Injury, Int. J. Care Injured 45 (2014) 752–756
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail Shih-Jie Lin a,1, Chi-Lung Chen a,1, Kuo-Ti Peng a, Wei-Hsiu Hsu a,b,* a b
Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan Department of Medicine, School for Medicine, Chang Gung University, Tao-Yuan, Taiwan
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 10 October 2013
Objective: Our study aimed to determine whether the displacement and morphology of a fragment in femur fracture with Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Orthopaedic Trauma Association/32B/32-C (AO/OTA/32-B/32-C) classification affect the outcomes following closed reduction and internal fixation with an interlocking nail. Design: This was a retrospective study. Setting: The study was conducted at a Level III trauma centre. Patients: A total of 50 consecutive patients presenting femoral shaft fracture with AO/OTA-type 32-B/32C were included in the present study. Interventions: Patients were divided into two groups according to the displacement of the fragments. In the large displacement group, patients were further subgrouped according to whether a reversed morphology of the fragment was present. Outcomes measurement: The radiographic union score of femur (RUSF), the mean union time and the reoperation rate were assessed. Results: The union rate of small- and large-gap groups at 12 months postoperatively was 75.9% and 21.1%, respectively (p = 0.000). The mean union time of those union cases in these two groups was 7.8 and 13.0 months, respectively (p = 0.000). The union rate of the non-reversed and reversed groups at 12 months postoperatively was 30% and 11.1%, respectively (p = 0.179). The mean RUSF at 12 months in the non-reversed and reversed groups was 8.8 and 8.3, respectively (p = 0.590). However, we found that patients presenting a reversed fragment had an increased risk of more than one re-operation (p = 0.030). Conclusions: A fragmentary displacement of >1 cm in AO/OTA-type 32-B/32-C femoral shaft fracture after nailing affected bone healing. Among the large-gap group patients, an unreduced reverse fragment presented a negative prognostic factor for re-operation. Level of evidence: Prognostic level III. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Reversed fragment Femoral shaft Fracture Displacement
Femoral shaft fractures were not uncommon in adults who sustain high-energy trauma. Intramedullary nailing of the femur was suggested because of its satisfactory union rate under stable biomechanical circumstances [1–11]. Nowadays, closed reduction and internal fixation with an interlocking nail for fracture of the femoral shaft is generally accepted as a standard treatment and it has been extended to nearly all shaft fractures from the proximal to the distal femur [11,12]. However, shortening and malrotation for Winquist grade III/IV femur shaft fracture following closed
* Corresponding author at: Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, No 6, West section, Chia Pu Road, Puzih, Chia Yi Hsien 613, Taiwan. Tel.: +886 5 3621000x2855; fax: +886 5 3623002. E-mail address: [email protected] (W.-H. Hsu). 1 Both authors equally contributed to this work. 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.015
intramedullary nailing was still a challenging problem [16]. Standard open reduction was not suggested because complications such as a high rate of infection, delayed union and nonunion occurred [7,13–16]. Specifically, Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Orthopaedic Trauma Association/32-B/32-C (AO/ OTA 32-B/32-C) femoral shaft fracture was demonstrated in 10.5– 34% of all femoral fractures, and such a large butterfly fragment may result in technical difficulties in anatomical restoration such that the residual gap usually persisted after closed reduction [17,18]. Whether a residual gap after closed reduction results in a higher risk of nonunion in such a group remains unclear. Furthermore, the butterfly fragment occasionally represents a reversed morphology such that the endosteum turns inside out. It is possible that the reversed fragment may further affect bone healing because of vascular bed compromise and difficult callus bridging over fragment gaps. Hence, it is worthy of investigation
S.-J. Lin et al. / Injury, Int. J. Care Injured 45 (2014) 752–756
753
