Outcome Of Open Interlocking Nailing In Closed Fracture Shaft Of Femur.

BACKGROUND: Various treatment modalities have been used in treating femoral shaft fractures, i.e., open intramedullary nailing, plating and external fixators but these does not always produce stable fixation and there is increased risk of infection, closed locked intramedullary nailing technique has being the gold standard and is a routine procedure but it requires proper orthopedic operation table with traction apparatus and the use of image intensifier. The use of open interlocking nailing technique doesn't require any special orthopaedic table nor it requires use of Image intensifier. The objective of this study is to find out and determine the frequency of fracture union and wound infection in open reamed interlocking nailing of close fractures of shaft of femur. METHODS: This study included fifty-eight patients from either gender, above 14 years of age with closed femoral shaft fracture presenting within 2 weeks. Data was collected on Performa about gender, age, address, date of fracture, date of operation and discharge, type of fracture and follow-up visits. RESULTS: Mean age of the patients were 31.24±8.662. According to Winquist & Hansen, femur shaft fractures were divided into four types. Type I were found in the 16(27.6%), Type II in 21 (36.2%), Type III in 12 (20.7%) and Type IV in 9 (15.5%). Total number of fracture union with regard to Winquist & Hensen Classification of fracture shaft femur were, Type I, 14 (24.1%), Type II, 21 (36.2%), Type III, 12 (20.7%), Type IV, 8 (13.8%) respectively while the rest 3 (5.2%) were found in non-union. Total number of fracture union with regard to gender of the patients were, 41 (70.7%) males and 14 (24.1%) were females while the rest 3 (5.2%) patients fracture union has not occurred. Fracture union was found in 55 (94.8%) out of 58 patients; while fracture union had not occurred in 3 (5.2%) out of 58 patients. The total number of patients who developed wound infection following surgery were 5 (8.6%) out of 58 patients; while the non-infected patients were 53 (91.4%) out of 58 patients. CONCLUSIONS: The open interlocking nailing technique for close fractures shaft of femur without the use of image intensifier achieved excellent results in terms of fracture union. Results obtained are mostly similar to the results of close interlocking nailing and it also requires less expertise, recourses and without the use of image intensifier.

[CLINICAL FEATURES AND SURGICAL EFFECTIVENESS OF ANKLE FRACTURES INVOLVING Tillaux-Chaput IN ADULTS].

OBJECTIVE: To investigate the clinical features of ankle fractures involving Tillaux-Chaput in adults, and to observe the surgical effectiveness. METHODS: Between May 2009 and May 2013, 15 adult patients with ankle fractures involving Tillaux-Chaput were treated by open reduction and internal fixation. There were 12 males and 3 females, with an average age of 32 years (range, 19-45 years). The causes included sport injury (8 cases), traffic accident injury (5 cases), and falling injury from height (2 cases). The left ankle was involved in 5 cases and the right side in 10 cases. There were 2 open fractures (Gustilo type I) and 13 close fractures. Five patients had single Tillaux-Chaput fractures. The mean time between injury and surgery was 8.5 days (range, 3 hours to 15 days). According to the Lauge-Hansen classification, there were 9 cases of supination-external rotation, 5 cases of pronation-external rotation, and 1 case of pronation-abduction. RESULTS: Primary healing of incisions was obtained in 13 patients without infection and neurovascular injury; 2 patients had superficial infection which was cured after oral antibiotics and dressing change. All cases were followed up for 23 months on average (range, 13-36 months). X-ray films showed complete fracture healing at 10-16 weeks postoperatively (mean, 13 weeks) in all cases. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 87 (range, 78-99), with an excellent and good rate of 80% (excellent in 9 cases, good in 3 cases, and fair in 3 cases). CONCLUSION: Open reduction and internal fixation for ankle fractures involving Tillaux-Chaput in adults can achieve excellent effectiveness.

Treatment With the SIGN Nail in Closed Diaphyseal Femur Fractures Results in Acceptable Radiographic Alignment.

