Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure

Introduction Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure. Materials and methods We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal—pertrochanteric, subtrochanteric—or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected. Results A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 ± 13.5 years and in the PO group was 65.6 ± 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure. Conclusion Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site.

Application of a Custom-designed External Fixation Restorer for Pediatric Femoral Fractures

Background: Closed reduction of pediatric femoral shaft fractures is one of the most difficult types of partial fracture reductions. Open reduction increases the harm to children. Although smaller invasive open reduction is mostly used at present, it has an impact on the microenvironment around the fracture and results in increased intraoperative bleeding, an increased risk of postoperative infection and surgical scarring, which has a great psychological impact on children. Methods: Given the above challenges, we propose another intraoperative reduction method. The technique described involves closed reduction and internal fixation for pediatric femoral shaft fractures using a new type of intraoperative fixator. Result: This technique brings hope that the success rate of closed reduction for pediatric femoral shaft fractures can reach 100%. Conclution: The method is demonstrated in a patient.

Simultaneous Ipsilateral “Floating Hip” with Hip Dislocation and Femoral Neck and Shaft Fractures Associated with “Floating Knee” Injuries with Patella Fracture and Traumatic Sciatic Nerve Injury

Simultaneous ipsilateral “floating-hip” and “floating-knee” injuries are very rare and severe, and they occur in high-velocity road traffic accidents. A 55-year-old man presented with posterior wall fracture – dislocation of the acetabulum, complete fracture – dislocation of the femoral head, ipsilateral femoral shaft fracture, open patellar fracture, Gustilo type II, tibial fracture, and traumatic sciatic nerve injury/peroneal division. Given the fact that hip dislocation is an orthopedic emergency, we first did closed external tibial fixation, femoral head reduction, osteosynthesis of the acetabular fracture, and partial patellectomy. After 2 days, the patient underwent a second surgery; fixation of the neck and femoral shaft fractures was done, with a self-dynamic internal fixator. After 14 months from the injuries, radiographs show complete healing of all fractures, the patient walks independently without crutches, and the peroneal nerve is partially recovered. Despite the seriousness of the presented injuries, we did not have any complications, and 14 months after the injury, the femoral head is still viable, with no signs of femoral head osteonecrosis.

A Comparative Study of Pediatric Fracture Shaft Femur Fixating by Plate and Screws Using Lateral Approach Between Subvastus Lateralis and Transvastus Lateralis Outcome

BACKGROUND: Femoral shaft fracture is a common fracture in pediatric age group reaching 62% of all fracture shaft femur in children in spite of rapid union rate and successful conservative treatment but some cases need surgical intervention and one of the methods using plate and screw by the lateral approach. AIM: This study aims to compare functional outcome fixation of mid-shaft femur fracture in children by plate and screws between (subvastus lateralis and transvastus lateralis) regarding infection, union, and limitation of knee movement. PATIENT AND METHOD: The study was done on 30 children who had diaphyseal fracture femur in Al-Kindy Teaching Hospital in period (April 2018–April 2020) with 6 months follow-up, and the patient was divided into two groups: Group A first treated by subvastus lateral approach 15 patients and the second group, Group B by transvastus lateral approach 15 patients and follow-up done for them after 2 weeks, 4 weeks, 6 weeks, 3 months, and 6 months. RESULTS: At week 16 of follow-up all patients in Group A had union, while in Group B, 14 of 50 patients had union and one patient had no union and one patient in Group B had an infection when compared to Group A. From 15 patients of Group A, two patients had limitation of knee movement in the 1st month of follow-up then in the 3rd month of follow-up, no patient had limitation of knee joint movement, while five patients had limitation of knee joint movement in Group B in the 1st month of follow-up and one patient had limitation knee joint movement in the 3rd month of follow-up. CONCLUSIONS: The subvastus lateralis approach results better than transvastus lateralis in union.

