A prospective study of 100 patients with fracture of shaft femur managed with intramedullary nailing at a level 1 trauma centre in a developing country set up was done. Patients had either Kuntscher nail or interlocking nail depending on financial status of the patient. Most of the patients were in the second and third decade and 87% of the patients were males. Road traffic accident was the etiology in all patients. The results were good in 73% and fair in 25% of patients. Intramedullary nailing with Kuntscher nail or interlocking nail is an excellent method of fixation of fracture of shaft of femur in a developing country set up.

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Management Of Fracture Of Shaft Of Femur By Intramedullary Nailing In A Developing Country: A Clinical Study

Complex acute fractures of the femoral diaphysis such as severely comminuted and segmental fractures are the results of massive traumatic insults and together with old fractures presented with nonunion or implant failure from previous internal fixation are difficult to treat. Various problems arise in the management of these fractures and in the patient's final functional outcome. A prospective study of 30 patients with such complex femoral fractures was conducted at Basrah General Hospital from January 2007 to June 2008. The technique of open reduction and simultaneous combined internal fixation by intramedullary Kuntscher’s nail and derotation plate was performed. The nail was left in situ, and was augmented with a short AO plate and screws applied to lateral or anterior surface of the femur. Cancellous bone graft was harvested from ipsilateral or contralateral proximal tibia and was added to fracture site in every case. There were 28 males and 2 females. Their age ranged from 17 to 37 years. The majority of the fractures were closed occurring in 23 patients (77%). There were 18 acute fractures (60%), 6 (20%) nonunited, and 6 (20%) with metal failure complicating previous internal fixation by conventional plates and screws. Fresh comminuted fractures were the most frequently reported fractures in this study, they occurred in 18 patients (60%), followed by oblique fractures in 9 patients (30%), and transverse fractures in the remaining 3 patients (10%).The oblique and transverse fractures belong to the group of 12 patients with old fractures more than 6 months since injury (6 patients with non-united fractures, and 6 patients with implant failure both complicating previous surgical fixation by long conventional plate and screws with or without cancellous bone grafting). For acute fractures, surgery was performed 2 to 10 days from the time of injury. Clinical and radiological signs of union were achieved in 27 patients (90%). The average time for solid callus to become evident on radiographic examination was 6 months. Deep seated infection which failed to respond to local wound care and parenteral antibiotic administration had developed in one patient whose initial injury was compound fracture from bullet injury. Revision surgery with removal of the whole implant and exchanging to external fixation was required in that patient. Loosening of the most proximal screw from the plate without affecting the mechanical stability of the combined implant construct had occurred after the 20th week following surgery in 5 patients (16.3%), and was the result of excess stress on that screw following full weight bearing after achieving clinical and radiographic evidences of fracture union. Proximal migration of the Kuntschers nail developed in 4 patients (13.3%) and was also the result of full weight bearing following fracture union. This migration was well tolerated by patients and was treated by nail removal leaving plate in situ. Significant limb shortening of about 3 cm had developed in one patient who presented initially with severe comminution and bone loss from bullet injury. Limitation of knee joint movements prior to surgery was present in 12 patients from the group of old fractures. True postoperative knee stiffness following combined fixation had developed in only three patients (10%). Composite implant construct using combined nailing and augmentation plate appears to give an acceptable outcome, in terms of union and function in treating complex femoral shaft fractures. It gives more rigid and stable fixation than conventional plate and screws alone or nail alone with relatively few complications. Iintramedullary nail and augmentation plate for femoral diaphyseal fractures Mohmmed R Abade & Ouday F Al-Ali Bas J Surg, 16, March, 2010 ٦١ Introduction emoral shaft fractures are among the most common fractures in orthopedic practice. These fractures are usually caused by high energy trauma like road traffic accidents and missile injuries. Stress fractures and pathological fractures due to osteoporosis and metastatic tumors can also develop. The femur has abundant blood supply both endosteal and periosteal. A nutrient artery usually enters along the linea aspera posteriorly and proximally on the femur and supplies the endosteal circulation which is responsible for supplying the inner three fourths of the cortex. The periosteal circulation serves only the remaining outer fourth of the cortex. However, the periosteal circulation is critical to fracture healing in the diaphysis.When a fracture is displaced, the medullary vessels are disrupted and the periosteal vessels predominate as the vascular supply to the fracture site during early healing. The significance of periosteal blood flow in healing also emphasizes the importance during surgery of avoiding extensive periosteal stripping especially along linea aspera. Currently femoral shaft fractures in adults are best treated by surgery because of the high rates of union, low rates of complications, and the advantage of early fracture stabilization which decreases the morbidity and mortality rates in the injured patients. Different types and modalities of surgical fixations are used such as interlocking nails, conventional long plates and screws, and external fixation. Currently, antegrade reamed interlocked intramedullary nailing with entrance through the piriformis fossa is the golden standard treatment for diaphyseal femur fractures.Because of increased complication rate with the use of conventional compression plate and screws compared with intramedullary nailing, plate fixation of acute femoral shaft fractures is reversed to cases with distal metaphyseal-diaphyseal junction fractures, ipsilateral femoral neck and shaft fractures, small intramedullary canal, associated major vascular injury, and peri-prosthetic fractures about intramedullary implants. External fixation is reserved mainly for patients with compound fractures (Gustillo IIIB or IIIC), and when time is of essence necessitating short time of operation such as in medically unstable patient, polytrauma patient, and in mass casualty situations. With complex acute fractures of the femoral diaphysis such as severely comminuted and segmental fractures significant injury to the bone and surrounding soft tissues occur imposing more difficulties in selecting the best surgical procedure and in the rate of possible postoperative complications. Similar difficulties are faced with in the management of previously operated upon and internally fixed fractures complicated by implant failure and/or nonunion. This prospective study was conducted to evaluate the union rates, complications, and the functional results of treating such complex fractures by open reduction and combined internal fixation using retrograde intramedullary Kuntscher’s nail augmented by short derotation plate applied to the surface of femoral diaphysis. Patients and Methods Thirty adult patients with complex femoral shaft fractures were included in a prospective study conducted at Basrah General Hospital between January 2007 and June 2008. There were 28 males and only 2 females. Age ranged from 17 to 37 years (the working age). Involvement of left femur was the predominant and was reported in 22 patients, right thigh involvement in 8 patients. There were 23 closed fractures and 7 open fractures (Gustillo A and B). The cause of the F Iintramedullary nail and augmentation plate for femoral diaphyseal fractures Mohmmed R Abade & Ouday F Al-Ali Bas J Surg, 16, March, 2010 ٦٢ fracture was road traffic accidents in the majority, 22 patients, bullet injuries in 7, and fall on the ground in one patient. Other associated injuries (skeletal and non skeletal) occurred in 10 patients, with head injuries being the most frequent associated injury reported in 7 patients. Sciatic nerve palsy from bullet injuries was reported in 2 patients. There were 18 acute fractures .The remaining 12 were old complicated fractures from previous open reduction and internal fixation using conventional AO plate and screws alone with or without cancellous bone grafting: 6 were nonunited fractures, and 6 with metal failure (plate loosening, breakage, or bending). For acute fractures, surgery was performed on 2 to 10 day since the injury. Under general anesthesia using ordinary operating table, the patient is operated upon in lateral decubetus position with the fractured limb up. Prophylactic antibiotics, intravenous Cefotaxime 1gram, was used in every patient The first dose was initiated at time of induction of anesthesia and was continued 8 hourly for a total of 5 days. The fracture site is exposed using the posterolateral approach to femur. Reflection of the vastus lateralis muscle (with as minimal as possible soft tissue dissection) is done. Very minimal stripping of periosteum on both sides of the fracture is done. No stripping is performed at region of linea aspera.Very minimal reaming of the medullary canal (to just 1mm larger than the diameter of the isthmus of the involved femur) is done using manual reamers. An ordinary Kuntscher’s nail is then inserted in a retrograde manner reducing the major fragments of the fracture and restoring the length and alignment of the injured limb. The knee joint is then examined in every patient to be sure that the nail does not penetrate and thus damages the knee. Depending on the geometry of the fracture, an AO metal plate (6-10 holes) is finally applied and fixed to the lateral or anterior surface of the femur. Cancellous bone graft from ipsilateral or contralateral tibia was used in all patients. Redivac drain was used in every patient and was removed after 48 hours. Average time required to complete surgery was 90-120 minutes. Above knee plaster of Paris back slab was applied in every patient for pain relief and to aid soft tissue healing. Postoperative hospital stay was 5-7 days in most cases. On removal of back slab in the seventh postoper

