Interlocked intramedullary nailing for treatment of open femoral shaft fractures

Twenty-eight patients with open femoral shaft fractures treated by reamed intramedullary nailing were reviewed retrospectively. Nine patients had Gustilo Grade I injuries; 14, Grade II; and five, Grade IIIA. Twenty cases had static locking, two cases had dynamic locking, and six cases were not locked. Average time to union was 20 weeks. The infection and nonunion rates were 0%. The data suggest that interlocked reamed intramedullary nailing is a safe treatment option for treating open femoral shaft fractures.     

Conservative treatment of femoral shaft fractures in patients with total hip arthroplasty

The proposed two-factor structure of the Psychopathy Checklist (Revised) was assessed by confirmatory factor analyses on a sample of 376 community and prison based methadones maintenance patients. Confirmatory factor analyses indicated that the two-factor model proposed by previous researchers did not fit well with the data from this population. Exploratory analyses extracted five interpretable factors, three psychological factors (glibness/manipulative, callousness, irresponsibility), and two behavioral factors (criminal behaviors, promiscuity), which accounted for 61% of the variance. The data provided support for the psychometric reliability of the PCL-R, as indicated by a Chronbach's alpha of 0.83, weighted kappas for concordance between raters ranging from 0.51 to 1.00, and 100% agreement on diagnoses of psychopathy between raters. The data indicate that a two-factor structure does not adequately capture the dimensions of psychopathy in this population. While the factors do fall into distinct psychological and behavioral dimensions, more than two general factors are required to describe the dimensions of psychopathy.     

Outcome of femoral shaft fractures in the elderly

Published literature on fractures of the femoral shaft has reported results of treatment stratified by fracture type or treatment type. The current study analyzes the outcome of fractures of the femoral shaft in elderly patients. One hundred thirty-eight patients older than the age of 65 years sustained femoral shaft fractures. Ten percent of the patients had associated injuries. The majority of the patients had significant prefracture medical problems. Nonsurgical treatment was used in 29 cases. Surgical treatment in 109 patients consisted of cerclage wires in 13 cases, plates and screws in 58 cases, intramedullary nails in 26 cases, and long stem prostheses in 12 cases. Complications of treatment occurred in 46% of patients. The type of treatment did not influence the frequency of complications. Twenty percent of patients died within 6 months of the fracture. There was a significant difference in the age of the patients who survived compared with those who did not survive. The mental status of the patient was also a major determinant of survival. Alert and oriented patients had a much better chance of survival. The outcome of fractures of the femoral shafts cited in the literature is different from the results seen in this population of elderly patients. The observed complication rate of 46% and mortality rate of 20% in this series is similar to those reported for intertrochanteric fractures and femoral neck fractures. Age and mental status are important determinants in the survival of the patient regardless of the treatment administered.     

Home traction of femoral shaft fractures in younger children

Radiation doses of occupational personnel exposed from diagnostic x rays, therapeutic installations, and patients were measured using thermoluminescent dosimeters. The monthly occupational doses from diagnostic x ray ranged from 0.1076 mSv to 0.5774 mSv, and those from therapeutic treatment ranged from 0.365 mSv to 0.657 mSv, which is within the dose limit recommended by ICRP 60. The patient organ doses were evaluated and found to range from 0.0615 mSv s(-1) to 2.8823 mSv s(-1) for gonad, 0.3676 mSv s(-1) to 2.1088 mSv s(-1) for thyroid, and 0.00972 mSv s(-1) to 4.01 mSv s(-1) for eyes.     

Economic evaluation of 2 treatments for pediatric femoral shaft fractures

The purpose of this study was to assess the relative health system costs of early hip spica cast immobilization and external fixation for pediatric femoral shaft fractures. A cost analysis was performed from the viewpoint of the study hospital and physicians using protocols based on current practice. Cost estimates were based on patient and financial information from April 1, 1993, to January 31, 1994, including the fully allocated inpatient and outpatient costs. A sensitivity analysis was conducted to analyze the effect of complications on costs. Total estimated costs (in 1994 Canadian dollars, $1.00 = $0.75 US) of uncomplicated external fixation and hip spica treatments were $7626.30 and $5970.11, respectively. Fifty percent of this difference was attributable to longer inpatient stays for the external fixation treatment. The remaining difference was because of the cost of the fixator, additional operating room staff time costs, and additional professional and technical fees. Total expected costs of treatment complicated by loss of reduction, pin tract infection, and return to the operating room were $7716.01 and $6128.44 for the external fixation and hip spica treatment options, respectively. For the range of complication probabilities considered, expected total costs were always greater with the external fixation option than with the hip spica treatment.     