whether the reversed fragment results in a worse outcome. We hypothesised that a larger fracture gap would result in a decreased union rate after closed reduction. In addition, the re-operation rate could increase if the fragments become reversed. Patient and methods From January 2007 to December 2011, a retrospective cohort of patients presenting femoral shaft fracture with AO/OTA-type 32-B/ 32-C treated in our hospital was included in the present study. The excluding criteria were periprosthetic fracture in patients with implanted hip or knee prosthesis, underlying bony pathology, concomitant brain injury, open fracture and use of steroids or immunosuppressive agents. This study was approved by the Institutional Review Board of the authors’ affiliated hospital. Through a careful review of medical charts and serial radiographs, parameters such as demographic data, fracture patterns, postoperative courses and union rates were recorded and analysed. Femoral shaft fracture was defined as the portion of bone between a point 5 cm distal to the lesser trochanter and a point 8 cm proximal to the adductor tubercle [19]. Fracture pattern was defined according to the Winquist–Hansen classification [8,16] and the AO/OTA classification [9,20]. All patients underwent locked antegrade reamed intramedullary nailing through a standard closed technique by the same team of surgeons [9,21]. Briefly, a patient was put in a supine position on a fracture table. The canal in an adult was prepared by reaming to 1.0 mm greater in diameter than the anticipated nail diameter, which was determined by a radiograph. In AO/OTA-type 32-B/32-C femoral shaft fracture, one proximal screw and two distal screws were inserted to maintain length and rotational stability. All reduction attempts were performed strictly by closed means. If a butterfly fragment was not reduced, a bridging nail would be applied with the fragment left in situ. The enrolled patients with femoral shaft fractures were subdivided into large- and small-gap groups according to the displacement of the butterfly fragment after the nailing procedure. The numerical value for the displacement of a butterfly fragment in millimetres was calculated as follows: Dprox + Ddist Bd, where Dprox/Ddist is the largest perpendicular distance of the proximal/distal end of fragments to the midline of the shaft measured from antero-posterior and lateral radiographs and Bd is the diameter of the shaft at the fracture site on the same radiographs. Those patients presenting a gap >10 mm between the butterfly fragment and reduced shaft were designated as the largegap group (Fig. 1), and those with a gap 210 mm as the small-gap group (Fig. 2). Patients with a large-gap butterfly fragment were further subgrouped according to whether a reversed morphology of the fragment occurred (Fig. 3). A reversed butterfly fragment was defined as an inverted one with the outer cortex apposing the medullary canal in biplanar radiographs. Clinical and radiological assessments were performed 1 week postoperatively. Antero-posterior and lateral radiographs were obtained every 3 months for at least 24 months or until bone union was attained. The main outcome was measured as radiological union score at 6, 9 and 12 months postoperatively and union time at the last visit. The radiographic union score of femur (RUSF) was determined in each follow-up radiograph. The RUSF was modified from the radiographic union score of the tibia system described by Whelan et al. [22]. Briefly, this scoring system was based on the assessment of healing at each of the four cortices visible on these projections (i.e., medial and lateral cortices on the antero-posterior plain film as well as anterior and posterior cortices on the lateral film) [22]. The radiographical union was defined as a bridging callus restored the continuity at the fracture gap with consolidation. The outcomes of treatment such as the RUSF, the mean union time and
Fig. 1. A 56-year-old woman sustained right femoral shaft fracture after closed intramedullary nailing. A long and displaced butterfly fragment presenting a >10 mm gap between the butterfly fragment and reduced shaft was demonstrated (A) anteroposterior view, (B) lateral view.
the re-operation rate were assessed. Failed union was defined by a disturbed consolidation of a fracture that needs re-operation or a prolonged healing time of >12 months [23,24]. Re-operation was performed if there was no progression of consolidation, if there was no bone bridging over bony gaps or if there was persistent local pain when weight bearing clinically after 6 months. The reoperation was performed with autogenous/allogenous bone grafting. Additional plating for de-rotation was performed if excessive motion was noted over the fracture site in response to rotatory load. Dynamisation was not practised because of this comminuted fracture pattern. Results A cohort of 50 patients presenting 51 femoral shaft fractures was identified. Three patients were excluded because of a short follow-up 1 cm in the complex femoral shaft fracture, after nailing, affected bone healing negatively. Larger displacement of the butterfly fragment may indicate a worse environment resulting from huge fragments diastasis, potential Table 3 Comparison of the patient groups with small and large gap.
