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ORIGINAL ARTICLE
Year : 2014  |  Volume : 41  |  Issue : 2  |  Page : 122-126

Study of treatment of short oblique and transverse fractures near isthmus of femur


1 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India

Date of Web Publication20-May-2014

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.132860

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  Abstract 

Background: Currently, the standard treatment for femoral shaft fractures in adults is intramedullary nailing. Objectives: Comparative assessment of results with open Kuntscher's nailing (K-nailing) and closed interlocking intramedullary nail in case of fracture shaft femur. Materials and Methods: This pilot project was conducted in a tertiary care hospital of a developing country on 40 patients in a time period of 1 year. A total of 20 patients were treated with intramedullary nailing in the tertiary care hospital while twenty received open fixation with K-nailing in a rural center. Results: There was no significant difference with regard to union rate, implant failure, infection, and fracture alignment between both groups. Conclusion: Open fixation with unlocked femoral nailing is technically less demanding and requires less operating time; additionally, there is no exposure to radiation and cost of the implant is cheaper. So, open K-nailing is still remains an option for the management of noncomminuted isthmus fractures of the femur in a developing country.

Keywords: Fracture shaft femur, interlocking intramedullary nailing, K-nailing


How to cite this article:
Ghosh S, Mondal BC, Chaudhuri A, Datta S, Roy DS. Study of treatment of short oblique and transverse fractures near isthmus of femur. J Sci Soc 2014;41:122-6

How to cite this URL:
Ghosh S, Mondal BC, Chaudhuri A, Datta S, Roy DS. Study of treatment of short oblique and transverse fractures near isthmus of femur. J Sci Soc [serial online] 2014 [cited 2020 Aug 9];41:122-6. Available from: http://www.jscisociety.com/text.asp?2014/41/2/122/132860


  Introduction Top


Currently, the standard treatment for most femoral shaft fractures in adults is intramedullary nailing, as it offers biomechanical and biologic advantages when compared with other methods of fixation. [1],[2],[3],[4],[5] Initial temporary fracture stabilization is more advantageous than initial definitive stabilization for femoral shaft fractures in patients with more severe injuries with regard to the development of systemic complications. The stabilization within 24 h in patients with multiple injuries decreases pulmonary complications and shortens hospital stay. Some of the known side effects of reaming the femoral canal in preparation for the nailing process are fat embolization and secondary activation of coagulatory and inflammatory pathways. The overall incidence of acute respiratory distress syndrome (ARDS) is low with primary stabilization of femoral shaft fractures with intramedullary nailing. There was no difference in the incidence of ARDS between the reamed and unreamed cases. [1],[2],[3],[4],[5],[6]

The femur is subjected to significant bending, axial, and torsional forces that can exceed three to four times body weight during normal activities. The torsional rigidity of a femur fracture treated with an intramedullary nails is determined by a combination of nail characteristics and fracture characteristics. The torsional stability of the nail itself is of minor concern, provided the loads encountered do not exceed the nails elastic deformation limits. Resistance to axial loading of the implant bone construct is primarily determined by the presence of interlocking screws and the bone contact at the fracture. In the case of a purely transverse middiaphyseal femur fracture with predicted cortical interdigitation after nailing, the biomechanical characteristics of the implant are less important than in a segmentally comminuted fracture that will have no inherent stability after reestablishment of the length, alignment, and rotation. [7],[8],[9],[10],[11],[12]

In virtually all currently available nails, there is a large mismatch between the radius of curvature of the nail and the radius of curvature of the femur. The number of distal interlocking screws necessary to maintain the proper length, alignment, and rotation of the implant bone construct depends on numerous factors including fracture comminution, fracture location, implant size, patient size, bone quality, and patient activity. Distal fractures, extensive comminution, poor bone quality, and the expectation of early weight bearing are all variables that suggest the need for two distal interlocking screws. In addition, interlocking screws are highly loaded in axial compression during weight bearing. Although the static stability may be similar with one versus two screws, constructs with two screws can endure more cycle loading. [13],[14],[15]

Bone healing after intramedullary nailing is usually predictable. Closed intramedullary nailing in closed fracture has the advantage of maintaining both the fracture hematoma and the attached periosteum. If reaming is performed, these elements provide a combination of osteoinductive and osteoconductive materials to the site of the fracture. [13],[14],[15]

