Radiographic Outcomes Of The Treatment Of Complex Femoral Shaft Fractures

 A Retrospective Analysis Of Different Techniques

Keyword: Comminuted femoral shaft fracture, complex femoral shaft fracture, intramedullary nailing, closed reduction, open reduction, radiographic imaging, retrospective study

Abstract 

Objectives: To assess the results of open versus closed reduction in intramedullary nailing (IMN) for complex femoral fractures (Arbeitsgemeinschaft fu¨r Osteosynthesefragen Foundation/Orthopaedic Trauma Association [AO/OTA]: 32-C) and to determine the factors involved in bone healing. 

Methods: This retrospective study involved 47 consecutive patients with complex femoral diaphyseal fractures who underwent reduction and fixation. 

Results: All open-reduction and 12 closed-reduction patients (52.17%) had an anatomical to a small gap. The closed-small group had the highest bone union rate (100%), followed by the open-reduction (79.17%) and closed-large groups (72.73%); intergroup differences were significant. The closed-small group had the shortest mean union time (7.31 months), followed by the open-reduction group (7.58 months). The closed-large group had a significantly longer union time (9.75 months) than those in the closed-small and open-reduction groups. Femoral radiographic union scores in the closed-small and open-reduction groups were similar at three-time points; scores were higher than those in the closed-large group, with a significant difference 6 and 9 months post-operatively. 

Conclusion: IMN with closed reduction for complex femoral shaft fractures had better outcomes and fewer complications versus open reduction. For unsatisfactory closed reduction outcomes (i.e., residual gap >10 mm), minimally invasive techniques or open reduction with minimal stripping should be considered. 

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Introduction 

Intramedullary nailing (IMN) is considered the gold standard for the treatment of femoral diaphyseal fractures. Specifically, closed reduction and internal fixation with an interlocking nail is the standard treatment for most shaft fractures of the proximal or distal femur.

However, the management of complex femoral diaphyseal fractures remains challenging and often results in delayed bone union or non-union. The recommended surgical techniques for these fractures are currently controversial.

While some studies have recommended closed reduction with internal fixation, which avoids the destruction of soft tissue attachments and blood supply,5 others have suggested that the displacement and size of residual fragments influence the prognosis.

The objective of the present study was to evaluate the radiographic outcomes of IMN for complex femoral diaphyseal fractures and to analyze the influence of different surgical strategies on the prognosis. 

To the best of our knowledge, this is the first study focusing on complex femoral diaphyseal fractures that compared the efficacy of open vs closed reduction to treat this subgroup (Arbeitsgemeinschaft fu¨r Osteosynthesefragen Foundation/ Orthopaedic Trauma Association [AO/ OTA] type: 32C).

Patients and methods 

Patients: A retrospective cohort of patients with complex femoral diaphyseal fractures (AO/OTA type: 32-C), who were treated using antegrade intramedullary nails by the same team of surgeons from January 2009 to December 2019, was included.7 The exclusion criteria were open fracture, periprosthetic fracture, pathological fracture, staged operation following initial external skeletal fixation or skeletal traction, brain injury, and fat embolism in patients with femoral diaphyseal fractures.

Surgery: All fractures were managed by senior attending surgeons or fellowship-trained orthopedic traumatologists in the orthopedic department of a single trauma center. The enrolled patients were subdivided into open- and closed-reduction groups, based on their medical records and the surgical techniques.

Radiographic assessment and outcomes: Pre-operative radiographs were obtained at admission, and postoperative radiographs were obtained immediately after surgery. Anteroposterior and lateral radiographs were acquired at every follow-up visit in the outpatient department (every month for at least 24 months or until the bone union was achieved). The quality of reduction was assessed by reviewing the post-operative radiographs and measuring the average gap between the fragments.

Data analysis: Statistical correlation was analyzed using the Mann–Whitney U test and one-way analysis of variance. The level of statistical significance was set at p < 0.05. Statistical analyses were performed using SPSS version 22 (IBM Corp., Armonk, NY, USA).

Results 

Between January 2009 and December 2019, 319 patients with a femoral shaft fracture were included, and 59 complex femoral shaft fractures (AO/OTA/32-C) were identified. After 8 patients were excluded, 51 patients with complex femoral shaft fractures were considered eligible. Four patients were excluded owing to a short follow-up duration and loss of follow-up (Figure 1). Therefore, 47 patients (36 men and 11 women) were enrolled consecutively. There were 24 (21 men, 3 women) and 23 (15 men, 8 women) patients in the open and closed-reduction groups, respectively.

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Reference

Chen, Y. H., Lin, S. M., Chang, C. H., & Lan, T. Y. (2021). Radiographic Outcomes of Treatment of Complex Femoral Shaft Fractures by Intramedullary Nailing: A Retrospective Analysis of Different Techniques.

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