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The Journal of Bone and Joint Surgery 82:781 (2000)
© 2000
The Journal of Bone and Joint
Surgery, Inc.
Conversion of External Fixation to Intramedullary Nailing for Fractures of
the Shaft of the Femur in Multiply Injured Patients*
Peter J. Nowotarski, M.D. 781.files/dagger.gif)
,
Clifford H. Turen, M.D. 781.files\Dagger(1).gif)
, Robert J. Brumback, M.D. and J. Mark Scarboro, B.A.
Investigation performed at the Section of Orthopaedic
Traumatology, The R Adams Cowley Shock
Trauma Center, The University of Maryland Medical
System, Baltimore, Maryland
*No benefits in any form have been received or
will be received from a commercial party related directly or indirectly to the
subject of this article. No funds were received in support of this
study.
Department
of Orthopaedic Surgery, University of Tennessee, 923 East Third Street, Suite
1203, Chatanooga, Tennessee 37421.
Shock Trauma Orthopaedics, The R Adams Cowley Shock
Trauma Center, 22 South Greene Street, Room T3R64,
Baltimore, Maryland 21201-1595. Please address requests for reprints to C. H.
Turen, c/o Elaine P. Bulson, Editor. E-mail address for Elaine P. Bulson: mailto:ebulson@smail.umaryland.edu
 781.files/rarrow.gif) |
Abstract |
Background:
From 1989 to 1997, 1507 fractures of the shaft of the femur were
treated with intramedullary nailing at The R Adams Cowley Shock
Trauma Center. Fifty-nine (4 percent) of
those fractures were treated with early external fixation followed
by planned conversion to intramedullary nail fixation. This two-stage
stabilization protocol was selected for patients who were critically
ill and poor candidates for an immediate intramedullary procedure
or who required expedient femoral fixation followed by repair of
an ipsilateral vascular injury. The purpose of the current
investigation was to determine whether this protocol is an
appropriate alternative for the management of fractures of the femur in patients
who are poor candidates for immediate intramedullary nailing.
Methods: Fifty-four multiply injured patients with a total of
fifty-nine fractures of the shaft of the femur treated with external
fixation followed by planned conversion to intramedullary nail
fixation were evaluated in a retrospective review to gather
demographic, injury, management, and fracture-healing data for
analysis.
Results: The average Injury Severity Score for the fifty-four
patients was 29 (range, 13 to 43); the average Glasgow Coma
Scale score was 11 (range, 3 to 15). Most patients (forty-four) had
additional orthopaedic injuries (average, three; range, zero to
eight), and associated injuries such as severe brain injury,
solid-organ rupture, chest trauma, and aortic tears were common. Forty
fractures were closed, and nineteen fractures were open. According
to the system of Gustilo and Anderson, three of the open fractures
were type II, eight were type IIIA, and eight were type IIIC.
Intramedullary nailing was delayed secondary to medical instability
in forty-six patients and secondary to vascular injury in eight. All
fractures of the shaft of the femur were stabilized with a unilateral
external fixator within the first twenty-four hours after the injury;
the average duration of the procedure was thirty minutes. The
duration of external fixation averaged seven days (range, one to
forty-nine days) before the fixation with the static interlocked
intramedullary nail. Forty-nine of the nailing procedures were
antegrade, and ten were retrograde. For fifty-five of the fifty-nine
fractures, the external fixation was converted to intramedullary nail
fixation in a one-stage procedure. The other four fractures were
associated with draining pin sites, and skeletal traction to allow
pin-site healing was used for an average of ten days (range, eight to
fifteen days) after fixator removal and before intramedullary
nailing. Follow-up averaged twelve months (range, six to eighty-seven
months). Of the fifty-eight fractures available for follow-up until
union, fifty-six (97 percent) healed within six months. There were
three major complications: one patient died from a pulmonary embolism
before union, one patient had a refractory infected nonunion, and one
patient had a nonunion with nail failure, which was successfully
treated with retrograde exchange nailing. The infection rate was 1.7
percent. Four other patients required a minor reoperation: two were
managed with manipulation under anesthesia because of knee stiffness,
and two underwent derotation and relocking of the nail because of
rotational malalignment. The rate of unplanned reoperations was 11
percent. The average range of motion of the knee was 107 degrees
(range, 60 to 140 degrees).
