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Conservative as well as operative treatment has been proposed for fractures above a knee prosthesis. Three cases are reported and an explanation for the fractures on a mechanical basis is given. Our results shows that closed treatment also leads to satisfactory results, avoiding the risks of extensive surgery.
Results of treatment distal femur fractures with damaged knee joint 20 patients with damaged distal femur and knee joint of 390 patients with femur fractures between 1976-1986 were examined. The material of osteosynthesis, the stability, the complications, the duration of stationary stay and the postoperative function of the knee joint are represented.
Twelve fractures of the femur occurred after irradiation in 12 patients during the past 15 years. All 12 patients had excision of a soft tissue sarcoma of the thigh. The periosteum was stripped in every case. The fractures had a deceptively innocuous radiographic appearance, which showed minimal comminution, displacement, and shortening. Treatment of the fractures was difficult and demanding. At a mean followup of 37 months, bony union was achieved in only four patients, and in all four cases union was delayed beyond 12 months. Because fracture healing typically is delayed, a loadsharing device such as an intramedullary nail may be preferable in treating these fractures. Primary or delayed bone grafting may be necessary, for no fracture united without bone graft. For elderly patients with low supracondylar fractures, primary endoprosthetic replacement may effect quicker rehabilitation. The possibility of local recurrence of tumor should be ruled out before definitive surgical treatment of the fracture. Closed, antegrade nailing in the presence of recurrent tumor may contaminate the flap for a salvage procedure such as hemipelvectomy and may compromise chances for cure.
The management of polytrauma patients is clinically challenging and requires a multi-disciplinary team approach. The immediate and definitive operative care of fractures represents the optimal treatment for polytrauma patients with orthopedic injuries. Early orthopedic intervention in long bone fractures and pelvic ring injuries has been shown to decrease pulmonary complications, improve hemodynamic stability, reduce ventilator time, and facilitate early patient mobilization. These factors decrease mortality and improve outcomes for patients with multiple injuries.
Three hundred thirty-nine diaphyseal fractures of the femur in 327 children were studied retrospectively. There were 196 boys and 131 girls, with a mean age of 5.59 years (range, 1 day-14 years). The majority of the children were < 6 years of age. In 67.8% of the children, the fracture was caused by a road traffic accident. Seventy-seven of the children had associated injuries. The minimum hospital stay was 15 days, and the maximum was 42 days (mean, 32.6 days). The most common site of fracture was at the middle third (N = 206), and 133 were the transverse type. The mode of treatment was balance skin traction in 146, skeletal traction in 72, hip spica in 22, internal fixation in 16, and external fixators in 5. The average follow up was 7.8 years. Complications were few. Our experience indicates that with a conservative mode of treatment, there is no risk of overgrowth, and a rotational malalignment of up to 20 degrees corrects during growth. We believe that diaphyseal fractures of the femur in children can be safely managed nonoperatively and economically, contrary to the present advocacy of operative treatment. The operative mode of treatment should be used in selected cases.
Dynamic intramedullary crosspinning was used in the surgical treatment of supracondylar and distal physeal fractures of the femur in 129 dogs and cats over a 5-year period; the records of the 44 dogs and 27 cats with follow-up information up to time of bony union were evaluated. The results were good or excellent in 66 of 71 animals (93%). The mean follow-up period was 22 months. Distal pin migration was the major complication (10 animals; 14%). The pin migrated before bony union in 2 animals because of instability and collapse at the fracture site. The pin migrated in 8 animals after bony union and was associated with intermittent lameness. In 5 of these, pin removal was performed and the lameness resolved.
On the basis of the experience with the treatment of 60 patients the authors recommend a one-step osteosynthesis of both femurs which allows timely mobilization of the patients, prevention of hypostatic and hypodynamic complications. The peculiarities of performing the operation are described.
BACKGROUND: This biomechanical study was designed to evaluate the predictive ability of dual-energy x-ray absorptiometry, cortical bone geometry as determined with computed tomography, and radiography in the assessment of torsional load to failure in femora with and without notching. METHODS: Thirteen matched pairs of cadaveric femora were randomized into two groups: a notched group, which consisted of femora with a 3-mm anterior cortical defect, and an unnotched group of controls. Each pair then underwent torsional load to failure. The ability of a number of measures to predict femoral torsional load to failure was assessed with use of regression analysis. These measures included dual-energy x-ray absorptiometry scans of the proximal and the distal part of the femur, geometric measures of both anterior and posterior cortical thickness as well as the polar moment of inertia of the distal part of the femur as calculated on computed tomography scans, and the Singh osteoporosis index as determined on radiographs. RESULTS: The torsional load to failure averaged 98.9 N-m for the notched femora and 143.9 N-m for the controls; the difference was significant (p < 0.01). Although several variables correlated with torsional load to failure, distal femoral bone-mineral density demonstrated the highest significant correlation (r = 0.85; p < 0.001). Moreover, multiple regression analysis showed that a combination of distal femoral bone-mineral density and polar moment of inertia calculated with the posterior cortical thickness (adjusted r (2) = 0.79; p < 0.001) had the strongest prediction of torsional load to failure in the notched group. The addition of other measures of cortical bone geometry, proximal femoral bone-mineral density, or radiographic evidence of osteopenia did not significantly increase the model's predictive ability. CONCLUSIONS: Femoral notching significantly decreases distal femoral torsional load to failure and is best predicted by a combination of the measures of distal femoral bone-mineral density and polar moment of inertia. Together, these values account for the amount of bone mass present and the stability provided by the cortical shell architecture.