Scorea at 6 months Scorea at 9 months Scorea at 12 months Mean union time (Mon) Union in 12 Mo (n)
Small gap (n = 29)
Large gap (n = 19)
p-Value
7.6 (1.79) 9.3 (2.03) 10.6 (2.39) 7.8 (2.9) 22 (75.9%)
5.8 (1.64) 7.3 (2.24) 8.6 (2.19) 13.0 (3.3) 4 (21.1%)
0.002* 0.008* 0.002* 0.000* 0.000*
Data was expressed as mean (S.D.). a Modified radiographic union score for femorae (Modified RUSF). * p < 0.05.
S.-J. Lin et al. / Injury, Int. J. Care Injured 45 (2014) 752–756 Table 4 Comparison of the patient groups presenting reversed and non-reversed morphology.
Mean age (years)(S.D.) Gender (n) Male Female Size (mm) Site (n) Middle DISTAL OR PROXIMAL Scorea at 6th Mo Scorea at 9th Mo Scorea at 12th Mo Union in 12 Mo (n) Reoperation (n) Reoperation (n) more than one times
Reversed (n = 9)
Non-reversed (n = 10)
p-Value
31.7 (18.1)
44.2 (21.4)
0.19 1.00
5 4 81.6 (22.54)
6 4 75.8 (33.38)
7 2 5.1 (1.21) 6.9 (1.95) 8.3 (2.06) 1 5 (55.5%) 4 (44.4%)
5 5 6.3 (1.80) 7.6 (2.50) 8.8 (2.39) 3 3 (30%) 0 (0%)
0.67 0.35
0.17 0.59 0.60 0.18 0.37 0.03*
Data was expressed in mean (S.D.). a Modified radiographic union score for femur (modified RUSF). * p < 0.05.
soft tissue interposition and poor axial load-bearing ability. This finding was compatible with previous literature [11,16]. The larger gap between fragments in the fracture resulted in more interfragmentary motion because of poor cortical contact after intramedullary nailing. The excessive interfragmentary motion either in the axial or torsional directions may lead to poor mineralised callus formation for the large-gap group [25,26]. It was further demonstrated that the reversed butterfly fragment represented an unfavourable outcome that needed repeated reoperations. Traditionally, qualitative descriptions, such as callus formation or absence of a fracture gap, were frequently reported in many studies for the outcome measure of femoral fractures [27–29], while quantitative criteria of radiological union were less employed. Indeed, cortical continuity and the number of cortices (out of four) with bridging callus were demonstrated as a reliable and scientific scoring system [29–32]. The RUSF was privileged in the determination of the degrees of healing in femoral shaft fractures, in the presence of an intramedullary nail, through quantifying the number of cortices bridged by callus [22]. Additionally, this scoring system also implicates better biomechanical strength in high-scoring cases [29]. In the present study, RUSF scores determined by antero-posterior and lateral views were adopted and exhibited reliability and reproducibility on fracture-healing evaluations [22]. Lower mean RUSF score was demonstrated in the large-gap patients in that the gap was >10 mm than those in small-gap group, which was associated with longer mean union time. This phenomenon was shown as early as 6 months after fractures and continued to 12 months after. It is possible that RUSF reflected the mechanical stability at the fracture site and indicated bone remodelling in the future. In the current study, RUSF demonstrated the effect of displacement in the fracture fragments. Further, we evaluated the effect of a reversed morphology on bone healing. Although the RUSF was not significantly different between the non-reversed and reversed groups, the reversed group did show an increased risk for repeated re-operation. The vascular supply to the reversed fragments may be strangulated and, therefore, led to necrosis of the fragment. In addition, it was also possible that neo-vascularisation to the callus became compromised as the periosteal callus was set in the opposite direction due to the reversed morphology [25]. In those cases undergoing more than one re-operation, advanced osteonecrosis over the flipped-out reversed fragment was noted during reoperation. Therefore, percutaneous and minimally invasive
755
