The role of fluoroscopy in avoiding rotational deformity of treated femoral shaft fractures: an anatomical and clinical study.

In the first part of the study we examined the accuracy of femoral anteversion (AV) determined by fluoroscopy, simulating a method used in closed intramedullary femoral nailing. Twenty cadaveric femora were used. The condyles and posterior trochanteric area were resting on a horizontal table. The proximal femur was imaged using a C-arm image intensifier with horizontal X-ray beam at an angle of 30, 45, or 60 degrees to the long axis of the femoral shaft. To evaluate the reliability of the measurements, the real AV angle was determined by radiography. A small difference (mean 2 degrees ) was found between the real AV angle and the angle between the horizontal plane and the central head-neck axis (NH angle) as displayed by the image intensifier. In a separate clinical study, the NH angle was assessed and used as a guide to intraoperative rotational reduction in ten patients with femoral shaft fracture using the aforementioned method. Follow-up examinations of the AV angle showed that rotational deformities of clinical significance were avoided.

11 femoral fractures with vascular injury: good outcome with early vascular repair and internal fixation.

We reviewed 11 consecutive cases with combined femoral fracture and vascular injury presenting with acute ischemia. 6 cases had ischemia exceeding 8 hours and 4 of them developed massive muscle necrosis in the lower leg. 5 cases with ischemia less than 8 hours had no muscle necrosis. Vascular repair preceded fracture stabilization in 5 cases; there were no vascular complications during the subsequent fracture stabilization. 6 fractures treated with internal fixation had uneventful fracture-healing, whereas the 4 which were treated with external fixation needed later reoperations to obtain fracture-healing. We conclude that the limb must be reperfused within 6-8 hours. Vascular repair should be the first procedure, and fracture fixation by internal fixation is then preferred.

Femoral shaft fractures treated by intramedullary nailing. A follow-up study focusing on problems related to the method.

One hundred and sixteen patients with 120 femoral fractures treated by reamed intramedullary nailing were reviewed. All fractures but one healed without additional procedures. One comminuted fracture had a bone transplant after 8 months to enhance bone remodelling in the lateral part of the fracture area. Three patients developed adult respiratory distress syndrome; all patients survived. Deep infection complicated one osteosynthesis. Thromboembolism was recorded in five cases. Twenty-three patients had a true torsional deformity (anteversion difference of 15 degrees or more), but only nine had complaints. Four of these patients needed a corrective osteotomy. Shortening of 10 mm or more was revealed in 11 patients; only one was above 20 mm. Prior to nail removal, hip and knee pain was present in 26 and 20 per cent, respectively. Few patients had such pain after nail removal. We conclude that reamed IM nailing of femoral fractures gives excellent fracture healing, rapid patient recovery and few complications. Some problems are, however, related to the method: torsional deformity occurs frequently, but will not always cause complaints. Shortening is a potential problem, but dramatic shortenings can be avoided when static locking is used. Hip and knee pain occurs frequently, but will usually disappear after nail removal.

Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anteversion angles in 110 patients.

The torsion of both femora was evaluated in 110 patients who had been treated by intramedullary nailing for unilateral femoral shaft fractures. The anteversion (AV) angle was measured by ultrasound, using a tilted-transducer technique. True torsional deformity, defined as an AV difference of 15 degrees or more between sides was found in 21 patients, but only eight had complaints related to the deformity. Three patients had reoperations for troublesome external torsional deformities. Of 26 patients with AV differences of 10 degrees to 14 degrees, defined as possible torsional deformity, three had complaints, but none had serious problems. AV differences of up to 29 degrees were observed in symptom-free patients, and no patients with AV differences below 10 degrees had complaints. Static and dynamic nailing showed almost equal tendencies to lead to torsional deformity. We conclude that torsional deformities are usually established during the operation. Many patients tolerate abnormal torsion, but efforts should be made to reduce and stabilise the femoral shaft fracture with an AV difference of less than 15 degrees.

Bone density and geometry after locked intramedullary nailing. Computed tomography of 8 femoral fractures.

8 patients with femoral shaft fracture treated with locked intramedullary (IM) nailing were examined by computed tomography (CT) a few days after nail removal. Cortical bone density, cortical thickness and geometrical shape of the fracture region were compared to those of the contralateral side. The cortical density was reduced by 23 percent at the mid-fracture level. However, at the same level the cortical thickness had increased by 47 percent, and the antero-posterior and medio-lateral diameters by 30 and 45 percent, respectively. We conclude that the fracture region of the femoral shaft had regained its mechanical properties at the time of nail removal.

Bone loss after locked intramedullary nailing. Computed tomography of the femur and tibia in 10 cases.

10 patients with previous femoral shaft fracture treated with locked intramedullary nailing were examined by computed tomography (CT) a few days after nail removal. The bone density, cortical thickness and geometric shape of the fractured extremity were compared with those on the contralateral side. Only a small reduction in cortical density and thickness (4 and 7 percent, respectively) was revealed outside the fracture area in the diaphyseal part of the nailed bones. A distinct reduction in trabecular density was observed in the femoral condyles as well as in the ipsilateral tibial condyle (19 and 17 percent, respectively). Our results indicate that the stress-reducing effect of intramedullary nails on the femoral diaphysis is small.

Leg length inequality measured by ultrasound and clinical methods.

Leg length inequality (LLI) was determined by ultrasound and two clinical methods in 100 subjects without previous disorders of the lower extremities. The mean LLI by ultrasound was 4.1 mm (range: 0-16 mm). An LLI of 10 mm or more was found in 4% of the subjects. The mean inter-observer variation by ultrasound was 0.9 mm (range: divided by 5-8 mm), which was significantly less than that obtained by clinical methods. The 95% confidence interval of inter-observer variation (+/- 2 SD) by ultrasound was +/- 5 mm and this interval is assumed to represent the accuracy of the method. Because LLI measurement by ultrasound is more reliable than clinical methods, ultrasound is recommended for routine use in clinical practice.

Femoral anteversion in normal adults. Ultrasound measurements in 50 men and 50 women.

The femoral anteversion (AV) angles were measured by ultrasound in a normal group of 100 adult subjects to find the normal range of anteversion, to determine the normal left/right difference, to assess the interobserver variation, and to find the correlation between AV angle and clinical hip rotation. All the ultrasound measurements were performed independently by 2 observers. The mean AV angle was 18 degrees in the women and 14 degrees in the men. The mean left/right difference in AV was 3.8 degrees, and the upper normal limit of side difference (mean +/- 2 SD) was 9.8 degrees. The mean (SD) interobserver variation was only 1.9 degrees (1.3 degrees). The correlations between AV angles and internal and external hip rotation were significant, but not very high (r = 0.49 and -0.49, respectively). We conclude that ultrasound is appropriate for measurement of femoral anteversion. Our results could be used as a basis when evaluating patients with clinically suspected rotational disorders of the femur.

Effects of medullary reaming on fracture healing. Tibial osteotomies in rabbits.

Unilateral, midshaft tibial osteotomy was made in 16 rabbits. Reaming of the medullary canal was performed in half the animals, while the other half were operated on without reaming. Intramedullary fixation was accomplished with multiple Kirschner pins in both groups. Bone healing occurred with abundant peripheral callus in both groups. Mechanical testing after 6 weeks revealed higher strength of the osteotomized bones where reaming had not been performed compared with bones with reaming. We conclude that bone healing is delayed by medullary reaming, whereas the pattern of healing is similar in bones with and without reaming.