Surgical treatment of type II floating knee: comparisons of the results of type IIA and type IIB floating knee

COMPARATIVE ANALYSIS OF OPEN AND CLOSED FLOATING KNEE INJURIES

Objective

To compare the functional outcomes between floating knee injuries with open femur and tibia fractures and closed floating knee injuries.

Methods

Floating knee injuries (followed up and treated in our clinic) were retrospectively analyzed. Patients were divided into two groups: floating knee injuries with open femur and tibia fractures (Group 1) and floating knee injuries with closed femur and tibia fractures (Group 2). Patients were compared according to their demographic characteristics and clinical and functional outcomes.

Results

Of 52 study patients, 28 had Group 1 injuries and 24, Group 2 injuries. We found a statistically significant difference in length of hospital stay between the two groups (p = 0.01) and a statistically significant difference in Karlström-Olerud functional scores between the groups (p = 0.02). We found osteomyelitis in five (17%) patients in Group 1 and in one (4%) patient in Group 2.

Conclusion

Patients with floating knee injuries and open fractures showed poorer outcomes than those with closed fractures. Those with open floating knee injuries show complications more often and longer hospital stays. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

The current issues and challenges in the management of floating knee injury: a retrospective study

Purpose

The management of floating knee injuries is still controversial and challenging for trauma specialists. This study aims to evaluate the incidence of the floating knee in lower limb trauma, analyzing the challenges in its management, and factors affecting clinical outcomes.

Methods

In this mono-center retrospective study, 36 consecutive patients were included. All individuals were diagnosed with an ipsilateral fracture of the femur and tibia, managed surgically according to their fracture pattern (Fraser classification), and the severity of the injury. The timing for each operation was determined based on the general condition of the patient and the local physiological condition of soft tissues. The patients' clinical outcomes were finally evaluated based on their Karlstrom and Olerud scores and were categorized as excellent, good, acceptable, fair, or poor.

Results

In this study, the mean follow-up period was 51.39 ± 16.02 months (11-130 months). Incidence of the floating knee was 2.32% in all lower limb traumas. From this number, 16 patients suffered from floating knee injury in the left lower extremity, and 18 in the right lower limb, while in 2 patients the condition was bilateral. The most common injury mechanism was road traffic accidents, accounting for 28 (77.78%) cases. The outcome was as follows; Excellent to good results in 22 (61.11%) cases, acceptable results in 2 (5.56%) cases, and fair to poor results in 12 (33.33%) cases according to the Karlström-Olerud scoring system. The most frequent early complications were wound infection and deep venous thrombosis in 5 (13.88%) of the cases. The most common late complication was common peroneal nerve palsy recorded in 2 (5.56%) cases.

Conclusion

The presence of important concomitant injuries to the floating knee together with poor soft tissue conditions constituted important factors influencing possible management options and may have led to poorer clinical outcomes.

Evaluation of the Interobserver Agreement of the Fraser and Blake & McBryde Classifications for Floating Knee

Objective  To evaluate the interobserver agreement of two classifications for floating knee: Fraser and Blake & McBryde. Method  Thirty-two observers, subdivided according to the degree of titration (26 resident physicians and 6 orthopedic physicians specialized in orthopedic trauma), classified 15 fractures of the ipsilateral femur and tibia. Interobserver agreement was evaluated by using the Kappa coefficient . Result  When evaluating the agreement between the 9 R1, a Kappa index of 0.58 was obtained for the Fraser classification and of 0.46 for the Blake & McBryde classification. Among the 7 R2, a rate of 0.59 was obtained for the Fraser rating and 0.51 for the Blake & McBryde rating. Among the 10 R3, the agreement index was higher for both classifications: 0.72 for the Fraser and 0.71 for the Blake & McBryde classification. Considering the 3 groups (R1, R2, R3) as one large group, the general Kappa index was calculated, which resulted in 0.63 for the Fraser classification and 0.56 for the Blake & McBryde classification. In the group of trauma and orthopedic knee specialists, in turn, an agreement of 0.597 was obtained for the Blake and McBryde classification and of 0.843 for the Fraser classification. Conclusion  Comparatively, the two classifications presented a weak to moderate degree of agreement. Fraser classification had better agreement in both groups. The agreement was higher when evaluating orthopedic trauma physicians.