techniques were suggested in the treatment of femoral shaft fractures with an intramedullary nail [24]. This study was limited by the retrospective design and its small case number. However, we collected those patients in a 5-year period from a 1000-bed hospital. We demonstrated the effect of gap in AO/OTA-type 32-B/32-C and further found that a reversed fragment represented a poor prognostic indicator. Further work is suggested to investigate whether reduction through a mini-open technique would result in an improved outcome. In conclusion, a displacement of fragment >1 cm in AO/OTAtype 32-B/32-C femoral shaft fracture after nailing affected bone healing. Among the large-gap group patients, an unreduced reversed fragment indicated poor prognosis. Conflict of interest statement The authors declared no conflict of interest. No external funding was received in the study. References [1] Kuntscher G. Progress in the field of intramedullary nailing. Langenbecks Arch Klin Chir Ver Dtsch Z Chir 1950;264:547–51. [2] Kuntscher G. Intramedullary nailing for the treatment of the fresh fractures. Wiederherstellungschir Traumatol 1953;1:18–35. [3] Kuntscher G. Further progress in the area of medullary nailing. Langenbecks Arch Chir 1966;316:224–31. [4] Rokkanen P, Slatis P, Vanka E. Closed or open intramedullary nailing of femoral shaft fractures? A comparison with conservatively treated cases. J Bone Joint Surg Br 1969;51:313–23. [5] Rascher JJ, Nahigian SH, Macys JR, Brown JE. Closed nailing of femoral-shaft fractures. J Bone Joint Surg Am 1972;54:534–44. [6] Winquist RA, Hansen ST. Segmental fractures of the femur treated by closed intramedullary nailing. J Bone Joint Surg Am 1978;60:934–9. [7] Hansen ST, Winquist RA. Closed intramedullary nailing of the femur. Kuntscher technique with reaming. Clin Orthop Relat Res 1979;138:56–61. [8] Winquist RA, Hansen Jr ST, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am 1984;66:529–39. [9] Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part II: fracture-healing with static interlocking fixation. J Bone Joint Surg Am 1988;70:1453–62. [10] Klemm KW, Borner M. Interlocking nailing of complex fractures of the femur and tibia. Clin Orthop Relat Res 1986;212:89–100. [11] Wiss DA, Fleming CH, Matta JM, Clark D. Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin Orthop Relat Res 1986;212:35–47. [12] Winquist RA. Locked femoral nailing. J Am Acad Orthop Surg 1993;1:95–105. [13] Johnson KD, Johnston DW, Parker B. Comminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail. J Bone Joint Surg Am 1984;66:1222–35. [14] Kempf I, Grosse A, Beck G. Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J Bone Joint Surg Am 1985;67:709–20. [15] Eid AM, Deif AI. Aetiological factors in non-union following Kuntscher intramedullary nailing of the femur. Arch Orthop Trauma Surg 1980;96:213–20. [16] Winquist RA, Hansen Jr ST. Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop Clin North Am 1980;11:633–48. [17] Pihlajamaki HK, Salminen ST, Bostman OM. The treatment of nonunions following intramedullary nailing of femoral shaft fractures. J Orthop Trauma 2002;16:394–402. [18] Salminen ST, Pihlajamaki HK, Avikainen VJ, Bostman OM. Population based epidemiologic and morphologic study of femoral shaft fractures. Clin Orthop Relat Res 2000;372:241–9. [19] Bostman O, Varjonen L, Vainionpaa S, Majola A, Rokkanen P. Incidence of local complications after intramedullary nailing and after plate fixation of femoral shaft fractures. J Trauma 1989;29:639–45. [20] Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma 1996;10 (Suppl. 1:v– ix):1–154. [21] Babhulkar S, Pande K. Nonunion of the diaphysis of long bones. Clin Orthop Relat Res 2005;431:50–6. [22] Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma 2010;68:629–32. [23] Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma 2001;15:254–63. [24] Rhorer AS. Percutaneous/minimally invasive techniques in treatment of femoral shaft fractures with an intramedullary nail. J Orthop Trauma 2009;23:S2–5.
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[25] Claes L, Eckert-Hubner K, Augat P. The effect of mechanical stability on local vascularization and tissue differentiation in callus healing. J Orthop Res 2002;20:1099–105. [26] Lienau J, Schell H, Duda GN, Seebeck P, Muchow S, Bail HJ. Initial vascularization and tissue differentiation are influenced by fixation stability. J Orthop Res 2005;23:639–45. [27] Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma 1994;8:45–9. [28] Dickson K, Katzman S, Delgado E, Contreras D. Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results. Clin Orthop Relat Res 1994;302:189–93.