Conclusions: We concluded that immediate external fixation
followed by early closed intramedullary nailing is a safe treatment
method for fractures of the shaft of the femur in selected
multiply injured patients.
|
Introduction |
Early
fixation by closed intramedullary nailing is the currently preferred
method of treatment of fractures of the shaft of the femur in
multiply injured patients5,7,16,17.
However, a small percentage of multiply injured patients are too
critically ill to tolerate the surgical stress or the operative
duration involved with an intramedullary nailing procedure. Injuries
or clinical conditions that may preclude immediate intramedullary
nailing include aortic rupture, coagulopathy, hypoxia, severe
intracranial injury, and solid-organ injuries. Patients with
concomitant fracture of the shaft of the femur and ipsilateral
vascular disruption require osseous stabilization as quickly as
possible to expedite emergent vascular repair. In these selected
clinical circumstances, patients may benefit from immediate external
fixation of the shaft of the femur with planned early conversion to
intramedullary fixation.
External fixation is an expedient and minimally invasive method of
long-bone fracture stabilization, but there have been reports of
high rates of complications when fractures of the femur have been
treated with this method until union1,8,13,18.
Although there have been numerous studies on the efficacy of
conversion of external fixation to intramedullary nailing for
fractures of the tibia, we are aware of only two small series in
which such treatment conversion was performed for fractures of the
femur6,22.
We postulated that treatment of fractures of the shaft of the femur
by immediate external fixation and early conversion to intramedullary
nailing in selected patients is a safe and effective method. The
purpose of this retrospective review was to determine whether
planned two-stage treatment is an effective alternative for
management of femoral fractures in
patients who are poor candidates for immediate intramedullary
nailing.
|
Materials and Methods |
From 1989
to 1997, 1507 fractures of the shaft of the femur were treated with
intramedullary nailing at The R Adams Cowley Shock Trauma
Center. During that same period, 112 patients underwent initial
external fixation of 118 fractures of the shaft of the femur. Of
these 112 patients, thirty-three (thirty-three fractures) died of
multiple injuries without a change in the fixation method and sixteen
(sixteen fractures) either were treated by external fixation until
union (seven fractures) or had conversion to plate fixation (nine
distal fractures with supracondylar and intra-articular extension,
three of which were associated with vascular injury). The remaining
sixty-three patients (sixty-nine fractures) were treated by
conversion of the external fixation to intramedullary nail
stabilization. Of the sixty-three patients, nine (ten fractures) were
lost to follow-up, leaving fifty-four patients (fifty-nine fractures)
in our study group. The minimum duration of follow-up was six months
(average, twelve months; range, six to eighty-seven months). The
fifty-nine femoral fractures represent 4 percent of all of the
fractures of the shaft of the femur treated with intramedullary
nailing during the study period. Data were compiled from the
hospital's computerized trauma
registries, medical records, telephone interviews, and a review of
radiographs.
The age of the thirty-five male patients and nineteen female patients
in the study averaged thirty-three years (range, fifteen to
seventy-one years). Thirty left femora and twenty-nine right femora
were fractured. Fifty-five fractures were the result of blunt
trauma secondary to (in order of
frequency) a motor-vehicle accident, a motorcycle accident, a
pedestrian-motor-vehicle accident, and a fall. Four fractures were
the result of a penetrating gunshot. Forty fractures were closed. Of
the nineteen open fractures, three were graded, according to the
system of Gustilo and Anderson9,10,
as type II; eight, as type IIIA; and eight, as type IIIC. According
to the Orthopaedic Trauma
Association classification system14,
eighteen of the fifty-nine fractures were classified as 32-A;
twenty-four, as 32-B; eight, as 32-C; three, as 33-A3; and six,
as 33-C2. Two patients had an associated ipsilateral fracture
of the neck of the femur that was treated by reduction and screw
fixation. The fracture of the shaft of the femur was then treated
by external fixation with subsequent intramedullary nailing
with a reconstruction nail.
