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

الملخص EN

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 Kuntscher' s 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.