[29] Panjabi MM, Walter SD, Karuda M, White AA, Lawson JP. Correlations of radiographic analysis of healing fractures with strength: a statistical analysis of experimental osteotomies. J Orthop Res 1985;3:212–8. [30] Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta 3rd P, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma 2002;16:562–6. [31] Whelan DB, Bhandari M, McKee MD, Guyatt GH, Kreder HJ, Stephen D, et al. Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation. J Bone Joint Surg Br 2002;84:15–8. [32] Panjabi MM, Lindsey RW, Walter SD, White 3rd AA. The clinician’s ability to evaluate the strength of healing fractures from plain radiographs. J Orthop Trauma 1989;3:29–32.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail Shih-Jie Lin a,1, Chi-Lung Chen a,1, Kuo-Ti Peng a, Wei-Hsiu Hsu a,b,* a b
Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan Department of Medicine, School for Medicine, Chang Gung University, Tao-Yuan, Taiwan
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 10 October 2013
Objective: Our study aimed to determine whether the displacement and morphology of a fragment in femur fracture with Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Orthopaedic Trauma Association/32B/32-C (AO/OTA/32-B/32-C) classification affect the outcomes following closed reduction and internal fixation with an interlocking nail. Design: This was a retrospective study. Setting: The study was conducted at a Level III trauma centre. Patients: A total of 50 consecutive patients presenting femoral shaft fracture with AO/OTA-type 32-B/32C were included in the present study. Interventions: Patients were divided into two groups according to the displacement of the fragments. In the large displacement group, patients were further subgrouped according to whether a reversed morphology of the fragment was present. Outcomes measurement: The radiographic union score of femur (RUSF), the mean union time and the reoperation rate were assessed. Results: The union rate of small- and large-gap groups at 12 months postoperatively was 75.9% and 21.1%, respectively (p = 0.000). The mean union time of those union cases in these two groups was 7.8 and 13.0 months, respectively (p = 0.000). The union rate of the non-reversed and reversed groups at 12 months postoperatively was 30% and 11.1%, respectively (p = 0.179). The mean RUSF at 12 months in the non-reversed and reversed groups was 8.8 and 8.3, respectively (p = 0.590). However, we found that patients presenting a reversed fragment had an increased risk of more than one re-operation (p = 0.030). Conclusions: A fragmentary displacement of >1 cm in AO/OTA-type 32-B/32-C femoral shaft fracture after nailing affected bone healing. Among the large-gap group patients, an unreduced reverse fragment presented a negative prognostic factor for re-operation. Level of evidence: Prognostic level III. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Reversed fragment Femoral shaft Fracture Displacement
Femoral shaft fractures were not uncommon in adults who sustain high-energy trauma. Intramedullary nailing of the femur was suggested because of its satisfactory union rate under stable biomechanical circumstances [1–11]. Nowadays, closed reduction and internal fixation with an interlocking nail for fracture of the femoral shaft is generally accepted as a standard treatment and it has been extended to nearly all shaft fractures from the proximal to the distal femur [11,12]. However, shortening and malrotation for Winquist grade III/IV femur shaft fracture following closed
* Corresponding author at: Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, No 6, West section, Chia Pu Road, Puzih, Chia Yi Hsien 613, Taiwan. Tel.: +886 5 3621000x2855; fax: +886 5 3623002. E-mail address: [email protected] (W.-H. Hsu). 1 Both authors equally contributed to this work. 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.015
intramedullary nailing was still a challenging problem [16]. Standard open reduction was not suggested because complications such as a high rate of infection, delayed union and nonunion occurred [7,13–16]. Specifically, Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Orthopaedic Trauma Association/32-B/32-C (AO/ OTA 32-B/32-C) femoral shaft fracture was demonstrated in 10.5– 34% of all femoral fractures, and such a large butterfly fragment may result in technical difficulties in anatomical restoration such that the residual gap usually persisted after closed reduction [17,18]. Whether a residual gap after closed reduction results in a higher risk of nonunion in such a group remains unclear. Furthermore, the butterfly fragment occasionally represents a reversed morphology such that the endosteum turns inside out. It is possible that the reversed fragment may further affect bone healing because of vascular bed compromise and difficult callus bridging over fragment gaps. Hence, it is worthy of investigation
S.-J. Lin et al. / Injury, Int. J. Care Injured 45 (2014) 752–756
753