For the patients in the study group, the managing trauma
team delayed intramedullary nailing of the fracture of the shaft of
the femur because of physiological instability (forty-six patients)
or vascular injury (eight patients). Physiological instability
was defined as progressive hypoxia, coagulopathy, hemodynamic
instability, elevated intracranial pressures (in patients with
a head injury), or a risk of disturbing contained solid-organ
injuries or aortic disruptions by changes in patient position
or by movement during the femoral nailing procedure. The forty-six
physiologically unstable patients included fifteen with a head
injury and elevated intracranial pressure (average Glasgow Coma
Scale score19,
6; range, 3 to 11) and thirty-one with severe visceral injuries
(spleen or liver lacerations).
The Injury Severity Score3
of the study group averaged 29 (range, 13 to 43) compared with an
average Injury Severity Score of 21 (range, 9 to 75) for the overall
patient group (1507 fractures) treated by femoral intramedullary
nailing during the same time period. The Glasgow Coma Scale score for
the study group averaged 11 (range, 3 to 15). Forty-four of the
patients had additional orthopaedic injuries (average, three
additional fractures or dislocations, or both; range, zero to
eight).
The treatment protocol involved external fixation of the fracture of
the shaft of the femur within the first twenty-four hours after the
injury. Forty-six fractures were managed by various configurations
of a standard unilateral half-pin external fixator, with two or
three five-millimeter half-pins inserted into the proximal and distal
femoral fragments and connected in a unilateral frame after fracture
reduction. Forty-two Hoffmann external fixators (Howmedica,
Rutherford, New Jersey) and four AO external fixators (Synthes,
Paoli, Pennsylvania) were used. Thirteen distal fractures of the
shaft of the femur were managed with a knee-bridging frame (Howmedica
or Synthes) with pins inserted into the proximal femoral fragment and
the proximal part of the tibia. The external fixation of the nineteen
open femoral fractures was followed by irrigation and débridement of
the fracture site. All pins were inserted with generous skin
incisions to avoid skin-tenting.
Intravenous antibiotics (cefazolin, one gram every eight hours) were
administered preoperatively and for twenty-four to forty-eight hours
postoperatively. Specimens were not taken from the open fracture
wounds for culture. The duration of the external fixation procedures
averaged thirty minutes for the patients for whom the time for each
procedure could be determined.
The external fixator was removed and intramedullary nailing was
performed when the managing trauma
surgeons deemed the patient to be stable and able to tolerate
surgery. A one-stage conversion procedure was considered appropriate
for patients with a relatively short duration of external fixation
(usually less than two weeks), no signs of systemic infection (that
is, if the patient was afebrile and had normal serum leukocyte
counts), and no loosening of the external fixator pins or erythema or
purulent drainage at the pin sites. Removal of the external fixator,
débridement of soft-tissue pin tracks, and curettage of the bone
holes were performed during a separate surgical setup before the
intramedullary nailing. A static interlocked nail with reaming was
used in all patients. There were forty-nine antegrade
intramedullary nailing procedures, with a Russell-Taylor nail (Smith
and Nephew Orthopaedics, Memphis, Tennessee) used in forty-two of
them and an AO titanium nail (Synthes) used in seven. There were
ten retrograde nailing procedures; seven Richards supracondylar
nails (Smith and Nephew Orthopaedics) and three AO titanium
nails were used for those operations.
All eight patients with associated vascular injuries had provisional
external fixation of the fracture of the shaft of the femur before
vascular bypass grafting with use of saphenous vein autograft (six
patients) or vascular conduits (PTFE [polytetrafluoroethylene]
Gore-Tex; Gore Industries, Elkton, Maryland) (two patients). Care was
taken to ensure that the fracture was stabilized out to length with
external fixation before revascularization. During the conversion
procedure for the patients with vascular repair, the patient was
placed supine on the fracture table and proximal tibial skeletal
traction was applied before removal of the external fixator; this was
done to decrease the risk of disrupting the vascular
reconstruction.