Unlocked intramedullary nails were initially developed for fixation of transverse and short oblique fractures around the midshaft region or the isthmus. Nails of the same diameter as the narrowest part of medullary canal were usually used as they resist rotational displacement by friction. Interdigitation of the fracture ends provided further resistance against rotation. Therefore, Kuntscher's nails (K-nails) were usually reserved for Winquist I and II femoral shaft fractures around the isthmus. Studies have demonstrated that there is no significant difference in outcomes between ILN and K-nail fixation of patients in regards to rate of union, speed of union, and femoral alignment. [13]

The present study was conducted for comparative assessment of results with K-nail and interlocking intramedullary nail (ILN) in term of cost-effectiveness, infrastructural facilities, intraoperative and postoperative complications, so that proper management technique in the specificdirection can be provided in a socioeconomically backward population for better functional outcome.


  Materials and methods Top


This prospective study was conducted in a medical college in a rural set up after taking clearance of the institutional ethical committee and informed consent of the patients. A total of 40 patients with short oblique span and transverse fracture near isthmus of femur were randomly assigned into two different treatment protocols, with K-nail or ILN nail. A total of 20 patients were treated with intramedullary nailing (Group I) in the tertiary care hospital, while 20 received open fixation with K-nailing in a rural center (Group II). Patients who refused to move to a tertiary care hospital due to financial problem or lack of manpower were treated at the rural center. In the rural center image intensifier (C-arm, X-ray facilities were not available in the operation theater).

Inclusion criteria

Patients with duration of fractures not more than 2 weeks.

Exclusion criteria

Subjects with open fracture, any associated fracture in the same limb, pelvic fracture and associated with serious internal organ injury and soft tissueinjury, fracture with vascular injury were excluded.

Most of the patients were in the age group 18-30 years. Males (75%) outnumbered females (25%). Motor vehicle accident was the most frequent cause of fractures (90%), followed by fall from height. Left femur was involved in 55% and right in 45% of cases. After initial resuscitation, the patientswere given skeletal traction. Radiographs were taken. The type of fracture and degree of comminution were assessed. All the patients were thoroughly examined and investigated and pre anesthetics check up done. [2],[6],[7],[8],[13]

Open K-nailing

Fracture was exposed through a posterolateral incision was done. Fragments were mobilized and reduced. A series of rigid reamers corresponding to the diameter of the nail were passed, first proximally, and then distally. The exact length of the nail was estimated. The correct-sized rigid reamer was driven from the fracture site into the proximal fragment to ream the trochanter with the hip in adduction and slight flexion. Now the proper sized nail with the extraction eye at the upper end of the nail oriented posteromedially, the open slot of the nail oriented anterolaterally along the tension side of the femur, was introduced into the proximal fragment from the fracture site. As the advancing nail in the proximal fragment approached the fracture site, reduction of the fracture was done under direct vision. Since the fracture tends to bow anterolaterally, manual pressure was exerted. Nail was then driven into the distal fragment with pressure against the flexed knee to maintain reduction and prevent distraction at the fracture site. When the nail is properly seated, its eye faces posteromedially and its proximal end does not extend more than 2.5 cm proximal to the trochanter.

Interlocking intramedullary nailing

The proper length and diameter of a femoral nail should be anticipated beforehand. The diameter of the intramedullary canal is estimated at the narrowest portion of the femoral canal. Traction to the foot applied with the fracture table foot holder. Hip rotation estimated and corrected with respect to the normal anteversion of the hip as determined with the image intensifier. The foot and distal fragment of the femur rotated to match the proximal fragment with the help of C-arm.

With patient in supine posture, the trunk and affected extremity are adducted. The unaffected limb should extend below the affected limb and the affected hip flexed 15-30°. Taking into account the normal femoral anteversion of 15-20°, it is possible to determine exactly the angle at which to place the foot. The image intensifier is used to view the entire femur.

Antegrade intramedullary nailing

The traditional open approach is accomplished through a longitudinal incision that begins at the proximal tip of the greater trochanter and extends proximally over a variable distance depending on the size of the patient. The gluteus maximus fascia is incised in line with the incision, and the muscle fibers separated. The greater trochanter and the trochanteric fossapalpated, and a curved awl is placed. Its position should be confirmed on the Antero-posterior (AP) and lateral planes. The awl is then advanced in line with the intramedullary canal.

Guide rod insertion

After the starting hole has been made, a ball-tipped guidewire is passed down the canal of the femur. Proximal fragment is reamed with 0.5 mm increments with cannulated reamer. Reduction is then done. The guide rod is advanced into the center of the distal fragment until the tip reaches the epiphyseal scar. Image intensification is used to verify the positions. Femoral length is confirmed before determining the desired nail length.