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Combined use of intramedullary nail and augmentation plate for treatment of complex femoral diaphyseal fractures.60

A prospective and comparative study of 44 cases of close locked static intramedullary (IM) nailing of Femur shaft fracture with two nailing systems was done. Comparing the cheap predrilled Kuntscher nail with standard but expensive Variwall nail of Biomet Company England, we found almost equal result in both groups regarding complications and healing of the fracture. Average healing time in Variwall and Kuntscher nailing were 16.4 and 16.1 weeks respectively, P value being in-significant. In Variwall nailing, stable fractures healed at the average of 13.5 weeks and unstable fractures at 17.2 weeks; open fractures at 18.4 weeks and close ones at 14.2 weeks; fractures due to Road Traffic Accident (RTA) at 16.3 weeks, gunshot injury at 18.6 weeks and fractures due to fall at 14 weeks. Similarly in Kuntscher nailing these figures were 14 and 16.7 weeks; 19.6 and 14.5 weeks; 16.6, 22 and 13 weeks respectively. Pre-drilled Kuntscher nail with good quality cortical screws for interlocking is recommended for any variety of femoral shaft fracture. It is cost effective, at the same time gives acceptable result as compared to standard interlocking intramedullary nail.

Amar Prasad Dhakal

Papers

Management of femur shaft fracture with close locked intramedullary nailing: comparison of Variwall and predrilled Kuntscher nail.