BACKGROUND: The burden of orthopaedic trauma in the developing world is substantial and disproportionate. SIGN Fracture Care International is a nonprofit organization that has developed and made available to surgeons in resource-limited settings an intramedullary interlocking nail for use in the treatment of femoral and tibial fractures. Instrumentation also is donated with the nail. A prospectively populated database collects information on all procedures performed using this nail. Given the challenging settings and numerous surgeons with varied experience, it is important to document adequate alignment and union using the device. QUESTIONS/PURPOSES: The primary aim of this research was to assess the adequacy of operative reduction of closed diaphyseal femur fractures using the SIGN interlocking intramedullary nail based on radiographic images available in the SIGN database. The secondary aims were to assess correlations between postoperative alignment and several associated variables, including fracture location in the diaphysis, degree of fracture site comminution, and time to surgery. The tertiary aim was to assess the functionality of the SIGN database for radiographic analyses. METHODS: A review of the prospectively populated SIGN database was performed for patients with a diaphyseal femur fracture treated with the SIGN nail, which at the time of the study totaled 32,362 patients. After study size calculations, a random number generator was used to select 500 femur fractures for analysis. Exclusion criteria included open fractures and those without radiographs during the early postoperative period. The following information was recorded: location of the fracture in the diaphysis; fracture classification (AO/Orthopaedic Trauma Association [OTA] classification); degree of comminution (Winquist and Hansen classification); time from injury to surgery; and patient demographics. Measurements of alignment were obtained from the AP and lateral radiographs with malalignment defined as deformity in either the sagittal or coronal plane greater than 5°. Measurements were made manually by the four study authors using on-screen protractor software and interobserver reliability was assessed. RESULTS: The frequency of malalignment greater than 5° observed on postoperative radiographs was 51 of 501 (10%; 95% CI, 6.5-11.5), and malalignment greater than 10° occurred in eight of 501 (1.6%) of the femurs treated with this nail. Fracture location in the proximal or distal diaphysis was strongly correlated with risk of malalignment, with an odds ratio (OR) of 3.7 (95% CI, 1.5-9.3) for distal versus middle diaphyseal fractures and an OR of 4.7 (95% CI, 1.9-11.5) for proximal versus middle fractures (p < 0.001). Time from injury to surgery greater than 4 weeks also was strongly correlated with risk of malalignment (p < 0.001). Inherent fracture stability, based on fracture site comminution as per the Winquist and Hansen classification (Class 0-1 stable versus 2-4 unstable) showed an OR of 2.3 (95% CI, 1.2-4.3) for malalignment in unstable fractures. Interobserver reliability showed agreement of 88% (95% CI, 83-93) and mean kappa of 0.81 (95% CI, 0.65-0.87). The SIGN database of radiographic images was found to be an excellent source for research purposes with 92% of reviewed radiographs of acceptable quality. CONCLUSIONS: The frequency of malalignment in closed diaphyseal femoral fractures treated with the SIGN nail closely approximated the incidence reported in the literature for North American trauma centers. Increased time from injury to surgery was correlated with increased frequency of malalignment; as humanitarian distribution of the SIGN nail increases, local barriers to timely care should be assessed and improved as possible. Prospective clinical study with followup, despite its inherent challenges in the developing world, would be of great benefit in the future. LEVEL OF EVIDENCE: Level III, therapeutic study.

[Effectiveness of open reduction and internal fixation for Bosworth fracture].

OBJECTIVE: To explore the operative methods and effectiveness of open reduction and internal fixation for Bosworth fracture. METHODS: Between January 2005 and January 2012, 6 patients with Bosworth fractures caused by sprain were treated. There were 4 males and 2 females with an average age of 45.8 years (range, 24-73 years). The time from injury to operation was 1-5 days (mean, 1.8 days). They were all closed fractures. According to Lauge-Hansen classification, 6 cases were classified as supination-external rotation type. The surgical treatments included open reduction and internal fixation by plate and screws. RESULTS: Infection occurred in 1 case and was cured after dressing changing; primary healing of incision was obtained in the other 5 cases. Six patients were followed up 15 months on average (range, 12-24 months). The X-ray films showed fracture healing in all cases, with an average healing time of 9.5 weeks (range, 8-13 weeks). No loosening or breaking of internal fixator was observed during follow-up. The average full load-walking time was 12 weeks (range, 10-17 weeks). According to the ankle and hindfoot scale of American Orthopaedic Foot and Ankle Society (AOFAS), the average score was 89.5 (range, 81-94). CONCLUSION: For Bosworth fractures, good results can be achieved by early diagnosis, open reduction and internal fixation.

The role of dynamisation vis-à-vis non-dynamisation after closed interlocking nailing in cases of closed tibial shaft fractures in adults.

The importance of dynamisation after static locked nailing in comminuted closed tibial fractures is a matter of contention. A prospective study was undertaken among 178 patients in the department of orthopaedics at RG Kar Medical College, Kolkata from January 2002 to December 2006, to analyse the usefulness of this procedure with respect to the degree of comminution. In this study it was seen that dynamisation was found to be of statistical significance in relatively less comminuted fractures as per Winquist-Hansen's classification.

Locked intramedullary nailing for the treatment of femoral shaft fractures: experience and result in 19 cases.

