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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 362-367

Study of prevalence and operative results of fracture shaft femur in adults


Department of Orthopaedics, Smt. NHL Municipal Medical College, Paldi 380006, Ahmedabad, Gujarat, India

Date of Submission24-Jul-2022
Date of Acceptance10-Aug-2022
Date of Web Publication29-Sep-2022

Correspondence Address:
Dr. Poojan V Shah
Department of Orthopaedics, Smt. NHL Municipal Medical College, Paldi 380006, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_117_22

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  Abstract 

Background: Being the principal weight bearing of the lower limb, fractures related to the femur pose a threat to humans and affect the overall quality of life. Conservative management is no longer preferred, and stable internal fixation is the modality of treatment these days. Aims and Objectives: The aim of this article is to study the operative outcomes of fixation of fracture shaft femur in terms of union, stability, functional outcomes, and complications. Materials and Methods: This study is a retrospective study of 35 patients with proximal, mid-shaft, and extra-articular distal shaft femur fractures admitted to Smt. SCL Municipal Hospital for 3 years from May 2019 to May 2022. Results: The results showed improvement in all the functional and radiological outcomes. More than 70% of the patients achieved greater than 125° of knee flexion. The radiological union of fractures was 4.4 months in our study. According to Neer’s score, 33 patients scored excellent to satisfactory. Conclusion: Internal fixation of fractures in the femoral shaft is an absolute must and has gained widespread acceptance as implants and technology have improved. The rationale for internal fixation is that it restores anatomical alignment and allows early mobilization of the patient and limb.

Keywords: Complications, functional outcomes, internal fixation


How to cite this article:
Shah PV, Tank PM, Patel NB, Italiya KS. Study of prevalence and operative results of fracture shaft femur in adults. MGM J Med Sci 2022;9:362-7

How to cite this URL:
Shah PV, Tank PM, Patel NB, Italiya KS. Study of prevalence and operative results of fracture shaft femur in adults. MGM J Med Sci [serial online] 2022 [cited 2022 Dec 7];9:362-7. Available from: http://www.mgmjms.com/text.asp?2022/9/3/362/357485




  Introduction Top


The femur also known as the thigh bone is the longest and strongest bone of the human body. It is one of the principal load-bearing bones of the lower limb. Fractures of the shaft and distal region of the femur can pose a significant threat to morbidity and mortality of human lives, owing to its complexity and difficulty in fixation due to various forces acting on it. Fractures of the femur are the result of high-energy trauma, which may be open/closed and associated with multiple skeletal and soft tissue injuries over the body.

Prompt reduction and rigid stable fixation are today’s accepted modes of treatment, which reduce the risk of pathophysiological complications as well as help to prevent permanent impairment of knee function by early mobilization. Previously, before the invention of different surgical modalities, treatment of shaft and distal femur fractures was performed conservatively via cast, traction, or aggregation of both. The problems associated with conservative management are as follows: (1) the limitation of correct anatomical reduction of fracture and (2) to keep reduction maintained. This would ultimately lead to multiple complications such as delayed union, non-union, malunion, infection, joint contracture, knee instability, and post-traumatic arthritis. Henceforth, multiple modalities have been developed for the proper fixation of these fractures. Antegrade and retrograde intramedullary nails, external fixation devices, and simple as well as locking plates that are also designed to be anatomically suitable are now available, which have made the anatomical and physiological restoration possible. They have also made it possible to reduce the chances of complications, which ultimately help improve the overall post-operative quality of life.


