males (55.6%), participants aged 18-25 years (66.7%), involved in a road traffic accident (88.9%), resulting in a complex (77.8%) and close fracture (88.9%). A similar association was seen between medial collateral ligament and anterior cruciate ligament injuries with age, injury mechanism, and fracture characteristics (p-value < 0.05).

Conclusion

Our study revealed the unaddressed fact that Pakistan has a significant incidence of ligamentous knee injuries accompanying femoral-shaft fractures. These insights can empower clinicians/surgeons to understand and manage this condition effectively.