Nowotarski, J Bone Joint Surg Am 2000 - Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients

Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients

Nowotarski, Scarboro, et al.·J Bone Joint Surg Am·2000·325 citations·Retrospective cohort

Background

From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. 59 (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This 2-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing.

Methods

54 multiply injured patients with a total of 59 fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis.

Results

The average Injury Severity Score for the 54 patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15).
Most patients (44) had additional orthopaedic injuries (average, 3; range, zero to 8), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common.
40 fractures were closed, and 19 fractures were open.
According to the system of Gustilo and Anderson, 3 of the open fractures were type II, 8 were type IIIA, and 8 were type IIIC.
Intramedullary nailing was delayed secondary to medical instability in 46 patients and secondary to vascular injury in 8.
All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first 24 hours after the injury; the average duration of the procedure was 30 minutes.
The duration of external fixation averaged 7 days (range, one to 49 days) before the fixation with the static interlocked intramedullary nail.
49 of the nailing procedures were antegrade, and 10 were retrograde.
For 55 of the 59 fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure.
The other 4 fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of 10 days (range, 8 to 15 days) after fixator removal and before intramedullary nailing.
Follow-up averaged 12 months (range, 6 to 87 months).
Of the 58 fractures available for follow-up until union, 56 (97 percent) healed within 6 months.
There were 3 major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing.
The infection rate was 1.7 percent.
4 other patients required a minor reoperation: 2 were managed with manipulation under anesthesia because of knee stiffness, and 2 underwent derotation and relocking of the nail because of rotational malalignment.
The rate of unplanned reoperations was 11 percent.
The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees).

Conclusions

We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.

Core

Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients

Nowotarski, Scarboro, et al.J Bone Joint Surg Am2000325 citationsRetrospective cohort