Elimination of the Femoral Neck in Measuring Femoral Version Allows for Less Variance in Interobserver Reliability

Background and Objectives: Producing consistent measures of femoral version amongst observers are necessary to allow for an assessment of version for possible corrective procedures. The purpose of this study was to compare two computed tomography (CT)-based techniques for the reliability of measuring femoral version amongst observers. Materials and Methods: Review was performed for 15 patients post-femoral nailing for comminuted (Winquist III and IV) femoral shaft fractures where CT scanograms were obtained. Two CT-based techniques were utilized to measure femoral version by five observers. Results: The mean femoral version, when utilizing a proximal line drawn down the center of the femoral head-neck through CT, was 9.50 ± 4.82°, while the method utilizing the head and shaft at lesser trochanter centers produced a mean version of 18.73 ± 2.69°. A significant difference was noted between these two (p ≤ 0.001). The method of measuring in the center of the femoral head and neck produced an intraclass correlation coefficient (ICC) of 0.960 with a 95% confidence interval lower bound of 0.909 and upper bound of 0.982. For the method assessing version via the center of the head and shaft at the lesser trochanter region, the ICC was 0.993 with a 95% confidence interval lower bound of 0.987 and an upper bound of 0.996. Conclusions: The method of measuring version proximally through a CT image of the femoral head–neck versus overlaying the femoral head with the femoral shaft at the most prominent aspect of the lesser trochanter produces differing version measurements by roughly 10° while yielding an almost perfect interobserver reliability in the new technique. Both techniques result in significantly high interobserver reliability.

Outcome of Retrograde Nailing in the Treatment of Extra Articular Supracondylar Femur Fractures

Objective: To find out outcome of retrograde nailing in the treatment of extra articular supracondylar femur fractures. Study Design: A prospective observational study. Place and Duration of the Study: The Department of Orthopedic Surgery, Ghurki Hospital, Lahore, Pakistan from January 2020 to August 2021. Methodology: A total of 92 patients of both genders aged 18 to 50 years with supracondylar femur fractures and supracondylar fractures with fracture line extending to distal third of femoral shaft were enrolled. Retrograde nailing was performed among all patients. Surgery time and functional outcome were noted. All surgeries were accomplished under spinal/epidural or general anaesthesia. Results: Out of a total of 92 patients, there were 59 (64.1%) were male and 33 (35.9%) female. Overall, the mean age of patients was 33.12±9.08 years. The mean surgery time was noted to be 85.29±7.48 minutes. A total of 85 patients completed the designated period of 12-weeks for the evaluation of functional outcome. Excellent outcomes were observed in 47 (55.3%) cases, good 25 (29.4%), fair 9 (10.6%) and poor in 4 (4.7%) cases. Excellent to good outcomes were observed in 72 (84.7%) cases. Conclusion: Retrograde nailing had good outcomes in the treatment of extra articular supracondylar femur fractures. Keywords: Femur fracture, nailing, surgery time, functional outcome.

Rotational Stability of Proximally Unlocked Retrograde Femoral Nail In Damage Control Surgery – Biomechanical Study

BACKGROUND: This biomechanical study was performed to look into the rotational stability of retrograde femoral intramedullary nail when it is used without proximal locking as a damage control device for management of femoral shaft fractures in emergency situations. This study compares this technique with the accepted methods for femoral shaft fixations in damage control surgeries. An alternative technique of using lateral compression screw to provide additional rotational stability is described.METHODS: Experiments were divided into four different sets. Distally locked retrograde nail was passed across the fracture without any proximal fixation in set 1, a compression screw passed from lateral cortex in set 2, a proximal locking screw fixation in set 3. In set 4, Saw bone was fixed with external fixator.The lateral compression screw group was further sub divided into three subgroups based on the amount of torque applied manually.The torsion test was applied to create an rotational displacement of 10 degrees and the maximum load required to create the rotational displacement was noted.RESULTS: Application of a compression screw improved the rotational stability significantly in comparison to no proximal locking. In the subgroup III of lateral compression screw application, the rotational stability was found to be equivalent to stability achieved with Nail with proximal locking and was found to be greater in comparison to external fixator application.CONCLUSION: This study shows that the addition of a lateral compression screw significantly improves rotational stability and has the potential to be used in emergency lifesaving procedures.