Canal preparation

Flexible reamers are passed over the guide wire and down the canal of the femur. The fracture should be maintained in a reduced position during the passage of each reamer to minimize eccentric bone removal.

Nail insertion

The ball-tipped guide wire is exchanged for a straight guide wire using a flexible exchange tube. The selected nail dimensions are confirmed, and the nail is attached to the proximal locking jig and placed over the guide wire. By internally rotating the nail by 90°, the tip of the nail is placed around the greater trochanter. The rotation of the nail is then corrected to match the rotation of the femur. The nail is advanced to the level of the fracture. At this point, the length, alignment, and rotation of the femur should be corrected accurately. The nail is advanced across the fracture, and the reduction parameters confirmed. The nail is then driven distally to the appropriate depth.

Proximal interlocking

Proximal interlocking is simplified with the use of an external jig that allows placement of screws using multiple sleeves.

Distal interlocking

Distal interlocking is usually accomplished using a free-hand technique that is highly dependent on fluoroscopic imaging. Regardless of how distal interlocking is accomplished, the alignment, especially in rotation, must be maintained until at least one screw is placed. The image intensifier is first used to localize a perfectly round circle of the interlocking screw hole.

Routine follow-up was done at out patient department with proper rehabilitation protocol, clinical and radiological assessmentat 2 weeks, 4 weeks, 6 weeks, 3 months, 6 months, 12 months, and 18 months. The result were graded as excellent, good, fair, and poor as compared with grading system done by Thoresen et al., scoring system. [5] Data were arranged in tabular form and analyzed using student's t test and chi-square test. P value < 0.05 was considered as significant.


  Results Top


There was no significant difference in between both groups in terms of demographic data (age, sex), fractures type and hospital stay and comorbidities except interval from injury to surgery and operating time. The average interval from injury to surgery was 4.9 ± 1.73 days for K-nail and 7.3 ± 1.8 days for interlocking nail (P = 0.0075). The average operating time was 59 ± 9.37 (min) for K-nail and 96.5 ± 12.9 (min) for interlocking nail (P < 0.0001). There was no significant difference between the two groups in terms of Thoresen's outcome score. Only two patients of K-nail group needed blood transfusion. In the ILN group, 70% of patients achieved union within four months and 60% of the K-nail group did so. There was no case of delayed union in the K-nail group. There was one case of delayed union in the ILN group who was successfully treated with dynamization. The ILN and K-nail groups did not differ significantly in their speed of radiological union or fracture healing.

Both groups had 80% of its scores in excellent range for each of the Thoresen parameters. One case in the INL-nail group developed superficial wound infection that resolved after a course of antibiotics. One case in the INL-nail group complained of sensory deficit medial aspect of leg. There were no cases of implant failure in the both group. Maximum number of fracture (70% in INL group and 60% in K-nail group) clinically united within 16 weeks. Mean time of radiological union of INL group was15.8 weeks and K-nail group was 16.4 weeks.


  Discussion Top


Intramedullary nailing has become the implant of choice for the treatment of virtually any femoral shaft fracture. The locking mechanism has enabled stabilization of even the most comminuted and unstable fractures that leads to more successful early rehabilitation. Most hospitals routinely use interlocking intramedullary nails to fix all types of femoral shaft fractures, including Winquist types I and II femoral isthmus fractures. Recent concerns are with the use of the newer Intramedullary (IM) nailing systems that uses longer cross screws, which have been developed with variation in implant designs. The newer implants provide less fracture stability, due to decreased stiffness of the IM nailing system. [6],[7],[8]

Although femoral nailing is generally considered a technically demanding procedure, the incidence of iatrogenic complications associated with the technique has not been well-documented. Such complications include comminution and, rarely, femoral neck fractures. Longitudinal splitting in the anterior cortex was revealed by Papadakis et al., in 5 of 18 cadaver femora macroscopically. Anterior splitting was not detectable in radiographic control. Cadaveric study using nine pairs of fresh-frozen femora from adult cadavers was done. The nine pairs of femora underwent a standardized antegrade intramedullary nailing and the detection of iatrogenic lesions, if any, was performed macroscopically and by radiographic control. Nail impingement against the anterior femoral cortex during nail insertion, or anterior cortex penetration, has been described in the literature as a worrying complication. [8],[9]

In studies by Yu et al.,[13] in 2008 no statistical significant difference was found with regard to union rate, implant failure, infection, and fracture alignment between open fixation and ILN. Open fixation with unlocked femoral nailing is technically less demanding and requires less operating time; additionally, there is no exposure to radiation and cost of the implant is cheaper. So, they concluded that unlocked nailing is still useful for the management of non-comminute isthmus fractures of the femur. [13]

Of concern is fact that the K-nail group had a higher rate of implant failures involving migration and bending. Surgeons should probably proceed more slowly in initiating weight bearing protocols when K-nail fixation is employed. Therefore, for economic and technical reasons, use of the K-nail is still a viable option for a developing country.