Neglected infected floating knee injury: evaluation of closed reduction techniques

PURPOSE

Floating knee injury is uncommon yet challenging problem. The situation is more complicated by presence of infection, open comminuted fractures, and late presentation. The aim of this study was to evaluate the closed reduction techniques by circular external fixation in a single stage to treat patients having infected neglected floating knee injuries.

METHODS

This retrospective study included 19 patients with a mean age of 34.4 years. The average duration from trauma to surgery was 51.1 days. All patients had at least one infected open fracture. According to Fraser's classification, ten injuries were type I, one case was type IIa, four were type IIb, and four were type IIc. Patients were treated by closed reduction techniques using the Ilizarov principles. Orthoplastic procedures were done in four cases in the same surgical setting.

RESULTS

Closed reduction and union were achieved in all cases with control of infection in 17 cases. The follow-up period averaged 41 months. The mean knee flexion was 97.4°. The complications included 5° extension lag (two cases), malunion (three cases), refracture (two cases), and DVT (four cases). The bone results were excellent (12 cases), good (5 cases), and poor (2 cases). The functional results were excellent (two cases), good (seven cases), acceptable (seven cases), and poor (three cases).

CONCLUSIONS

Closed reduction techniques using a circular frame provided a valid treatment option for infected neglected floating knee injuries in one stage without bone grafting. However, the high rate of complications and the diminished knee range of motion should be considered.

Acute Femoral Nailing and Ipsilateral Knee-Spanning External Fixation: Improved Early Stability for Floating Knee Injuries Involving the Tibial Plateau

Ipsilateral femoral shaft and tibial plateau fractures, termed a "floating knee," are rare and challenging injuries. There is limited literature guiding the operative technique and the outcomes associated with these injuries. The author's preferred technique is early intramedullary of the femoral shaft fracture with knee-spanning external fixation of any length unstable plateau fractures in the same operative setting. Early fixation of the femur fracture allows for improved hemodynamic and inflammatory stability. External fixation of the tibial plateau restores length and alignment and allows for soft tissue rest until definitive fixation. The purpose of this study is to describe this operative technique and determine the infection rate and complications requiring return to the operating room in patients with femoral shaft fractures and length unstable plateau fractures.

Challenges and outcomes in the treatment of floating knees. A case series of ipsilateral femur and tibia fractures around the knee

BACKGROUND

Ipsilateral femur and tibia fractures around the knee (floating knee) are rare injuries that threaten both limb viability and patient life. A correct surgical strategy is essential to reduce complications and sequelae. The aim of this study was to evaluate characteristics and results of treatment in patients with a floating knee treated at a single trauma center.

MATERIAL AND METHODS

This is a retrospective and non-consecutive case series of 18 floating knees occurred in 17 patients. All patients were operated in a single third-level public and university hospital from December 2010 to December 2018. Data on demographics, injuries, treatment and follow-up were collected. A general health questionnaire (SF-12) and a knee functional questionnaire (KOOS-PS) were used to display results.

RESULTS

We identified 13 men and 4 women, aged between 16 and 52. Mean follow-up period was 16.49 months. High-energy trauma following a traffic collision was the most frequent mechanism. Mean Injury Severity Score (ISS) was 39.05, and a damage control strategy was used in 15 (83.33%) injuries. Extra-articular fractures (Fraser I) largely predominated, resulting in double intramedullary nailing in 72.22% of cases. Eleven injuries (61.11%) presented with an open fracture. Complications appeared in 6 (33.33%) injuries, being 3 infections. Mean score for the SF-12 was 35.59 for the physical dimension and 50.44 for mental dimension. Mean score for the KOOS-PS was 43.64.

CONCLUSION

Floating knee injuries usually occur in polytrauma contexts. Visceral involvement and exposed fractures are common, so the most appropriate strategy is usually a staged treatment. Complications and sequelae are frequent.

Comparison of functional outcomes among subtypes of Fraser's type Ⅱ floating knee

PURPOSE

The poor prognosis in patients with floating knee injuries is mainly contributed to articular involvement (Fraser's type Ⅱ). This study aims to evaluate and compare the functional outcomes among different Fraser's type Ⅱ floating knee injuries after surgical management.

METHODS

Twenty-seven patients with Fraser's type Ⅱ floating knee injuries (54 fractures) between September 2014 and December 2015 were enrolled prospectively in this study and were distributed according to Fraser's floating knee classification into three different groups as type ⅡA (ipsilateral femoral shaft and tibial intra-articular involvement, n = 11), type ⅡB (ipsilateral tibial shaft and femoral intra-articular involvement, n = 9) and type ⅡC (both femoral and tibial intra-articular involvement, n = 7). The differences among the groups were evaluated and compared. The functional outcomes of these injuries at one year were analyzed using Knee Injury and Osteoarthritis Outcome Score (KOOS) which covers 5 subscales of pain, other symptoms, activities of daily living, sports and recreation, and quality of life. The result was also compared with standardized age-sex matched healthy population using paired samples t-test.

