Advertisement

Small residual fracture gaps delay time to union in length stable femur fractures treated with intrameduallary fixation

Published:November 11, 2022DOI:https://doi.org/10.1016/j.injury.2022.11.006

      Abstract

      Objectives

      The purpose of this study was to investigate whether residual fracture gapping and translation at time of intramedullary nail (IMN) fixation for diaphyseal femur fractures were associated with delayed healing or nonunion.

      Design

      Retrospective cohort study

      Setting

      Level 1 trauma hospital, quaternary referral center

      Patients/Participants/Intervention

      Length stable Winquist type 1 and 2 diaphyseal femur fractures treated with IMN at a single Level I trauma center were retrospectively reviewed.

      Main Outcome Measure

      The largest fracture gap and translation were evaluated on immediate anteroposterior (AP) and lateral postoperative radiographs. Radiographic healing was assessed using Radiographic Union Score in Femur (RUSF) scores at each follow-up. Radiographic union was defined as a RUSF score ≥8 and consolidation of at least 3 cortices. ANOVA and student's t-tests were used to evaluate the influence of fracture gap parameters on time to union (TTU) and nonunion rate. Patients were stratified to measured average gap and translation distances <1mm, 1-3mm and >3mm for portions of the analysis.

      Results

      Sixty-six patients who underwent IMN with adequate follow-up were identified. A total of 93.9% of patients achieved union at an average of 2.8 months. Fractures with average AP/lateral gaps of <1mm, 1-2.9 mm, and >3mm had an average TTU of 70.1, 91.7, and 111.9 days respectively; fractures with larger residual gap sizes had a significantly longer TTU (p=0.009). Fractures with an average gap of 1-2.9mm and >3 mm had a significantly higher nonunion rate (1.5% and 4.5% respectively) compared to 0% nonunion in the <1 mm group (p=0.003).

      Conclusion

      Residual gapping following intramedullary fixation of length stable diaphyseal femur fractures is associated with a significant increase in likelihood of nonunion.

      Summary

      Residual displacement of length stable femoral shaft fractures following intramedullary nailing can have a significantly negative impact on fracture healing. An average 3 mm AP/lateral residual fracture gap or a total of 6 mm of the AP + lateral fracture gap appeared to be a critical gap size with increased rates of nonunion and time to union. Therefore, we suggest minimizing the sum of the residual AP and lateral fracture gap to less than a total of 6 mm.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Denisiuk M
        • Afsari A.
        Femoral shaft fractures.
        StatPearls Publishing, Treasure Island (FL)2022 (StatPearls [Internet]2022 Jan)
        • Harvin JA
        • Harvin WH
        • Camp E
        • Caga-Anan Z
        • Burgess AR
        • Wade CE
        • et al.
        Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures.
        J Trauma Acute Care Surg. 2012; 73 (discussion 1448-9.3): 1442-1448
      1. Canadian Orthopaedic Trauma Society. Nonunion following intramedullary nailing of the femur with and without reaming, results of a multicenter randomized clinical trial. J Bone Joint Surg Am 2003;85(11):2093–2096.

        • Lerner RK
        • Esterhai Jr., JL
        • Polomano RC
        • Cheatle MD
        • Heppenstall RB.
        Quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower-extremity amputation.
        Clin Orthop Relat Res. 1993; : 28-36
        • Shroeder JE
        • Mosheiff R
        • Khoury A
        • Liebergall M
        • Weil YA.
        The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions.
        J Orthop Trauma. 2009; 23: 653-657
        • Basumallick MN
        • Bandopadhyay A.
        Effect of dynamization in open interlocking nailing of femoral fractures. A prospective randomized comparative study of 50 cases with a 2-year follow-up.
        Acta Orthop Belg. 2002; 68: 42-48
        • Karadimas EJ
        • Papadimitriou G
        • Theodoratos G
        • Papanikolaou A
        • Maris J.
        The effectiveness of the antegrade reamed technique: the experience and complications from 415 traumatic femoral shaft fractures.
        Strategies Trauma Limb Reconstr. 2009; 4: 113-121https://doi.org/10.1007/s11751-009-0071-2
      2. Epub 2009 Nov 21.
        • Pihlajamäki HK
        • Salminen ST
        • Böstman OM
        The treatment of nonunions following intramedullary nailing of femoral shaft fractures.
        J Orthop Trauma. 2002; 16: 394-402
        • Winquist RA
        • Hansen ST
        Segmental fractures of the femur treated by closed intramedullary nailing.
        J Bone Joint Surg Am. 1978; 60: 934-939
        • Ricci WM
        • Gallagher B
        • Haidukewych GJ.
        Intramedullary nailing of femoral shaft fractures: current concepts.
        J Am Acad Orthop Surg. 2009; 17: 296-305
        • Taitsman LA
        • Lynch JR
        • Agel J
        • Barei DP
        • Nork SE.
        Risk factors for femoral nonunion after femoral shaft fracture.
        J Trauma. 2009; 67: 1389-1392
        • Lin SJ
        • Chen CL
        • Peng KT
        • Hsu WH.
        Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail.
        Injury. 2014; 45: 752-756
        • Claes L
        • Eckert-Hübner K
        • Augat P.
        The effect of mechanical stability on local vascularization and tissue differentiation in callus healing.
        J Orthop Res. 2002; 20: 1099-1105
        • Lim HS
        • Kim CK
        • Park YS
        • Moon YW
        • Lim SJ
        • Kim SM.
        Factors associated with increased healing time in complete femoral fractures after long-term bisphosphonate therapy.
        J Bone Joint Surg Am. 2016; 98: 1978-1987
        • Whelan DB
        • Bhandari M
        • Stephen D
        • Kreder H
        • McKee MD
        • Zdero R
        • et al.
        Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation.
        J Trauma. 2010; 68: 629-632
        • Kanakaris N.
        • Giannoudis P.
        The health economics of long-bone non-unions.
        Injury. 2007; 38: S77-S84
        • Zeckey C
        • Mommsen P
        • Andruszkow H
        • Macke C
        • Frink M
        • Stübig T
        • Hüfner T
        • Krettek C
        • Hildebrand F.
        The aseptic femoral and tibial shaft non-union in healthy patients - an analysis of the health-related quality of life and the socioeconomic outcome.
        Open Orthop J. 2011; 5: 193-197