Fifty-two CFLP mice had an open femoral diaphyseal osteotomy held in compression by a four-pin external fixator. The movement of 34 of the mice in their cages was quantified before and after operation, until sacrifice at 4, 8, 16 or 24 days. Thirty-three specimens underwent histomorphometric analysis and 19 specimens underwent torsional stiffness measurement. The expected combination of intramembranous and endochondral bone formation was observed, and the model was shown to be reliable in that variation in the histological parameters of healing was small between animals at the same time point, compared to the variation between time-points. There was surprisingly large individual variation in the amount of animal movement about the cage, which correlated with both histomorphometric and mechanical measures of healing. Animals that moved more had larger external calluses containing more cartilage and demonstrated lower torsional stiffness at the same time point. Assuming that movement of the whole animal predicts, at least to some extent, movement at the fracture site, this correlation is what would be expected in a model that involves similar processes to those in human fracture healing. Models such as this, employed to determine the effect of experimental interventions, will yield more information if the natural variation in animal motion is measured and included in the analysis.
OBJECTIVE: The determination of rotation of the femur during intramedullary nailing procedures can be difficult, particularly when the fracture pattern does not lend itself to interdigitation. We studied 22 patients who had isolated femur fractures treated by closed intramedullary nailing to determine the degree of malrotation introduced at the time of surgery. DESIGN AND METHODS: Anteversion of the affected and normal femora was determined by a standard computed tomography (CT) torsion study. The range of motion of the hip was measured in the prone position. Foot progression angles (FPAs) were measured in 14 patients who were fully ambulatory for at least 6 months. MAIN RESULTS: The average malrotation of the fractured femur was 16 degrees (4 to 61 degrees). The median malrotation was 14 degrees. The differences in CT-measured anteversion (delta A), FPA (delta FPA), internal rotation (delta IR), and external rotation (delta ER) between the affected and normal sides were determined. Linear regression was used to analyze delta A with delta FPA, delta IR, and delta ER. Changes in internal and external rotation as determined by physical exam had a stronger correlation with delta A than did delta FPA. This indicates that malrotation of the femur is accommodated for during gait. CONCLUSIONS: Based on this data, we found that anteversion of the normal femur can be determined in the operating room using the image intensifier and can be duplicated on the fractured side using the described technique in cases where comminution prevents fragmentational alignment. This method has been used for 12 patients in a prospective trial, and malrotation has been kept to under 10 degrees in all cases.
A Salter-Harris type-II fracture of the distal portion of the femur in a 1-year-old Pony of America was repaired by use of lateral plating combined with interfragmentary compression. The configuration of the fracture and the method of internal fixation with a condylar buttress plate were unique and resulted in primary bone healing, seen at the 5-month follow-up examination.
The first 50 consecutive cases of fixation of the femur using the Sampson fluted medullary rod are described. In suitable fractures this device has been inserted by the closed technique whenever possible. It also proved useful in the management of the complications of fractures treated by other methods and in the treatment of pathological fractures. The strength of the nail itself and the security of the fixation achieved allowed patients to be up and about very soon. There was one case of deep infection which resolved, but otherwise complications were minor.
Concomitant intertrochanteric and diaphyseal fracture of the femur is an uncommon injury that is probably best managed by open reduction and internal fixation as soon as the patient is hemodynamically stable. Four cases are presented in which rigid fixation of both fractures allowed early mobilization of the patient, facilitating nursing care and allowing rapid rehabilitation. Use of the sliding compression screw with a long side plate, although technically demanding, achieved rigid fixation with compression at both fracture sites. All fractures in the present series united, but in two of four cases moderate hip and knee stiffness compromised the final result, probably as a result of the severity of the initial trauma and associated injuries.
In this study we wanted to demonstrate the relationship between the fracture of the femoral neck and femoral head necrosis. For this purpose we reviewed the new literature, the dates of the ASIF documentation and some cases from the Davos Hospital. Head necrosis appears in all types of fractures and is independent of the implant. We can find femoral head necrosis in all age groups but the risk is higher the younger the patient. The necrosis can develop many years after the accident. There are not enough long-term studies to explain this phenomenon.
There is a significant transient increase in the number of osteoclasts in intact bone after bleedings and fractures in rats. This rise in the osteoclast population might be due to an increased parathyroid activity released by the trauma, but other factors may be involved. Both bleedings and ractures in rats are followed by hypercalcemia.
The treatment of supracondylar fractures of the femur in total knee arthroplasty is still challenging, and a variety of methods has been recommended. In a retrospective analysis, we reviewed six patients (average age: 70.5 years) with this type of fracture that had been stabilized with a retrograde intramedullary locking nail [Green-Seligson-Henry (GSH) nail]. The fracture had occurred 34.5 months after implantation of total knee arthroplasty. The average time of the operation was 97.16 min. There were no intra- or postoperative complications. All patients could be followed up at 17.3 months on average. Fracture healing was uneventful in all six cases. The postoperative range of motion was similar to the prefracture level in five patients. One patient demonstrated a loss of extension (10 degrees) associated with a valgus malalignment of 10 degrees. According to our experience, retrograde intramedullary nailing of supracondylar fractures in total knee arthroplasty is a promising alternative, which allows closed reduction and preservation of the soft tissue envelope. Immediate mobilization with partial weight bearing is possible, and the rate of complications is low.
The management of fractures occurring below the tip of an Austin Moore prosthesis varies greatly. Four cases are presented which provides difficulties have been overcome. The new method involves the insertion of a Küntscher nail posterior of the stem of the prosthesis.
Fifty elderly patients with fractured femurs were followed up for six months. A hospital stay of less than 28 days and a good prefracture mental state were such important favourable prognostic factors that their absence made the outlook poor and carried clear implications concerning management.