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.

Ilizarov Fixator-Assisted Management of Neglected Femur Fractures by Open Intramedullary Nailing: A Case Series

Femoral shaft fractures are major life- and limb-threatening injuries. Such injuries, when neglected for months or years, can lead to a range of debilitating consequences. In the Indian subcontinent, there are multiple such cases that are presented to tertiary care hospitals late due to a lack of awareness and low socioeconomic constraints. These neglected cases on presentation are usually in a state of nonunion or malunion, with gross shortening and deformity affecting adjacent joint mobility. The management of neglected femur shaft fractures (NFFs) demands uphill tasks, such as achieving mechanical stability, restoring length and alignment, and having strong rehabilitation schedules. The functional outcomes of these cases are always not proportional to their radiological counterparts and must be taken care of separately. In this study, intramedullary nailing of the fracture after initial distraction with the Ilizarov fixator aims to reduce deformity and shortening while restoring near-optimal functional life. The study aimed to evaluate the functional and radiological outcomes of NFFs operated with distraction by an Ilizarov fixator followed by intramedullary nailing.

METHODS

Fourteen cases of NFFs presented to Kalinga Institute of Medical Sciences, Bhubaneswar, India, between January 2020 and June 2022 were recruited for the study. After preoperative evaluation and explanation of available treatment options to patients, they were operated on with a two-stage procedure of Ilizarov fixator application, followed by intramedullary interlocking nailing, with a period of gradual distraction in between. They were then followed up for a minimum of 12 months to assess functional and radiological outcomes.

RESULTS

The average time for all of the fractures to heal was 25.2 weeks. The average knee flexion increased from 28.2 degrees before surgery to 87.1 degrees after surgery. All 14 patients could walk with complete weight bearing on the operated limb postoperatively after proper pain control measures were taken. The mean Tegner Lysholm knee score was 77.8. There was residual limping in six of the cases, which could be attributed to muscle atrophy and/or shortening in the affected limbs. In three cases, skin blisters were formed due to the acute nature of the distraction, but they all healed with a scab and scar, otherwise uneventfully. The shortening, in 13 cases, came down to 4 cm or less, which was managed with a shoe raise. The one case with a residual 5 cm shortening had a short, limping gait, and it was attributed to an extremely overriding osteopenic femur preoperatively.

CONCLUSION

A two-stage operation with distraction by an Illizarov fixator followed by an intramedullary fixation provides the basic advantage of not having to excise an excessive amount of bone, which may be required in primary open reduction and intramedullary fixation. It also allows the patient to carry on his daily activities as mobilization is not restricted, which is the case in an individual to whom skeletal traction is applied. Hence, in any NFF case, this algorithm of management can be considered a frontrunner in the comprehensive management of disability and deformity.

Physiotherapy Rehabilitation in an Infected Non-union Shaft of Femur Repair Patient: A Case Report

While definitions may vary, infected non-union is generally described as a condition where a fracture fails to heal due to infection, typically persisting for a duration of six to eight months. Infected non-unions occurring in the shaft of the femur are infrequent and typically result from severe open fractures with deep fragmentation and segmental bone loss or following internal fixation of a severely fragmented closed fracture. Some associated factors contributing to non-union include positive bacterial cultures from deep wounds, histological evidence of bone necrosis, exposed bone without a vascularized periosteum for more than six weeks, and the presence of purulent discharge. Osteomyelitis, stiffness in adjacent joints, smoking, loss of soft tissue resulting in multiple sinus tracts, osteopenia, and deformities leading to limb length discrepancies are all complicating factors that impact treatment and prognosis. Infected non-union of bones, although rare, presents a significant challenge for physiotherapists striving to provide appropriate treatment. The level of stabilization at the fracture site is the most critical factor influencing whether a fracture progresses to non-union or successfully heals. Infection, such as osteomyelitis, also contributes to the development of non-union. Additionally, issues like tissue atrophy, joint stiffness, and muscle contractures can further complicate the non-union of a bone, posing a considerable challenge for physical therapists in helping patients achieve their recovery goals. Top of form this case report reviews the case of a 35-year-old male who was reported to Acharya Vinoba Bhave Rural Hospital (AVBRH) with an infective non-union of the shaft of the femur fracture after two months of repair. This case report highlights the recovery of patients from post-operative complications like non-union, stiffness, and reduced range of motion through tailored physiotherapy rehabilitation and improved quality of life.