Ender nailing for ipsilateral femoral shaft fractures after Austin-Moore hemiarthroplasty

Some dentists have voluntarily chosen to leave the dental profession despite the considerable time, effort, and financial expenditures involved in their educations. The purpose of this study was to survey the entire population of dentists who had identified themselves as being principally employed in a career outside of clinical practice in the American Dental Association's 1991 Census. A four-page survey was mailed to 654 former dentists, with a total of 237 usable responses (36%). Analysis of major demographic variables showed no significant difference between the survey respondents and the 1992 ADA Survey of Dentists. Major reasons cited by respondents for entering dentistry included professional, financial, and independence factors. Respondents as a group rated their dental school experience as average in degree of difficulty. Clinical dental experience was varied, with a substantially smaller percentage (37%) choosing solo clinical positions than the 1992 ADA Survey of Dentists reported (69%). Reasons for leaving practice included financial, stress, and external regulation concerns. Current careers varied widely, with business, teaching, medicine, and investing being the most common. Respondents ranked their current careers as considerably more favorable on measures of perceived creativity, freedom, belonging, and whether they would choose the same career again. These findings indicate that there was a difference between the perception of a dental career and the reality of clinical practice for the study sample.     

Valgus deformity of the femoral neck after nailing of infantile femoral shaft fractures (author's transl)

In 6 patients out of 29 who had suffered fractures of the femoral shaft at childs age and were treated mainly by open nailing, considerable growth disturbances of the major trochanter and valgus deformities of the neck of the femur had been observed in check-ups. The origin and prevention of these complications in nailing and nailremoval are discussed.     

The evolution of femoral shaft plating technique

There has been an evolution in the AO/Association for the Study of Internal Fixation plating technique during the past 3 decades that includes the use of longer plates and fewer plate screws, fewer lag screws outside the plate, fewer unicortical screws at the plate periphery, and greater use of the 95 degrees blade plate to achieve balanced fixation of proximal and distal shaft fractures. These changes reflect an evolving technique of plate osteosynthesis that emphasizes indirect reduction techniques, biologic internal fixation, and improved biomechanics. Outcome data suggest that there has been an improvement with time that is reflected by shorter time to union, a decrease in the frequency of implant failures, delayed unions, nonunions, malunions, number of reoperations, and in overall rate of failure. The best predictor of success was the length of plate by logistic regression analysis. With the evolution of plating techniques and a greater emphasis on biology of fracture healing, the incidence of complications and failures has decreased after femoral shaft plating. Plate osteosynthesis of the femoral shaft is particularly advantageous in many situations and can be quite successful (87% success rate in Group III).     

Gait study in evaluation of results in intramedullary nailing for femoral shaft fractures

The present preliminary investigation conducted on six adult males whose femur shaft fractures had been fixed internally by means of Hansen-Street intermedullary nails indicated that our gait study technic helps confirm the clinical findings in such cases. Five patients, although their fractures had united and they had resumed their usual activities, were not deemed quite normal as yet and the causes for their gait abnormality were identified in the clinical examination. The gait study technic thus provided fairly accurate quantitative support of the clinical findings.     

Minimally invasive method for treatment of supra-diacondylar femoral fractures

The "gold standard" treatment modality for extra-articular and combined intra-, extra-articular fracture of the distal femur is the condylar blade plate (CP). Large exposure of the distal femur with unavoidable iatrogenic trauma to the soft tissue surrounding the fracture site and perhaps the lack of stiffness of the eccentric lateral cortical location of the CP has been suggested to play a role in the high rate of infections and pseudarthrosis reported in the literature. In an effort to overcome some of the difficulties with the condylar blade plate and to reduce complications, an unreamed, titanium, solid nail, locked proximally with two locking screws and distally with a screw and twisted blade was developed (DFN). The nail was designed for minimal invasive reduction through a small median parapatellar arthrotomy of the articular fracture (percutaneous screw) and of the supracondylar fracture. The DFN is a modular system sharing many components and almost all instrumentation with the AO-UFN and it is expected that the nail is much better in axial stiffness and strength than the condylar blade plate. The treatment of supracondylar femoral fractures should be improved by providing early weight bearing and accelerated fracture healing with a reduced incidence of delayed unions and infections.     