RESULTS

All the patients were male, and the injury mechanism was solely roadside accident. The mean age was 29.8 years and injury severity score 17.9 (comparable in all the three groups). Most injuries were observed on the right side (20 cases, 74.1%). Based on paired samples t-test, the KOOS score of patients with Fraser's type ⅡA was found to be better than that of type ⅡB and type ⅡC. Compared with the reference age-sex matched control group, patients with Fraser's type ⅡB and ⅡC fractures had significantly lower mean score in all KOOS subscales (all p < 0.01). However, Fraser's type ⅡA only revealed significant difference regarding the subscales of activities of daily living (p < 0.0001), sports and recreation (p < 0.0001), and quality of life (p < 0.0001).

CONCLUSION

The results of this study show that patients with Fraser's type ⅡA fractures had a better functional outcome as compared to those with type ⅡB and ⅡC fractures. This might be due to the open intra-articular involvement of the distal femur of the latter two fracture types.

Management of the Floating Knee: Ipsilateral Fractures of the Femur and Tibia

The "floating knee" is defined as fractures of the ipsilateral femur and tibia, which consists of a spectrum of injury, and may be in isolation or part of multiple system trauma for a given patient. A floating knee may compromise limb viability due to severe soft-tissue and vascular injury. Expeditious fracture reduction and patient resuscitation are crucial, while type and timing of provisional and definitive management is guided by the extent of injury to the involved extremity and associated systemic injuries. Numerous surgical techniques are available to treat the floating knee, including external fixation and internal fixation with plates or intramedullary nails. Fracture complexity and severity of soft-tissue injury present challenges, with articular injuries potentially more debilitating in the long term. Complications such as infection, deep vein thrombosis, knee stiffness, nonunion, malunion, and posttraumatic arthrosis after these injuries should be considered.

[Patellar tendon rupture with distal closed fracture of the ipsilateral femur]

We here report the case of a 45-year old patient who had injured his right knee because of a road accident. The patient had right comminuted supracondylar femur fracture and ipsilateral patellar tendon rupture. This association is exceptional and no case has been reported in the literature. Targeted clinical and radiological diagnostic tests followed by early and suitable management based on internal osteosynthesis and suitable early functional rehabilitation enabled good long term outcome.

Functional outcomes and quality of life in adult ipsilateral femur and tibia fractures

Objective

The aim of our study is to evaluate the functional outcomes and quality of life in adult ipsilateral femur and tibia fractures.

Methods

26 patients (21 male, 5 female; mean age 30 years, range: 18 to 66) treated for adult ipsilateral femur and tibia fractures were evaluated retrospectively. For femur fractures, intramedullary nails were used in 15 patients (12 antegrade, 3 retrograde), plate in 11 patients (10 locked-plate, and 1 blade-plate with a 95 degree angle). For tibia fractures, locked-plate were used in 13 patients, intramedullary nails in 9 patients, external fixator in 3 patients and multiple screws in 1 patient. According to Blake and McBryde classification, 17 fractures were type I, 9 fractures were type II (7 type 2A and 2 type 2B). The functional outcomes were evaluated by Karlström and Olerud criteria, and quality of life was evaluated by Short Form-36. The mean follow-up duration was 4.4 years (range: 1.1 to 7.3 years).

Results

The functional outcomes were excellent in 6 patients, good in 8 patients, acceptable in 6 patients and poor in 6 patients. The mean values of quality of life scales were; physical function: 64.8, physical role limitation: 60.5, pain: 68.2, general health: 63.3, vitality: 58.4, social function: 68.2, emotional role limitation: 62.7, and mental health: 65.8.

Conclusion

Adult ipsilateral femur and tibia fractures are severe injuries and adversely affect the quality of life and functional outcomes. The quality of life scales should be used along with functional outcome scores in evaluating these injuries.

The translational potential of this article

Adult ipsilateral femur and tibia fractures cause severe morbidity. Functional outcomes and quality of life scales should be used together to evaluate these fractures. Karlström and Olerud criteria for functional outcomes and Short Form-36 scales for quality of life are suitable methods to evalute these fractures.