whether the reversed fragment results in a worse outcome. We hypothesised that a larger fracture gap would result in a decreased union rate after closed reduction. In addition, the re-operation rate could increase if the fragments become reversed. Patient and methods From January 2007 to December 2011, a retrospective cohort of patients presenting femoral shaft fracture with AO/OTA-type 32-B/ 32-C treated in our hospital was included in the present study. The excluding criteria were periprosthetic fracture in patients with implanted hip or knee prosthesis, underlying bony pathology, concomitant brain injury, open fracture and use of steroids or immunosuppressive agents. This study was approved by the Institutional Review Board of the authors’ affiliated hospital. Through a careful review of medical charts and serial radiographs, parameters such as demographic data, fracture patterns, postoperative courses and union rates were recorded and analysed. Femoral shaft fracture was defined as the portion of bone between a point 5 cm distal to the lesser trochanter and a point 8 cm proximal to the adductor tubercle [19]. Fracture pattern was defined according to the Winquist–Hansen classification [8,16] and the AO/OTA classification [9,20]. All patients underwent locked antegrade reamed intramedullary nailing through a standard closed technique by the same team of surgeons [9,21]. Briefly, a patient was put in a supine position on a fracture table. The canal in an adult was prepared by reaming to 1.0 mm greater in diameter than the anticipated nail diameter, which was determined by a radiograph. In AO/OTA-type 32-B/32-C femoral shaft fracture, one proximal screw and two distal screws were inserted to maintain length and rotational stability. All reduction attempts were performed strictly by closed means. If a butterfly fragment was not reduced, a bridging nail would be applied with the fragment left in situ. The enrolled patients with femoral shaft fractures were subdivided into large- and small-gap groups according to the displacement of the butterfly fragment after the nailing procedure. The numerical value for the displacement of a butterfly fragment in millimetres was calculated as follows: Dprox + Ddist Bd, where Dprox/Ddist is the largest perpendicular distance of the proximal/distal end of fragments to the midline of the shaft measured from antero-posterior and lateral radiographs and Bd is the diameter of the shaft at the fracture site on the same radiographs. Those patients presenting a gap >10 mm between the butterfly fragment and reduced shaft were designated as the largegap group (Fig. 1), and those with a gap 210 mm as the small-gap group (Fig. 2). Patients with a large-gap butterfly fragment were further subgrouped according to whether a reversed morphology of the fragment occurred (Fig. 3). A reversed butterfly fragment was defined as an inverted one with the outer cortex apposing the medullary canal in biplanar radiographs. Clinical and radiological assessments were performed 1 week postoperatively. Antero-posterior and lateral radiographs were obtained every 3 months for at least 24 months or until bone union was attained. The main outcome was measured as radiological union score at 6, 9 and 12 months postoperatively and union time at the last visit. The radiographic union score of femur (RUSF) was determined in each follow-up radiograph. The RUSF was modified from the radiographic union score of the tibia system described by Whelan et al. [22]. Briefly, this scoring system was based on the assessment of healing at each of the four cortices visible on these projections (i.e., medial and lateral cortices on the antero-posterior plain film as well as anterior and posterior cortices on the lateral film) [22]. The radiographical union was defined as a bridging callus restored the continuity at the fracture gap with consolidation. The outcomes of treatment such as the RUSF, the mean union time and
Fig. 1. A 56-year-old woman sustained right femoral shaft fracture after closed intramedullary nailing. A long and displaced butterfly fragment presenting a >10 mm gap between the butterfly fragment and reduced shaft was demonstrated (A) anteroposterior view, (B) lateral view.
the re-operation rate were assessed. Failed union was defined by a disturbed consolidation of a fracture that needs re-operation or a prolonged healing time of >12 months [23,24]. Re-operation was performed if there was no progression of consolidation, if there was no bone bridging over bony gaps or if there was persistent local pain when weight bearing clinically after 6 months. The reoperation was performed with autogenous/allogenous bone grafting. Additional plating for de-rotation was performed if excessive motion was noted over the fracture site in response to rotatory load. Dynamisation was not practised because of this comminuted fracture pattern. Results A cohort of 50 patients presenting 51 femoral shaft fractures was identified. Three patients were excluded because of a short follow-up 1 cm in the complex femoral shaft fracture, after nailing, affected bone healing negatively. Larger displacement of the butterfly fragment may indicate a worse environment resulting from huge fragments diastasis, potential Table 3 Comparison of the patient groups with small and large gap.