Closed humeral shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE: We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures. DESIGN: A prospective, randomized clinical study was performed with detailed comparison parameters. MATERIALS AND METHODS: Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months). MEASUREMENTS AND MAIN RESULTS: In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's exact test were used to evaluate the statistical significance. CONCLUSION: In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.     

Distal femoral fractures

Techniques of operative treatment of supra- and intercondylar fractures have changed in recent years. These changes refer to reduction techniques and implant selection. Operative approach concepts, which remained unchanged for several decades were critically evaluated and modified to a minimal invasive osteosynthesis [MIO]. This included for intraarticular fractures a trans-articular joint reconstruction and a retrograde plate osteosynthesis (TARPO). This technique result in better operative visualization and management of intraarticular comminution, saver fracture healing and better functional outcome. For extraarticular fractures a minimally invasive percutaneous plate osteosynthesis (MIPPO) via stab incisions only or retrograde intramedullary nailing is available. Beside that new strategies and techniques for the avoidance of axial malalignment, rotational deformities and leg length discrepancies are described, as well as a new plate generation (LISS: less invasive stabilization system), which behaves more like an internal fixator. The complex nature of combined fractures and soft tissue injuries of the distal femur and proximal tibia needs special attention and specific management. Distal femoral and proximal tibial fractures in young patients are usually caused by a high energy trauma. They are complicated by a high rate of systemic and local injuries to cartilage, ligaments and skin. The patients in this group with severe injuries need a detailed treatment algorithm, because the surgeon's individual skill, enthusiasm and wishful thinking frequently led to unsatisfactory results. A decision making scheme is presented specifically addressing timing and treatment modalities.     

Interprosthetic fracture of the femoral shaft

Acute occlusion of the left main coronary artery is usually responsible for cardiogenic shock, severe arrhythmias or sudden death. Despite the widespread use of emergency coronary angiography in acute myocardial infarction, occlusion of the left main coronary artery is rarely observed and its treatment remains controversial. The authors report the case of a young man with a previous history of radiotherapy for Hodgkin's disease, admitted for acute myocardial infarction due to complete thrombosis of the left main coronary artery treated as an emergency by percutaneous transluminal angioplasty and implantation of a Palmaz Schatz stent. There were no complications of the procedure and the patient was asymptomatic one year later.     

The conservative and surgical therapy of traumatic humeral shaft fractures

Sixty-three patients with humeral shaft fractures were evaluated clinically and radiographically 18 months after injury; 27 patients were treated surgically (group A) and 36 patients conservatively (group B). Analysis of the results according to a score by Kwasny revealed 6.2 points in group A and 2.2 points in group B (P < 0.0001; F = 46.9). The results of these two comparable groups suggest that conservative treatment of humeral shaft fractures is superior regarding mobility of the shoulder and elbow, strength, the incidence of neurological complications, pain, subjective rating and cosmesis. There were no differences on roentgenograms between the two groups (P = 0.48).     

406 femoral fractures in children

406 fractures of the femur in persons younger than 17 years of age were treated at Haukeland University Hospital, Bergen, from January 1980 to December 1993. The incidence was 35/100,000 per year; 57/100,000 for boys, and 24/100,000 for girls. No significant changes in the incidence occurred during the study period. 70% of the fractures occurred in boys. 78% had an isolated fracture, while 7% had other fractures, 7% head injuries and 8% injuries of multiple organs as well. Traffic accidents accounted for 35% of the fractures. 65% of the femur fractures were treated by skeletal traction (mean hospitalisation 30 days), 21% were operated on initially (hospitalisation 12 days), and 14% were given early spica cast (hospitalisation three days). The results of the treatment were generally satisfactory. Neither anisomelia (8.5% more than 10 mm) nor malrotation (12% more than 10 degrees) of the femur was a serious problem, but the length of time the patients were hospitalized was rather long.