  Materials and methods Top


This is a study of 35 patients with proximal, mid-shaft, and extra-articular distal femur fractures admitted to our institute from the period of May 2019 to May 2022 that satisfied our inclusion criteria. All skeletally mature patients having femur fracture according to AO type 32 as well as 33-A1, osteoporotic, and poliotic femur fractures have been included. Patients who came for follow-up for at least 6 months since the time of injury have been included. Data of all patients included in the study have been taken after prior written, informed consent and the Institutional Review Board approval from the concerned authority. Of 35 patients in our study, 26 were males. Out of the 35 patients, 26 belonged to age between 18 and 40 years. Three patients were above the age of 60 years. As per our hospital protocol and the ATLS guidelines, all patients were initially stabilized hemodynamically first after ruling out injuries to the head, chest, and abdomen. Standard X-rays in the form of an anteroposterior (AP) and a lateral view were obtained. Whenever needed, a computed tomography (CT) scan was performed to assess fracture morphology in detail. In case of an open fracture, after a thorough wash with saline, cleaning and dressing were done and antibiotics were started along with IV tetanus immunoglobulin. Skin traction was given in almost all patients with weights up to 5–7 kg applied, depending on the weight and built of the patient and displacement of the fracture segment. Immobilization in the form of a high above knee splint was given whenever needed. Definitive management was done with either antegrade or retrograde intramedullary nails or plates. Patients were operated on as per their surgical fitness status. Patients were discharged on an average of 6.6 days and followed up regularly at 2 weeks, 4 weeks, and thereafter monthly up to 6 months.


  Operative scenario Top


In the case of antegrade nailing [Figure 1]A, all patients are positioned supine on the fracture table. The incision is centered at the tip of the greater trochanter and extended 4 cm proximally, and slightly posterior, distal extension carried out if and when necessary. The entry portal is done using fluoroscopy, and entry is made at the lateral aspect of the piriform fossa at the junction of the medial wall of the greater trochanter. This was confirmed both in the AP and lateral views. Guidewire insertion is done and reduction at the fracture site is done using traction and manipulation and then guidewire is passed across the fracture site. This is confirmed by the image intensifier in both views. Reaming of the canal is done in 1 mm increments using flexible intramedullary reamers. Then the desired nail is mounted onto the jig. Alignment of proximal jig holes to nail holes is confirmed before insertion. Distal locking is done using the freehand technique under fluoroscopic imaging. The locking of the bolts is confirmed in both views. Proximal locking is done using the proximal jig. Later after confirming the final views on fluoroscopy, the wound is closed in layers.
Figure 1: (A) Antegrade and (B) retrograde nailing apparatus

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For retrograde nailing [Figure 1]B, the position of the patient is supine with the knee flexed 30o. A 2 cm skin incision is made longitudinally just distal to the inferior patellar pole, over the midline of the patellar tendon. The entry point is the anatomical landmark, Blumensaat’s line. This corresponds to the roof of the intercondylar notch. Entry achieved is at the center of the intercondylar notch, just superior to Blumensaat’s line. Guide wire insertion is done and passed through the fracture line after reducing the fracture using traction and manipulation of fracture fragments. Sometimes, a bone hook or tension band wire is required to reduce a spiral fracture. Reaming is done using 1 mm increments of flexible reamers passed through the guide wire. The nail is mounted onto the jig. Alignment of distal jig holes to nail holes is confirmed before insertion. Proximal locking is done using the free-hand technique under fluoroscopic imaging. Locking of the bolts is confirmed in both the views, similar to that of interlock nailing. In the end, after confirmation of reduction in both views, closure is done in layers.

For distal femur plating [Figure 2], the operative approaches are usually subjective to each patient based on the particular pattern of the injury, location of the fracture, associated injuries, and soft tissue involvement. The standard approach in our study is the lateral approach, and fracture is fixed by putting a plate after elevating the vastus lateralis [Figure 3]. Wound closure is done in a standard manner using polyglactin absorbable sutures followed by synthetic non-absorbable nylon sutures. A suction drain is also usually placed in distal femur fractures.
Figure 2: Distal femur locking plate with screws

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Figure 3: Plate fixed to the bone after the elevation of vastus lateralis muscle through a lateral approach

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  POST-OPERATIVE PROTOCOL Top


Once the patients are operated on, standard AP and lateral radiographs are taken to confirm implant position and quality of fracture reduction. Physiotherapies such as quadriceps-drill, quadriceps strengthening, and ankle pumping exercises are taught as well as encouraged. Thereafter, depending on the fixation and soft tissue condition, knee bending is ideally started on post-operative day 1. In the case of distal femur fractures, depending on the stability of fracture reduction and degree of comminution, continuous passive motion (CPM) is started and the degree of CPM gradually increased. A high knee brace is given for support. The drain is removed on post-operative day 2. Injectable antibiotics are given for 3 days in case of closed reduction internal fixation and for 5 days in case of open reduction internal fixation. Thereafter, the patient is put on oral antibiotics for 1 week. Suture removal is done ideally after 2 weeks of surgery.