Variables affecting functional outcome in floating knee injuries

BACKGROUND

The surgical outcome of floating knee injuries is difficult to predict. The high-velocity nature of the injury, complex fracture pattern and associated soft tissue/visceral injuries may have some impact on the functional outcome. The present study evaluates the variables affecting the clinical and radiological outcomes of floating knee injuries.

MATERIALS AND METHODS

The clinical, radiological and functional outcome (Karlstrom and Olegrud criteria) of 89 patients with 90 floating knee injuries were evaluated at the end of one year who were managed in our level 1 trauma center between January 2013 and December 2016. The details of the injury, fracture pattern, management and complications were collected retrospectively from their records.

RESULTS

There were 81 (91.1%) males and 8 (8.9%) females with mean age of 34.34 ± 12.28 years. The mean time for tibia and femur union was 9.52 (±6.6) and 10.5 (±7.37) months. There was significant delay (p < 0.005) in time taken for union in segmental femur fractures (14.3 ± 9.6 months) compared to nonsegmental femur fractures (8.68 ± 5.18 months). Such significant difference in time taken for union was not seen in tibial segmental (10.6 ± 4.62 months) and nonsegmental fractures (9.05 ± 7.27 months). As per the Karlstrom and Olegrud criteria, there were 22 (24.4%) excellent, 26 (28.9%) good, 24 (26.7%) fair and 11 (12.2%) poor outcome. There were 15 patients with malunited tibia, 6 with malunited femur, 10 with limb length discrepancy and 39 with knee stiffness. 28 (33.3%) patients underwent major additional procedures such as bone grafting, re-fixation or bone transport or tendon transfer. It was observed that open tibia fracture, segmental fracture, intra-articular fracture, additional surgical procedures, initial external-fixator (ex-fix) application were significantly associated with development of knee stiffness, limb shortening, malalignment and unsatisfactory (Karlstrom and Olegrud fair to poor) functional outcome.

CONCLUSION

Open tibial fractures, segmental fractures, intraarticular involvement, additional surgical procedures and initial external fixator application are the poor prognostic indicators of floating knee injuries.

Traumatic Floating Knee: A Review of a Multi-Centric Series of 172 Cases in Adult

The traumatic floating knee in adults (FK) is a combined injury of the lower limb defined by ipsilateral fractures of the tibia and femur. The first publications emphasized the severity of injuries, the bad results after conservative treatment, the most severe functional outcome in case of articular fracture and the frequency of associated cruciate ligament injuries. The surgical management of FK has been highly modified according the improvement of the fracture fixation devices and the operative techniques. This retrospective multicentric observational study included 172 adults with a FK injury admitted in emergency in 5 different level I or II trauma centers. All the patients data were collected on an anonymized database. Results were evaluated by the overall clinical Karlström's score at latest follow-up. Fracture union was assessed on X-rays when at least 3 out of 4 cortices were in continuity in two different radiological planes. A statistical analysis was performed by a logistic regression method. Despite some limitations, this study confirms the general and local severity of this high-energy trauma, mainly occurring in young people around the third decade. A special effort should lead to a better initial diagnosis of associated ligamentous injury: a tear of PCL can be suspected on a lateral-ray view and a testing of the knee should be systematically performed after fixation of the fracture under anesthesia. Secondary MRI assessment is sometimes difficult to interpret because of hardware artifacts. The timing of fracture fixation is discussed on a case by case basis. However, a first femoral fixation is recommended except in cases of tibia fracture with major soft tissue lesion or leg ischemia requiring the tibia fixation first. Also a tibia stabilized facilitates the reduction and fixation of a complex distal femur fracture. The dual nailing remains so far for us the best treatment in Fraser I FK. Further prospective studies are needed to validate treatment algorithms, best fixation techniques in order to decrease the rate of complication and improve the functional outcome of floating knee injuries.

The intramedullary nailing using a single knee incision for treatment of extraarticular floating knee (nine cases)

Context:

Floating knee injuries are uncommon and complex injuries. Management of this injury has been variously described in the literature.

Aims:

We present the outcome of the intramedullary nailing using a single knee incision for treatment of extraarticular floating knee.

Materials and Methods:

We report a retrospective series of nine patients with extraarticular floating knee.