Postoperative management with regard to weight-bearing and the
range of motion of the extremity was individualized according to
the fracture configuration and stability, the size of the implant,
and associated injuries. Routine pin-site care involved cleaning
the sites two or three times daily with a half-strength hydrogen
peroxide solution (50 percent hydrogen peroxide and 50 percent normal
saline solution) with use of a cotton-tipped applicator. Patients
were generally advised to restrict weight-bearing on the fractured
femur until early callus was noted on follow-up radiographs. Union
was defined as a nontender fracture site in a patient who was able
to bear full weight and who was seen to have bridging callus on
anteroposterior and lateral radiographs.
|
Results |
The
duration of external fixation averaged seven days (range, one to
forty-nine days). In fifty patients (fifty-five fractures) with no
evidence of pin-loosening or pin-track infection before the external
fixator was removed, conversion from external fixation to
intramedullary nailing was performed as a one-stage procedure (that
is, under the same anesthesia but with separate preparation and
draping procedures). The remaining four patients (four fractures) had
draining pin sites and underwent fixator removal, pin-track
débridement, and a period of skeletal traction to allow pin-site
healing before the intramedullary nailing was performed. For these
patients, the duration of external fixation averaged twenty days
(range, ten to thirty-three days) and the duration of traction
averaged ten days (range, eight to fifteen days). Antibiotic therapy
for these four patients consisted of vancomycin (500 milligrams four
times daily) for fourteen days; ciprofloxacin (500 milligrams every
twelve hours) for fourteen days, beginning on admission; multiple
courses of antibiotics for non-orthopaedic indications with the
patient taking Bactrim DS (trimethoprim and sulfamethoxazole) (one
tablet twice daily) on discharge; and Ancef (cefazolin) (one gram
every eight hours) for two days, starting on the first postoperative
day. (One regimen was used for each patient.)
Of the fifty-eight fractures available for follow-up until union (one
patient died before union), fifty-six (97 percent) healed within six
months without complications (Fig.
1-A, Fig.
1-B, Fig.
1-C, Fig.
1-D, Fig.
1-E, and Fig.
1-F). Two patients (two fractures) underwent dynamization of the
construct by removal of distal interlocking screws at four months,
and the fracture healed uneventfully within six months after that
procedure. At the time of final follow-up, the average range of
flexion of the knee for the fifty-three living patients (fifty-eight
fractures) was 107 degrees (range, 60 to 140 degrees). Fifty-two
patients (fifty-seven fractures) had more than 90 degrees of knee
flexion.
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Fig. 1-A: Figs. 1-A through 1-F: A
twenty-eight-year-old woman with an Injury Severity Score of 27 who
sustained a type-IIIC open fracture9,10
of the left femur, multiple fractures of the contralateral lower
limb, and a pneumothorax in a motor-vehicle accident.
Fig. 1-A: Preoperative anteroposterior radiograph showing the
displaced left supracondylar femoral fracture.
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Fig. 1-C: Postoperative anteroposterior
and lateral radiographs showing the fracture of the femur reduced
and stabilized with a uniplanar external fixator before vascular
bypass grafting.
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Fig. 1-E: Follow-up anteroposterior and
lateral radiographs, made six months after the injury, showing the
healed fracture of the femur. The external fixator had been
converted to an intramedullary nail seventeen days after the injury
and the emergent application of the fixator. The patient had no
complications and, at the time of final follow-up, had more than 120
degrees of knee motion.
| |
There
were three major complications. A refractory infected nonunion
developed in one patient (1.7 percent) who had had a one-stage
conversion; this was the only infection in the series. This
twenty-one-year-old man had sustained open femoral and tibial
fractures bilaterally in a motor-vehicle accident and had required a
contralateral above-the-knee amputation. After several débridements
and immediate conversion to intramedullary nailing, a
three-centimeter bone defect was treated with bone-grafting and
exchange nailing eight weeks after the injury. Deep infection with
Staphylococcus aureus developed, which was thought to have
been the result of seeding from open wounds on the contralateral
necrotic above-the-knee amputation stump. The patient was lost
to follow-up at seven months, at which time he had an ununited
fracture with drainage from the fracture site.