Ipsilateral Foot Drop After Leg Traction on Fracture Table for Mid-Shaft Femur Fracture Nailing: A Rare Case Report

Femoral shaft fracture, one of the most common orthopaedic injuries, is usually treated with intramedullary nailing. During the operative procedure patients are placed on a traction table. Traction tables facilitate the procedure but are associated with some risk. Here we are sharing a case of a 35-year-old male healthy young patient who sustained a foot drop post nailing of femoral shaft fracture on a traction table. This patient has had some recovery in six weeks but is still not fully recovered. We think traction tables are a very helpful tool but carry some risks that should be kept on mind for every surgeon, and for the patients too.

Shaft Fractures in Patients Requiring Primary or Revision Total Knee Arthroplasty Can Be Successfully Treated with Long-Stemmed Implants without Additional Fixation

The aim of this study was to evaluate the bone union, complication rate, clinical and functional outcomes of long-stemmed total knee arthroplasty (TKA) in patients with periprosthetic femoral or tibial shaft fractures and in patients with femoral or tibial shaft fractures with coexisting advanced knee osteoarthritis (OA). This retrospective study comprised 25 patients who underwent surgery due to tibial or femoral shaft fractures: (1) with coexisting severe knee OA or (2) with a periprosthetic fracture requiring implant exchange. In all cases, fracture stabilization was performed intramedullary with the use of long-stemmed implants without the use of additional fixation material (plates, screws, or cerclage). Bone union was achieved in 22/25 patients (88%). One patient required revision with additional plate stabilization due to non-union, and asymptomatic partial bone union was observed in two cases. The group with periprosthetic fractures demonstrated good clinical (mean 73.1 ± 13.3) and moderate functional (mean 59.2 ± 18.8) outcomes in the Knee Society Scoring system (KSS). In the group with shaft fracture and coexisting OA significantly higher clinical (excellent results, mean 84.1 ± 11; p = 0.03) and functional (good results, mean 76.2 ± 20.6; p = 0.04) results were noted. There were no statistically significant differences in terms of range of motion (ROM) or complication rate between these two groups. One-stage TKA with a long-stemmed implant without the use of additional fixation material is an effective method for the treatment of femoral or tibial shaft fractures in patients who require joint replacement. Despite being technically demanding, the approach yields bone union and moderate to excellent clinical and functional outcomes with a relatively low complication rate.

Leg-length discrepancy and associated risk factors after paediatric femur shaft fracture: a multicentre study

PURPOSE

This study was performed to investigate leg-length discrepancy (LLD) and associated risk factors after paediatric femur shaft fractures.

METHODS

A total of 72 consecutive patients under 13 years old (mean age 6.7 years; 48 boys, 24 girls) with unilateral femur shaft fracture, and a minimum follow-up of 18 months, were included. The amount of LLD was calculated by subtracting the length of the uninjured from that of the injured limb. Risk factors for an LLD ≥ 1 cm and ≥ 2 cm were analyzed using multivariable logistic regression analysis.

RESULTS

Hip spica casting, titanium elastic nailing and plating were performed on 22, 40 and ten patients, respectively. The mean LLD was 7.8 mm (sd 8.8) and 29 (40.3%) had a LLD of ≥ 1 cm, while nine (12.5%) had a LLD of ≥ 2 cm. There were significant differences in fracture stability (p = 0.005) and treatment methods (p = 0.011) between patients with LLD < 1 cm and ≥ 1 cm. There were significant differences in fracture site shortening (p < 0.001) and LLD (p < 0.001) between patients with length-stable and length-unstable fractures. Fracture stability was the only factor associated with LLD ≥ 1 cm (odds ratio of 4.0; p = 0.020) in the multivariable analysis.

CONCLUSION

This study demonstrated that fracture stability was significantly associated with LLD after paediatric femur shaft fractures. Therefore, the surgeon should consider the possibility of LLD after length-stable femur shaft fracture in children.

LEVEL OF EVIDENCE

Prognostic level III.

The risk factors of nonunion after intramedullary nailing fixation of femur shaft fracture in middle age patients