Scorea at 6 months Scorea at 9 months Scorea at 12 months Mean union time (Mon) Union in 12 Mo (n)
Small gap (n = 29)
Large gap (n = 19)
p-Value
7.6 (1.79) 9.3 (2.03) 10.6 (2.39) 7.8 (2.9) 22 (75.9%)
5.8 (1.64) 7.3 (2.24) 8.6 (2.19) 13.0 (3.3) 4 (21.1%)
0.002* 0.008* 0.002* 0.000* 0.000*
Data was expressed as mean (S.D.). a Modified radiographic union score for femorae (Modified RUSF). * p < 0.05.
S.-J. Lin et al. / Injury, Int. J. Care Injured 45 (2014) 752–756 Table 4 Comparison of the patient groups presenting reversed and non-reversed morphology.
Mean age (years)(S.D.) Gender (n) Male Female Size (mm) Site (n) Middle DISTAL OR PROXIMAL Scorea at 6th Mo Scorea at 9th Mo Scorea at 12th Mo Union in 12 Mo (n) Reoperation (n) Reoperation (n) more than one times
Reversed (n = 9)
Non-reversed (n = 10)
p-Value
31.7 (18.1)
44.2 (21.4)
0.19 1.00
5 4 81.6 (22.54)
6 4 75.8 (33.38)
7 2 5.1 (1.21) 6.9 (1.95) 8.3 (2.06) 1 5 (55.5%) 4 (44.4%)
5 5 6.3 (1.80) 7.6 (2.50) 8.8 (2.39) 3 3 (30%) 0 (0%)
0.67 0.35
0.17 0.59 0.60 0.18 0.37 0.03*
Data was expressed in mean (S.D.). a Modified radiographic union score for femur (modified RUSF). * p < 0.05.
soft tissue interposition and poor axial load-bearing ability. This finding was compatible with previous literature [11,16]. The larger gap between fragments in the fracture resulted in more interfragmentary motion because of poor cortical contact after intramedullary nailing. The excessive interfragmentary motion either in the axial or torsional directions may lead to poor mineralised callus formation for the large-gap group [25,26]. It was further demonstrated that the reversed butterfly fragment represented an unfavourable outcome that needed repeated reoperations. Traditionally, qualitative descriptions, such as callus formation or absence of a fracture gap, were frequently reported in many studies for the outcome measure of femoral fractures [27–29], while quantitative criteria of radiological union were less employed. Indeed, cortical continuity and the number of cortices (out of four) with bridging callus were demonstrated as a reliable and scientific scoring system [29–32]. The RUSF was privileged in the determination of the degrees of healing in femoral shaft fractures, in the presence of an intramedullary nail, through quantifying the number of cortices bridged by callus [22]. Additionally, this scoring system also implicates better biomechanical strength in high-scoring cases [29]. In the present study, RUSF scores determined by antero-posterior and lateral views were adopted and exhibited reliability and reproducibility on fracture-healing evaluations [22]. Lower mean RUSF score was demonstrated in the large-gap patients in that the gap was >10 mm than those in small-gap group, which was associated with longer mean union time. This phenomenon was shown as early as 6 months after fractures and continued to 12 months after. It is possible that RUSF reflected the mechanical stability at the fracture site and indicated bone remodelling in the future. In the current study, RUSF demonstrated the effect of displacement in the fracture fragments. Further, we evaluated the effect of a reversed morphology on bone healing. Although the RUSF was not significantly different between the non-reversed and reversed groups, the reversed group did show an increased risk for repeated re-operation. The vascular supply to the reversed fragments may be strangulated and, therefore, led to necrosis of the fragment. In addition, it was also possible that neo-vascularisation to the callus became compromised as the periosteal callus was set in the opposite direction due to the reversed morphology [25]. In those cases undergoing more than one re-operation, advanced osteonecrosis over the flipped-out reversed fragment was noted during reoperation. Therefore, percutaneous and minimally invasive