BACKGROUND: Fractures in the proximal or distal third of the femoral shaft or those with severe comminution are known to be less suitable for intramedullary nailing with Kuntscher nail. With the introduction of interlocking intramedullary nailing the problems of rotational malalignment and shortening that accompany such fractures are now less common. At the National Orthopaedic Hospital Igbobi, Interlocking Intramedullary Nailing was introduced as a form of surgical treatment for fractures of the femur, our initial experience in this type of intramedullary nailing form the basis of this report. METHOD: This is a retrospective study of all cases of fractured femur that were treated with locked intramedullary nailing between March 2002 and September 2003. RESULTS: During a 19-month period, 19 patients with 19 fractures were treated for fracture of the femoral shaft with locked intramedullary nailing using the Russell-Taylor (18 fractures) and Grosse-Kempf (1 fracture) nails. Thirteen fractures (68.5%) had comminution of the Winquist-Hansen type III and IV 12 of which were statically locked. There were three intra-operative technical problems including the case of a subtrochanteric fracture, where the nail missed the medullary canal of the proximal segment. There were 2 cases of superficial wound infection, which responded to local wound care and antibiotics. Although limb length discrepancy and rotational mal-alignment were not assessed routinely during the follow-up of patients, no symptomatic malrotation was recorded. Sixteen out of the 19 patients were available for follow-up for an average period of 11 months. All these cases progressed to union, without the need for dynamization in statically locked fixations. CONCLUSION: In spite of the initial problems encountered with this relatively new procedure in our centre, we were able to achieve a reasonably good result in addition to supporting the notion that dynamization of a statically locked nail is not always necessary for healing of fractures.

The treatment of unstable ankle fractures in patients over eighty years of age.

BACKGROUND: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury. METHODS: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems. RESULTS: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each. CONCLUSIONS: These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.

Results of operative fixation of unstable ankle fractures in geriatric patients.

It is widely accepted that operative fixation of unstable ankle fractures yields predictably good outcomes in the general population. The current literature, however reports less acceptable results in the geriatric population age 65 years and older. The current study analyzes the outcome of the surgical treatment of unstable ankle fractures in patients at least 65 years old. Twenty three patient over 65 years old were surgically treated after sustaining 21 (91%) closed and 2 (9%) open grade II unstable ankle fractures. Fractures were classified according to the Danis-Weber and Lauge-Hansen schemes. Fracture type was predominantly Weber B (21/23, 91%), or supination external rotation stage IV (21/23, 91%). Fracture union rate was 100%. There were three significant complications including a lateral wound dehiscence with delayed fibular union in an open fracture dislocation, and two below knee amputations, neither of which was directly related to the fracture treatment. There were three minor complications; one superficial wound infection and two cases of prolonged incision drainage, all of which resolved without further surgical intervention. Complications were associated with open fractures and preexisting systemic disease. These results indicate that open reduction and internal fixation of unstable ankle fractures in geriatric patients is an efficacious treatment regime that with results that are comparable to the general population.

Clinical experience with reamed locked nails for close and open comminuted tibial diaphyseal fractures: a review of 50 consecutive cases.

We present the results of our experience in treating comminuted tibial shaft fractures with reamed interlocking intramedullary nail from September 1993 to December 1995. In this retrospective study, there were fifty patients with an average follow-up of 14.3 months (range six to twenty-eight months). Ninety-eight percent of the fractures were due to motor-vehicle accident with majority of the patients being motorcyclist (96%). Thirty-eight fractures were closed and twelve were open (Gustilo grade I--8; grade II--4); 44% of them had additional fractures or other injuries. According to Winquist-Hansen classification of diaphyseal fracture comminution, there were 24% type I; 18% type II; 26% type III and 32% type IV. The union rate was 98%. There were 6 infections, 2 superficial and 4 deep. All these infections arose from closed fractures, which was possibly due to the long operative time. No patients with open fractures, which underwent delayed nailing, had infection. One of the patient had severe deep infection which required early nail removal before union. Anterior knee pain following nailing occurred in 6% of the patients. The average hospital stay after operation was 3.4 days. Ninety-four percent of the patients had excellent to good functional outcome after nailing. The mean time to regain full range of movement of knee and ankle was 8.4 weeks. Patients were allowed full weight bearing in the average time of 10.7 weeks and the mean time to return to work was 24.7 weeks.

Ender nail in unstable closed tibial fractures.

BACKGROUND: This retrospective study aims to evaluate the effect of Ender nail in management of unstable closed tibial fractures. METHODS: From January 1985 to May 1992, 99 cases of unstable closed tibial shaft fractures (with fibular fractures) were collected for retrospective study. All the 99 tibiae were fixed with Ender nails. The mean follow up period was 80 (26-115 months). RESULTS: The clinical results were evaluated with special charts. The average blood loss was 126 ml. Operation time was 45 minutes. Hospital day was 10.2 days. Union time was 16.8 weeks for Winquist-Hansen (WH) type I-II fractures and 20.5 weeks for VVH type III-V fractures. Student t test revealed statistically significant differences between the clinical results of WH type I-II cases and those of WH type III-V cases. The postoperative complications included superficial infection in 1 case (1%), nail protrusion in 13 (13%), malunion in 10 (10%), aseptic nonunion in 2 (2%) and infected nonunion in 1 (1%) (overall 18% in the 99 cases). CONCLUSIONS: Ender nail is no doubt effective in treatment of less comminuted unstable tibial shaft fractures, but should be used carefully for more comminuted unstable tibial shaft fractures.