Results:

There were seven men and two women with an average age of 35 years. At least one of the fractures was open in three cases. The average Injury Severity Score was 17. According to Fraser's classification, 100% of the cases are type I. All our patients were treated by the intramedullary nailing using a single knee incision. The mean operating time was 146 min. The mean follow-up is 19 months. According to the Karlström criteria, the end results were excellent in two cases, good in four, acceptable in two, and poor in one. Bone union was achieved in eight cases with an average period of 93 days.

Conclusions:

The intramedullary nailing using a single knee incision has shown in this series better results.

Patella osteotomy: a new approach for complex trauma around the knee

Complex floating knee injuries, comprising complete articular distal femur and proximal tibia fractures, are a significant challenge in Orthopedic Traumatology. Traditional surgical approaches can result in a limited exposure, compromising osteosynthesis, with an extensive soft tissue dissection predisposing to adhesion of the quadriceps and arthrofibrosis. The Patella Osteotomy technique provides unrivaled visualization of the articular surfaces of the knee, with a limited soft tissue dissection to permit the anatomical reconstruction of the articular injury, while minimizing the risk of postsurgical complications and reducing intraoperative fluoroscopy time.

Floating knee injury associated with patellar tendon rupture: a case report and review of literature

Floating knee injuries are frequently associated with other concomitant injuries to the ipsilateral limb or other parts of body of which injury to the ipsilateral knee ligaments carries significance for various reasons. A middle-aged man sustained a floating knee injury following RTA. DCS fixation by bridge plating technique for the distal femur and lateral buttress plating by MIPO technique for proximal tibia were planned and executed under spinal anesthesia with image intensifier. In addition, there were patellar tendon rupture along with avulsion of VMO from the medial border of patella and torn MPFL, which we have missed initially. To the best of our knowledge no similar case has been reported in English literature so far. We have reviewed the literature and proposed a different interpretation of Blake and McBride classification.

Surgical management of ipsilateral fracture of the femur and tibia in adults (the floating knee): postoperative clinical, radiological, and functional outcomes

Background

This study evaluated the outcomes of surgical management of ipsilateral femoral and tibial fractures in adults.

Methods

Fifteen patients (13 men, 2 women; mean age, 34.8 years; range, 18 to 65 years) were enrolled in this study. The fractures types were classified according to the classification by Fraser et al. as follows: type I (5), type IIa (3), IIb (4), IIc (3). Femur fractures were treated using locked intramedullary nails, plate-screws, or dynamic condylar screws, and tibia fractures were treated with an external fixator (in open fractures), or plate-screws, and locked intramedullary nailing. The mean follow-up duration was 2.2 years (range, 1.3 to 4 years).

Results

The extent of bony union according to the Karlstrom criteria was as follows: excellent, 8; good, 4; acceptable, 2; poor, 1.

Conclusions

The associated injuries and type of fracture (open, intra-articular, comminution) are prognostic factors in a floating knee. The best management of the associated injuries for good final outcome involves intramedullary nailing of both the fractures and postoperative rehabilitation.

Peri-articular fractures of the knee: an update on current issues

Peri-articular fractures of the knee in the young and elderly pose several management dilemmas. Over the last decade enormous interest has been generated in various fixation modalities, none proving to be an ideal stabilisation method. The problem is compounded by a lack of well-designed studies comparing various treatment options. In this article, the issues surrounding the diagnostic and management strategies of peri-articular fractures of the knee are discussed.

The floating knee: epidemiology, prognostic indicators & outcome following surgical management

Background

Floating Knee injuries are complex injuries. The type of fractures, soft tissue and associated injuries make this a challenging problem to manage. We present the outcome of these injuries after surgical management.

Methods

29 patients with floating knee injuries were managed over a 3 year period. This was a prospective study were both fractures of the floating knee injury were surgically fixed using different modalities. The associated injuries were managed appropriately. Assessment of the end result was done by the Karlstrom criteria after bony union.

Results

The mechanism of injury was road traffic accident in 27/29 patients. There were 38 associated injuries. 20/29 patients had intramedullary nailing for both fractures. The complications were knee stiffness, foot drop, delayed union of tibia and superficial infection. The bony union time ranged from 15 – 22.5 weeks for femur fractures and 17 – 28 weeks for the tibia. According to the Karlstrom criteria the end results were Excellent – 15, Good – 11, Acceptable – 1 and Poor – 3.

Conclusion

The associated injuries and the type of fracture (open, intra-articular, comminution) are prognostic indicators in the Floating knee. Appropriate management of the associated injuries, intramedullary nailing of both the fractures and post operative rehabilitation are necessary for good final outcome.