Although the optimal treatment for femur shaft fracture is intramedullary nailing fixation, nonunion still occurs. We determined the oligotrophic nonunion rate among femur fractures managed operatively and identified risk factors for reoperation. This was a retrospective clinical study. The data of the patients between 40 and 70 years old with diaphyseal femur fracture who have received reamed and interlocked intramedullary nailing fixation in our hospital from February 2014 to April 2018 were collected. They were followed at regular intervals for at least 1 year after the operation. The primary outcome was nonunion of the fracture site that required reoperation in accordance with the radiographic union scale for tibial shaft fracture (RUST), which is a reasonable score system for lower limb diaphyseal fracture. Three of them were hypertrophic nonunion (1.9%) and the other 13 cases were oligotrophic nonunion (8.6%) at postoperative 12 months follow-up. All of the postoperative plain films showed adequate reduction quality. The three hypertrophic nonunion cases were all obese male with fracture site comminution. Fracture at the proximal third junction, hypertension (HTN) and diabetes mellitus (DM) was significantly associated with oligotrophic nonunion of the fracture site from logistic regression analysis. The mean RUST score 3 months after the operation was not significantly different between the union group and nonunion group but was significantly lower 6 months after the operation in the nonunion group. In conclusion, intramedullary nailing of the femur shaft fractures was associated with a low risk of nonunion at the 1-year follow-up in the middle age group. Those with comorbidity such as obese, HTN, and DM, with fracture site at the proximal third junction or comminution should be followed up closely and rehabilitation with cause aggressively. Radiographic scale as the RUST score at postoperative 6 months could be used to predict this complication.

Incidence of Varus Malalignment Post Interlocking Nail in Proximal Femur Shaft Fractures Comparing Two Types of Entry Points

Introduction: Osteosynthesis of the femur using an interlocking nail is the gold standard for treating diaphyseal fractures of the femur. There are two established entry points for the antegrade interlocking nails which is the piriformis fossa or the greater trochanter. It has been reported that varus malalignment was frequently seen in proximal femur fracture which were treated with interlocking nail utilizing the greater trochanter entry point. The study was done to find out if the problem was of significance.

Materials and Methods: This was a retrospective study which included 179 patients with femur fractures which were treated from January 2013 till September 2015 in one Hospital. They were treated with interlocking nail either by utilizing the piriformis fossa (PF) or the greater trochanter (GT) entry points. Post-operative radiographs of the femur were used to measure the varus deformity.

Results: Out of 179 patients, there were 5 patients who were reported to have unacceptable varus malalignment (2.79%). These 5 patients were out of the 88 (5.68%) patients utilizing the greater trochanter as the entry point. The same 5 patients were out 90 patients that were diagnosed with proximal femur shaft fractures (5.55%). Analysis with logistic regression was statistically not significant.

Conclusion: There was higher rate of varus malalignment seen in proximal femur shaft fractures treated with interlocking nails utilizing the greater trochanter entry point. The incidence of varus malalignment was not significant statistically.

[Effectiveness of rigid interlocking nails through tip of greater trochanter for fixation of femur shaft fracture in adolescent]

Objective

To explore the effectiveness of rigid interlocking nails through the tip of the greater trochanter for fixation of femur shaft fracture in adolescent.

Methods

A retrospective analysis was made on the clinical data of 23 adolescents with femoral shaft fractures treated between June 2011 and June 2015. Of 23 cases, 19 were male and 4 were female, aged from 13 years and 6 months to 17 years (mean, 15.2 years), weighed from 40 to 77 kg (mean, 53.5 kg). The causes were traffic accident injury in 13 cases, sports injury in 7 cases, and falling injury in 3 cases. Fracture located at the proximal 1/3 in 6 cases, middle 1/3 in 10 cases, and distal 1/3 in 7 cases; fracture was typed as transverse in 10 cases, oblique in 6 cases, spiral in 1 case, and comminuted in 6 cases. The course of disease was 3-17 days (mean, 6.2 days). At last follow-up, the leg length discrepancy, femoral neck shaft angle, femoral neck diameter, and articulotrochanteric distance (ATD) were measured on the X-ray films.

Results

Wounds healed in all patients, and no infection occurred. All patients were followed up 15-36 months (mean, 26.5 months). The patients had no pain and had normal gait, without lameness. The X-ray films showed bone healing at 5-13 months (mean, 6.5 months). No nonunion, delayed union, malunion of more than 5 °, or rotational deformity occurred. The removal time of internal fixations was 12-24 months (mean, 19.5 months) after operation. No heterotopic ossification, re-fracture, proximal femoral deformity, or femoral head necrosis occurred during follow-up. Two patients had early epiphyseal closure of greater trochanter, which had no impact on gait; leg-length inequality of less than 1 cm was observed in 2 cases. At last follow-up, the neck shaft angle, femoral neck diameter, and ATD of normal and affected sides were (131.7±6.3) and (132.9±7.8)°, (34.1±3.2) and (33.9±3.8) mm, and (27.8±9.2) and (26.5±8.5) mm, showing no significant difference between two sides ( t=-0.24, P=0.86; t=0.18, P=0.92; t=1.03, P=0.49).

Conclusion

It is a reliable and effective method to use rigid interlocking nails inserted through the tip of the greater trochanter for the fixation of femur shaft fracture in adolescent.