One late aseptic nonunion with nail breakage was successfully treated
with retrograde exchange nailing with reaming. This nonunion occurred
in an obese sixty-five-year-old woman who had sustained an open
supracondylar femoral fracture bilaterally. The femoral fractures
were initially treated with débridement and external fixation,
with early conversion at two days to retrograde intramedullary
nailing on the right side and plate fixation with bone-grafting
on the left. She presented eighteen months later, after minor
trauma, with a broken nail, and nonunion was
confirmed by tomograms. The nonunion healed within four months after
the retrograde exchange nailing procedure.
The third patient who had a major complication was an eighteen-year-old
man who had sustained a type-IIIC open femoral fracture and an
ipsilateral tibial fracture in a motor-vehicle accident. This patient
died, ten days after the conversion to an intramedullary nail
(approximately two weeks after the external fixation), from a massive
pulmonary embolism despite prophylaxis (5000 units of heparin
administered subcutaneously twice daily and the use of intermittent
pneumatic-compression stockings) to prevent deep-vein
thrombosis.
Four other patients required a minor reoperation. Two patients with
a bilateral femoral fracture underwent manipulation under anesthesia
for knee stiffness. In one, who had a bilateral open supracondylar
femoral fracture with intracondylar extension, this procedure
resulted in more than 90 degrees of functional motion of each knee.
The second patient had a head injury, a severe pelvic fracture,
ipsilateral (right) fractures of the neck and shaft of the femur,
and a fracture of the shaft of the left femur. Excision of
heterotopic bone from the right hip and knee was planned at the time
of writing because manipulation had failed to achieve a
functional range of motion. Two other patients, with rotational
malalignment, underwent derotation and reinsertion of interlocking
screws early after the intramedullary nailing. The rate of
unplanned reoperations was 11 percent in this series.
|
Discussion |
There are
many benefits of early fracture stabilization in multiply injured
patients: the procedure facilitates patient mobility, improves
pulmonary toilet, decreases pain and thus the need for narcotics,
decreases inflammatory mediator response, and decreases
thromboembolic phenomena. Early stabilization of femoral fractures
has been shown to decrease morbidity and mortality5,17.
However, a severely injured patient who remains physiologically
unstable may be able to tolerate only the shortest surgical procedure
for fixation of a fracture of the femur.
In the current series of multiply injured patients, immediate
intramedullary femoral nailing was postponed because of progressive
hypoxia, elevated intracranial pressure, persistent metabolic
acidosis, coagulopathy, and severe solid-organ or aortic injuries.
Patients with lower-limb ischemia from a vascular injury associated
with a femoral fracture also had the nailing delayed until external
fixation and revascularization was completed. After consultation with
the trauma surgeons, anesthesiologists,
neurosurgeons, and orthopaedists, it was decided that, for these
patients, external fixation was the most expedient and atraumatic means of femoral fracture fixation.
The philosophy at our center is that skeletal traction is a poor
method of femoral fracture stabilization in this patient population
and that early external fixation of the shaft of the femur provides
substantial benefits to the patient.
Options for surgical stabilization of fractures of the shaft of
the femur include plate fixation, intramedullary nailing with or
without reaming, and external fixation. Both open plate fixation and
intramedullary nailing entail greater blood loss and require
increased operative time compared with closed reduction and external
fixation of a fracture of the femur. Although retrograde nailing
off the fracture table may afford shorter operative times and
decreased blood loss compared with antegrade intramedullary nail
fixation, two recent prospective randomized studies15,20
comparing retrograde and antegrade nailing for fractures of the shaft
of the femur demonstrated that retrograde nailing had no advantage in
terms of these parameters. In the current series, the operative
time for applying external fixation as provisional stabilization
of a fracture of the shaft of the femur averaged only thirty
minutes.