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techniques were suggested in the treatment of femoral shaft fractures with an intramedullary nail [24]. This study was limited by the retrospective design and its small case number. However, we collected those patients in a 5-year period from a 1000-bed hospital. We demonstrated the effect of gap in AO/OTA-type 32-B/32-C and further found that a reversed fragment represented a poor prognostic indicator. Further work is suggested to investigate whether reduction through a mini-open technique would result in an improved outcome. In conclusion, a displacement of fragment >1 cm in AO/OTAtype 32-B/32-C femoral shaft fracture after nailing affected bone healing. Among the large-gap group patients, an unreduced reversed fragment indicated poor prognosis. Conflict of interest statement The authors declared no conflict of interest. No external funding was received in the study. References [1] Kuntscher G. Progress in the field of intramedullary nailing. Langenbecks Arch Klin Chir Ver Dtsch Z Chir 1950;264:547–51. [2] Kuntscher G. Intramedullary nailing for the treatment of the fresh fractures. Wiederherstellungschir Traumatol 1953;1:18–35. [3] Kuntscher G. Further progress in the area of medullary nailing. Langenbecks Arch Chir 1966;316:224–31. [4] Rokkanen P, Slatis P, Vanka E. Closed or open intramedullary nailing of femoral shaft fractures? A comparison with conservatively treated cases. J Bone Joint Surg Br 1969;51:313–23. [5] Rascher JJ, Nahigian SH, Macys JR, Brown JE. Closed nailing of femoral-shaft fractures. J Bone Joint Surg Am 1972;54:534–44. [6] Winquist RA, Hansen ST. Segmental fractures of the femur treated by closed intramedullary nailing. J Bone Joint Surg Am 1978;60:934–9. [7] Hansen ST, Winquist RA. Closed intramedullary nailing of the femur. Kuntscher technique with reaming. Clin Orthop Relat Res 1979;138:56–61. [8] Winquist RA, Hansen Jr ST, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am 1984;66:529–39. [9] Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part II: fracture-healing with static interlocking fixation. J Bone Joint Surg Am 1988;70:1453–62. [10] Klemm KW, Borner M. Interlocking nailing of complex fractures of the femur and tibia. Clin Orthop Relat Res 1986;212:89–100. [11] Wiss DA, Fleming CH, Matta JM, Clark D. Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin Orthop Relat Res 1986;212:35–47. [12] Winquist RA. Locked femoral nailing. J Am Acad Orthop Surg 1993;1:95–105. [13] Johnson KD, Johnston DW, Parker B. Comminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail. J Bone Joint Surg Am 1984;66:1222–35. [14] Kempf I, Grosse A, Beck G. Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J Bone Joint Surg Am 1985;67:709–20. [15] Eid AM, Deif AI. Aetiological factors in non-union following Kuntscher intramedullary nailing of the femur. Arch Orthop Trauma Surg 1980;96:213–20. [16] Winquist RA, Hansen Jr ST. Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop Clin North Am 1980;11:633–48. [17] Pihlajamaki HK, Salminen ST, Bostman OM. The treatment of nonunions following intramedullary nailing of femoral shaft fractures. J Orthop Trauma 2002;16:394–402. [18] Salminen ST, Pihlajamaki HK, Avikainen VJ, Bostman OM. Population based epidemiologic and morphologic study of femoral shaft fractures. Clin Orthop Relat Res 2000;372:241–9. [19] Bostman O, Varjonen L, Vainionpaa S, Majola A, Rokkanen P. Incidence of local complications after intramedullary nailing and after plate fixation of femoral shaft fractures. J Trauma 1989;29:639–45. [20] Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma 1996;10 (Suppl. 1:v– ix):1–154. [21] Babhulkar S, Pande K. Nonunion of the diaphysis of long bones. Clin Orthop Relat Res 2005;431:50–6. [22] Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma 2010;68:629–32. [23] Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma 2001;15:254–63. [24] Rhorer AS. Percutaneous/minimally invasive techniques in treatment of femoral shaft fractures with an intramedullary nail. J Orthop Trauma 2009;23:S2–5.
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