  Conclusion Top


Kuntscher's intramedullary nailing can provide comparable rate of union with interlocking intramedullary nailing when used for fixation of short oblique and transverse fractures near isthmus of femur. Considering the cost and surgical aspects of this treatment option, Kuntscher's intramedullary nailing is still a viable option for selected femoral fractures in many hospitals, especially those with limited financial resources or less technical expertise.

 
  References Top

1.Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. EPOFF Study Group. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg 2007;246:491-501.  Back to cited text no. 1
    
2.Giannoudis PV, Griensven MV, Hildebrand F, Krettek C, Pape HC. Femoral nailing-related coagulopathy determined by first-hit magnitude. Clin Orthop Relat Res 2008;466:473-80.  Back to cited text no. 2
    
3.The Canadian Orthopaedic Trauma Society. Reamed versus unreamed intramedullary nailing of the femur: Comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma 2006;20:384-7.  Back to cited text no. 3
    
4.Hu¨fner T, Citak M, Suero EM, Miller B, Kendoff D, Krettek C, et al. Femoral malrotation after unreamed intramedullary nailing: An evaluation of influencing operative factors. J Orthop Trauma 2011;25:224-7.  Back to cited text no. 4
    
5.Thoresen BO, Alho A, Ekeland A, Strømsøe K, Follerås G, Haukeb A. Interlocking intramedullary nailing in femoral shaft fractures. A report of forty-eight cases. J Bone Joint Surg Am 1985;67:1313-20.  Back to cited text no. 5
    
6.Arpacioðlu MO, Akmaz I, Mahiroðullari M, Kiral A, Rodop O. Treatment of femoral shaft fractures by interlocking intramedullary nailing in adults. Acta Orthop Traumatol Turc 2003;37:203-12.  Back to cited text no. 6
    
7.Bekmezci T, Baca E, Kaynak H, Kocabaº R, Tonbul M, Yalaman O. Early results of treatment with expandable intramedullary nails in femur shaft fractures. Acta Orthop Traumatol Turc 2006;40:1-5.  Back to cited text no. 7
    
8.Karuppiah S, Johnstone A, Shepherd D. How cross screw length influences the stiffness of intra medullary nail systems. J Biomed Sci Eng 2010;3:35-8.  Back to cited text no. 8
    
9.Papadakis SA, Zalavras C, Mirzayan R, Shepherd L. Undetected iatrogenic lesions of the anterior femoral shaft during intramedullary nailing: Acadaveric study. J Orthopaedic Surg Res 2008;3:30.  Back to cited text no. 9
    
10.Maniscalco P, Rivera F, D'Ascola J, Del Vecchio EO. Failure of inter trochanteric nailing due to distal nail jamming. J Orthop Traumatol 2013;14:71-4.  Back to cited text no. 10
    
11.Minoda Y, Kobayashi A, Iwaki H, Ohashi H, Takaoka K. TKA Sagittal alignment with navigation systems and conventional techniques vary only a few degrees. Clin Orthop Relat Res 2009;467:1000-6.  Back to cited text no. 11
    
12.Bouchard JA, Barei D, Cayer D, O'Neil J. Outcome of femoral shaft fractures in the elderly. Clin Orthop Relat Res 1996;105-9.  Back to cited text no. 12
    
13.Yu CK, Wong HY, Vivek AS, Se BC. Unlocked nailing vs. interlocking nailing for Winquist Type I and II femoral isthmus fractures. Is there a Difference? Malays Orthop J 2008;2:23-7.  Back to cited text no. 13
    
14.Schandelmaier P, Farouk O, Krettek C, Reimers N, Mannss J, Tscherne H. Biomechanics of femoral interlocking nails. Injury 2000;31:437-43.  Back to cited text no. 14
    
15.Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma 2004;18:410-5.  Back to cited text no. 15
    



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