Elsevier

Injury

Volume 50, Issue 4, April 2019, Pages 956-961
Injury

Minimally invasive treatment of old femoral fractures in adults

https://doi.org/10.1016/j.injury.2019.03.002Get rights and content

Highlights

Abstract

Objective

Extensive incision associated with large-scale callus exfoliation and internal fixation is the common therapeutic approach employed by the majority of orthopaedists in the treatment of old femoral fractures. Inspired by the surgical techniques of intramedullary fixation and reduction by traction, the present study attempted to treat old femoral fractures with minimally invasive methods utilising the principles of biological osteosynthesis (BO).

Methods

A retrospective analysis involving 16 patients with old femoral fractures treated with combined traction, small incision, limited callus treatment, reduction by leverage and intramedullary fixation was conducted. The operative effect was evaluated by the operation time, intraoperative blood loss, bone grafting, healing time of fractures during follow-up, VAS score, and Harris hip score.

Results

Intraoperative observation revealed an average operation time of 1.53 ± 0.34 h and average blood loss of 268.13 ± 97.29 ml without bone grafting in all patients. All enrolled patients had outcomes resulting in effective fixation restoration of limb alignment. Of the 16 enrolled patients, 13 patients completed follow-up with an average follow-up time of 7.42 ± 3.29 months. The average healing time for proximal femoral fractures was 3 months. The average healing time of femoral shaft fractures was 4 ± 1.09 months; two of these cases took 4 months to heal, whereas 1 case demonstrated a delayed healing time of 6 months. The VAS score was 1.15 ± 1.70, 1 patient experienced sciatica, and the Harris hip score was 92.92 ± 5.42. There were no complications of malunion, nonunion or infection among any of the patients who completed follow-up.

Conclusions

Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft. This finding is consistent with BO principles, thereby providing a possible new method for the treatment of old femoral fractures.

Introduction

With the expansion of urban development, there has been a significant rise in polytraumatic and compound injuries caused by traffic accidents [1] and injury by fall from height. With the primary goal of preserving life, in cases of polytrauma, craniocerebral trauma, chest injury and abdominal injury are given priority [2,3], and limb fractures are typically managed with temporary fixation [4,5]. Multiple trauma is often severe with a relatively longer recovery time. In clinical practice, utilising this procedural treatment strategy based on the theory of damage control operation (DCO) [3] may mean that limb fractures are not able to be managed within the ideal time frame. As a vast developing country with a large population, China, especially in the remote rural areas of the Central and Western regions, is subject to an imbalance of transportation availability, economic opportunity and medical treatment. Due to these circumstances, there are patients who experience missed diagnosis, delayed treatment and unregulated treatment [6] of multiple fractures; consequently, these injuries then develop into old fractures. Also related to the development of old fractures is the frequent association between high-energy multiple trauma and craniocerebral trauma. Prior research has documented that craniocerebral trauma can accelerate the healing of fracture sites [7,8], but it can also make the treatment of old fractures considerably more difficult.

Clinically, the definition of an old fracture is one that has gone without effective treatment for more than 3 weeks. Due to this long period of time without effective medical intervention, primary callus formation has already begun, and a large amount of callus has formed [9], leading to malunion of the fracture and even to the formation of pseudo-joints. This process will occur even earlier in cases of combined craniocerebral trauma [7,8].

The femur is one of the major bones of the lower extremity, and old femoral fractures seriously affect the quality of life of patients without effective treatment [10]. There are both advantages and disadvantages to large incision and wide dissection, which is the routine treatment of old femoral fractures. Specifically, reduction and fixation under direct vision is relatively easy, which is an obvious advantage. However, this approach may induce greater trauma and larger amounts of blood loss (Fig. 1). Therefore, it is our pursuit to explore a minimally invasive and effective surgical technique to minimise the shortcomings of the conventional approach. The inspiration behind the minimally invasive surgical technique utilised in this study is femoral intramedullary fixation, implemented with appropriate modification and improvement.

Section snippets

Patients and methods

The present retrospective analysis was conducted in the Department of Orthopaedics, First Affiliated Hospital of Chongqing Medical University. Inclusion criteria for patients in this study were as follows: 1. patients who had proximal femur and femoral shaft fractures more than three weeks old (patients with femoral condylar fractures were excluded), with imaging examination revealing displaced fracture with callus growth; 2. patients with fractures caused by trauma and without organic lesions

Surgical outcomes

The average operation time for all patients was 1.53 ± 0.34 h (only considering duration of the femur operation), with the longest time being measured at 2.3 h. The average incision length was 6.44 ± 1.52 cm. The intraoperative blood loss was 100–450 ml, and the average blood loss was 268.13 ± 97.29 ml without blood transfusion or bone grafting. Sciatica occurred in 1 patient, and no infection was found (Table 1, Table 2).

Follow-up finding

Of the 16 patients, 13 patients successfully completed follow-up through

Discussion

It is difficult to achieve functional reduction for old femoral fractures utilising manual reduction. In these cases, surgical treatment is required to restore limb alignment, correct deformities [14], and establish optimal conditions to promote fracture healing.

There is massive amount of bleeding at the broken ends of a femoral fracture, and haematoma at these broken ends plays an essential role in the formation of callus [15]. Consequently, massive callus and scar tissue formation frequently

Conflict of interest

The authors declare no conflict of interest.

Author contributions

Xiang Zhang: Writing the manuscript, Collecting the data, Statistical analysis, Assisted in the surgeries.

Wei Shui: Writing the manuscript, Collecting the data, Statistical analysis, Assisted in the surgeries.

Weidong Ni: Supervising the study, Editing the manuscript.

Zhenming Hu: Editing the manuscript.

Wei Huang: Editing the manuscript.

Gang Luo: Reviewing the literature.

Bo Qiao: Reviewing the literature.

Shuquan Guo: Chief surgeon, Designing the study, Editing the manuscript.

Acknowledgment

This work does not have any fund support.

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