  Rehabilitation Top


For rehabilitation, once the patients have been operated on and the drain removed, non-weight-bearing walking with a walker is taught to all patients having a shaft and distal femur fractures provided that they can tolerate it. Thereafter, we start with partial weight bearing with a walker at 6 weeks of surgery after confirming callus formation radiologically [Figure 4]. In the case of non-compliant patients, it is started at 8 weeks. Full weight-bearing walking is started between 10 and 12 weeks, depending on union status. In the case of osteoporotic and poliotic patients, it is extended by 2–4 weeks [Figure 5]. Thereafter, the patient is followed at 6 months and 1 year to clinically assess and be watchful for any late complications.
Figure 4: (A) Pre-operative, (B) post-operative, and (C) complete union

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Figure 5: Clinical images of a patient having poliotic left segmental shaft femur treated by nailing

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  Observation and results Top


In our study, the most common presentation of fracture femur was in young males. The average age of males in our study is 35 years, whereas females are 38 years. Road traffic accidents and domestic falls have equal incidence as a mode of injury (42.8%). It should be noted that some patients in our study suffered from fractures due to self-fall from their vehicles due to different reasons and not due to any road traffic accidents. We had five (14.28%) such patients in our study. The most common type of fracture is AO type 32-A (74.2%), of which 32-A3 (transverse type) is the most common and accounts for almost 50% of the patients. There were six patients of AO type 32-B (shaft wedge fracture), two patients of AO type 33-A (extra-articular distal femur), and only one patient with a 32-C2 type of fracture (complex segmental femur fracture). Approximately 23% of the patients had other associated injuries. There were four patients with head injury (11.42%) and two patients (5.71%) each with ipsilateral IT/GT and shaft tibia fracture [Table 1]. Patients were operated on an average of 2.34 days from the day of injury.
Table 1: Other associated injuries

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In our study, superficial infection was managed with antibiotics and regular dressing. However, deep infection required surgery in the form of removal of the implant after fracture union was achieved and the discharge was sent for culture and sensitivity according to which antibiotics were started. There were three patients (8.5%) who had delayed union and one patient (2.85%) who had non-union [Table 2]. All four patients had residual poliomyelitis. The case of non-union was treated in the form of revision plating with bone grafting. There were no other complications in our study. We did not encounter any complications related to thromboembolism such as acute respiratory distress syndrome, pulmonary embolism, or deep vein thrombosis. In our study, 26 patients (75%) achieved knee flexion >125o at the end of the evaluation period. There were seven patients (20%) who achieved knee flexion between 100o and 125o. Only two patients (5%) achieved knee flexion less than 100o. There were 9 patients (25.7%) who achieved union in 4 months, 13 patients (37.14%) in 5 months, and 9 (25.7%) patients in 6 months. Three (8.5%) patients had delayed union and one patient (2.85%) had non-union. The mean union time in our study is 4.4 months.
Table 2: Post-operative complications

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  Discussion Top


In our study, 22 (62.8%) patients had excellent Sander’s scores, 10 (28.5%) had a satisfactory score, and 3 patients (8.5%) had fair scores. There were no patients with a poor score. Twenty-nine patients (82.8%) had excellent Neer’s scores, four (11.4%) had a satisfactory score, and two patients (5.7%) had unsatisfactory scores. There were no patients with failure. Further comparison has been done with other studies, as mentioned in [Table 3] and [Table 4].
Table 3: Comparison of mean age of our study with previous studies

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Table 4: Average period of the union in previous studies

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The material of implant was stainless steel in our study with the union being achieved with excellent callus and only one case of non-union reported. In sharp contradiction to this, a study conducted by Henderson et al.[7] found less callus formed in patients treated with stainless steel plates in comparison to titanium plates. Earlier studies have shown reduced non-union rates for locked plating of distal femoral fractures when compared with non-locking plates, but more recent studies by Markmiller et al.[8] found non-union rates up to 20%. In our study, 11.3% of the fractures showed signs of delayed or non-union. All of those patients had poliomyelitis. Multiple reasons influence union rates that can be attributed to the coexisting patient morbidity, comminution at the fracture site, and initial damage to the surrounding soft tissue.[9] Interlocking techniques (antegrade and retrograde) lead to fewer complications such as non-union/malunion, lesser soft tissue dissection, earlier fracture healing, and lesser chances of infection. Fractures in any zone from the subtrochanteric to distal supracondylar part of the femur are accessible to nailing. Closed nailing results in lesser intraoperative blood loss, shorter operative time, earlier weight bearing, early union rates, and early return to work with reduced morbidity.[10]