Unfortunately, definitive treatment of fractures of the femur with
external fixation until union is associated with a high risk of
several complications. Nonunion in up to 20 percent of patients, deep
pin-track infection in up to 20 percent, and knee stiffness in
up to 45 percent have all been reported in contemporary series of
fractures of the femur treated with external fixation1,8,13,18.
We hypothesized that conversion to interlocking intramedullary
nailing before the development of complications related to long-term
external fixation would be a good alternative for the management of fractures of the femur in
multiply injured patients.
Conversion of external fixation to intramedullary nailing in the
tibia has been studied extensively. Two noteworthy early reports
condemned this treatment protocol because of infection rates of as
high as 44 percent (seven of sixteen); however, in both series
the patients had extended periods of external fixation and high
rates of pin-track infection before nailing11,12.
By limiting the duration of external fixation and the associated
prevalence of pin-track infection, Blachut et al.4
and Antich-Adrover et al.2
were able to achieve high union rates with low infection rates (less
than 6 percent).
We are aware of only two small series in the literature in which planned
conversion of external fixation to intramedullary nailing was
carried out for fractures of the femur in multiply injured patients.
Broos et al.6
reported on ten fractures in nine patients with an average Injury
Severity Score of 35.5. All of the fractures healed without
complications after an average of twenty-one days of external
fixation. There were no infections. Wu and Shih22
reported on a series of fifteen open fractures of the shaft of the
femur that were treated with an average of one month of external
fixation before nailing; there were nine immediate and six delayed
conversions. Fourteen of the fractures united, and two (one treated
with immediate conversion and one, with delayed conversion) were
complicated by infection. All other reports of which we are aware
have described intramedullary nailing as a late procedure for the
treatment of complications of external fixation of fractures of the
femur1,13.
Our protocol of delayed nailing usually within two weeks after
stabilization by external fixation proved to be a safe and effective
approach for the management of fractures of the femur in selected
multiply injured patients whose physiological instability precluded
primary intramedullary nailing. We view the use of this two-stage
protocol in patients with ipsilateral vascular disruption as a way to
maximize the time available to the vascular surgeon for prompt
revascularization of an ischemic extremity. The rates of fracture
union (97 percent) and infection (1.7 percent) are comparable with
those in previous studies of intramedullary nailing of the femur in
similar patient populations7,21.
Although the average knee motion of 107 degrees appears to be less
than that in series of primary intramedullary nailing of these
fractures7,21,
we attribute this difference to several factors, including the large
number of associated orthopaedic injuries (forty-four of fifty-four
patients had multiple fractures) and the overall severe degree of
polytrauma in our patient population.
Because fifty patients (fifty-five fractures) had conversion from
external fixation to intramedullary nailing in a one-stage procedure,
a "safe interval" in traction between fixator removal and definitive
nailing appears unnecessary. The importance of experienced clinical
judgment in determining whether a one-stage conversion procedure is
appropriate for a particular patient should not be underestimated.
Clinical and laboratory data indicating a physiologically stable,
noncatabolic patient without signs of systemic sepsis, pin-loosening,
or pin-track erythema or purulent drainage is required. It must
be stressed that most patients in our series underwent conversion
within one week after the injury.
The possibility of infection after union is of some concern, considering
the relatively short follow-up of our study population. However,
the only infection noted in this series developed before union,
and published reports of late infection after union of fractures of
the femur and tibia treated with conversion from external fixation to
intramedullary nailing are extremely rare2,4,6,11,12,22.
It remains unknown how long external fixation can safely remain in
place before there is an increase in the risk of infection after
conversion to intramedullary nailing. However, we have shown that
external fixation, as an interim management technique before one-stage delayed
intramedullary nailing, is associated with a low and acceptable
infection rate. This early conversion procedure provides the benefits
of immediate femoral stabilization and prevents the
complications associated with traction. We concluded that immediate
external fixation followed by early closed intramedullary nailing
is a safe and effective treatment method for fractures of the
shaft of the femur in multiply injured patients who cannot
tolerate immediate intramedullary nailing but who may benefit from
long-bone fixation.
|
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