In our study, we have fixed distal femur fractures with both nailing as well as plating, depending on fracture morphology. In a study conducted by Zlowodzki et al.,[11] intramedullary nails and locking plates were found to have equivalent functional outcome scores.


  Conclusion Top


Internal fixation of fractures of the femoral shaft has gained widespread acceptance as implants and technology have improved. The rationale for internal fixation is that it restores the anatomical alignment and allows early mobilization of the patient and limb. The use of a plate to achieve osteosynthesis necessitates wide operative exposure and excessive soft tissue stripping, resulting in increased blood loss and operating time. The risk of infection is increased. Hence, this study advocates internal fixation with antegrade or retrograde nailing as the treatment of choice for all shaft femur fractures. For extra-articular distal femur fractures (AO type 33-A1), anatomical reduction of fracture fragments and rigid fixation is a must. Along with anatomical reduction and rigid fixation, early mobilization and aggressive physiotherapy should be started with the use of plating in such cases.

Ethical consideration

The ethical approval to undertake the proposed research work on “Study of prevalence and operative results of fracture shaft femur in adults” has been obtained from the Institutional Ethics Committee of Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India, vide letter no. NHLIRB/2022/July/14/01 dated July 14, 2022.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Song SH Radiologic outcomes of intramedullary nailing in infraisthmal femur-shaft fracture with or without poller screws. Biomed Res Int 2019;2019:9412379.  Back to cited text no. 1
    
2.
Kumar R, Kumar S, Choudhry L Surgical management of fracture shaft of femur with an intramedullary interlocking nail. Int J Orthop Sci 2018;4:627-30.  Back to cited text no. 2
    
3.
Wiss DA, Brien WW Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res1992:231-6.  Back to cited text no. 3
    
4.
Arpacioğlu MO, Akmaz I, Mahiroğullari M, Kiral A, Rodop O. Erişkinlerdeki femur cisim kiriklarinin kilitli intramedüller çivileme yöntemiyle tedavisi [Treatment of femoral shaft fractures by interlocking intramedullary nailing in adults]. Acta Orthop Traumatol Turc 2003;37:203-12.  Back to cited text no. 4
    
5.
Kumar A, Krishnaiah G, Biju R, Krishnamurthy MO Study of outcome of closed interlocking intramedullary nailing of fracture shaft of femur in adults. IOSR J Dent Med Sci 2015;14:48-52.  Back to cited text no. 5
    
6.
Brumback RJ, Virkus WW Intramedullary nailing of the femur: Reamed versus nonreamed. J Am Acad Orthop Surg 2000;8:83-90.  Back to cited text no. 6
    
7.
Henderson CE, Lujan TJ, Kuhl LL, Bottlang M, Fitzpatrick DC, Marsh JL 2010 mid-America Orthopaedic Association Physician in Training Award: Healing complications are common after locked plating for distal femur fractures. Clin Orthop Relat Res 2011;469:1757-65.  Back to cited text no. 7
    
8.
Markmiller M, Konrad G, Südkamp N Femur-LISS and distal femoral nail for fixation of distal femoral fractures: Are there differences in outcome and complications? Clin Orthop Relat Res2004:252-7.  Back to cited text no. 8
    
9.
Raju S, Singhi PK, Thangamani V, Muthu C A Study of surgical intervention in fractures of post-polio residual paralytic lower limb, challenges encountered, and outcome analysis. J Orth Joint Surg 2020;2:10-6.  Back to cited text no. 9
    
10.
Ricci WM, Gallagher B, Haidukewych GJ Intramedullary nailing of femoral shaft fractures: Current concepts. J Am Acad Orthop Surg 2009;17:296-305.  Back to cited text no. 10
    
11.
Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ Operative treatment of acute distal femur fractures: A systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma 2006;20:366-71.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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