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The Art Of Intramedullary Nailing For Femoral F...

Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures.

The Art of Intramedullary Nailing for Femoral F...

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This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis.

Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

Surgical fixation of metastatic bone disease is principally indicated for pathological femoral fractures [14, 16]. Durable implants and mechanically stable internal fixation need to be considered due to the poor bony union of pathological fractures [11, 18]. Antegrade intramedullary nailing is an option for treating pathological femoral shaft fractures, since several studies have reported that patients treated with this method had good functional outcomes [19,20,21,22,23]. Although the benefits of internal fixation after a pathological fracture of the femur are known, patients who incurred adverse events following this surgical procedure have been reported [14, 24,25,26,27].

Postoperative adverse events reported in patients with femoral fractures showed relatively higher rates of adverse events in pathological fractures than those in non-pathological fractures; even non-pathological fractures have been associated with severe soft tissue injuries and multiple surgical procedures [7, 15, 28]. However, these studies included patients with different characteristics and various surgical procedures, for which the adverse events were not comparable. These adverse events have been reported to increase mortality in patients with pathological fractures after an operation [7, 29]. Few studies have assessed the risk of reoperation and readmission, which are essential for further treatment planning [27]. Hence, this study we analyzed not only adverse events, but also their consequences, including readmission and reoperation. This study aimed to compare the risk of inpatient adverse events and complications after discharge between patients with metastatic pathological and non-pathological femoral fractures undergoing intramedullary nailing. It was hypothesized that patients with pathological femoral fractures had more adverse events, reoperations, and readmissions following surgical fixation.

Acute postoperative anemia was the most frequent adverse surgical event following intramedullary nailing, which was consistent with a previous study that assumed that performing intramedullary nailing was susceptible to bleeding during canal reaming. This resulted in postoperative anemia, which in turn required postoperative blood transfusions [30]. Moreover, significantly higher acute anemia rates have been found in patients with pathological fractures. The explanation is that a high amount of blood loss from passing the intramedullary nail through the hypervascular metastatic femoral lesion, particularly spread from thyroid, prostate, and renal cancer, may prevail the ongoing bleeding with coagulopathic state from high-energy trauma in the non-pathological group [31,32,33]. Although intraoperative total blood loss and blood transfusions in our study were not different between both groups, the blood loss measured by the volume of drainage was higher in the pathological group, which supported the results of postoperative anemia. No established difference in the incidence of surgical site infection, hematoma, or nerve injuries were found between both groups.

Recognizing the probability of postoperative adverse events in patients undergoing intramedullary nailing will assist clinicians in providing pertinent information to both patients and their families. Moreover, as a consequence of high adverse surgical and medical events rates, preoperative patient preparation should be heeded, especially reserved blood components. During the postoperative period, hematocrit and vital sign monitoring are suggested, due to the high risks of postoperative anemia and infection. A larger multi-center, prospective study with large sample size is suggested.

The risks of inpatient postoperative adverse events, especially postoperative anemia, were significantly greater in patients with metastatic pathological femoral shaft fractures than patients with non-pathological fractures undergoing intramedullary nailing after adjusting for potential confounders. Exploring through one-year follow-up, the risks of readmission in patients with pathological fractures seem higher; however, reoperation rates were not different. Counseling patients about the risk of adverse events along with well-prepared preoperatively patient care should be undertaken.

A 46-year old female presented to our institution with increasing groin pain one month after antegrade intramedullary nailing of a femoral shaft fracture at an outside hospital. Radiographic evaluation revealed a displaced ipsilateral femoral neck fracture, adjacent to the piriformis starting point of the nail. A revision fixation of the femoral shaft and neck fracture was performed. The patient sustained a series of complications requiring multiple revision surgeries, including a total hip arthroplasty. Despite the cascade of complications, the patient had an uneventful long-term recovery, without additional complications noted at one-year follow-up.

Radiographs of the left femur in the same patient, demonstrating early signs of fracture healing of a transverse femur shaft fracture treated by intramedullary interlocking nail fixation. The arrow and inset picture depict the displaced femoral neck fracture adjacent to the piriformis starting point of the antegrade nail.

This case report describes a series of complications secondary to a missed femoral neck fracture after antegrade femoral nailing in a 46-year old patient. The patient eventually achieved an acceptable functional outcome at one-year follow-up, despite multiple adverse events and re-operation. This unfortunate case illustrates the importance of an increased awareness combined with a high level of suspicion for the presence of associated femoral neck and shaft fractures. In the present case the initial index surgery was performed at an outside hospital and given a lack of access to initial radiographs, it is impossible to speculate whether the femoral neck fracture occurred as an iatrogenic complication during the intramedullary nail procedure, or whether this was a trauma-related injury missed during the initial assessment. Regardless of the exact root cause, this case presents a series of adverse events and preventable complications which are ultimately due to the initially missed femoral neck fracture, which would have been amenable to primary stabilization as part of the index procedure. We will further discuss the individual specific complications in relation to the pertinent peer-reviewed literature.

The tip-apex distance as described by Baumgartner et al. is the sum of the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior radiograph and this same distance on a lateral radiograph [29]. Their study evaluated 198 pertrochanteric fractures stabilized with sliding hip-screw devices including side-plate and intramedullary devices. They discovered a direct relationship between an increased tip-apex distance and risk of lag screw cut out with a 2% failure rate with tip-apex distances less than 30 mm and no failures with tip-apex distances less than 25 mm. Additionally they found the greatest rates of cutout for lag screws placed in the posterior-inferior and anterior-superior zones and higher rates of failure for unstable fracture patterns [29].

Congenital or acquired limb length discrepancy is a relatively common pathologic condition, usually treated by limb lengthening with external fixation. This is a complex procedure with a high rate of complications, including vascular and nerve injuries, axial deviations, fractures of regenerated bone following external fixator removal, joint stiffness, and infection [1,2,3,4,5,6,7]. Paley et al. [8] described a new technique of femoral lengthening over an intramedullary nail 20 years ago, with the main goal of reducing the duration of external fixation for limb lengthening, since prolonged use of the external fixator is generally poorly tolerated by the patient. Moreover, this technique prevents axial deviations of the lengthened skeletal segment, fractures of the regenerated bone after removal of the external fixator, and joint stiffness. After that first description, several authors used this method for lengthening with satisfactory results [9,10,11,12,13,14,15,16,17]. Self-elongating intramedullary nails have recently been introduced (mechanical or motorized) to avoid the discomfort and problems of the external fixator, but their technology needs further improvements and their cost remains very high [18,19,20,21,22,23,24,25,26,27]. 041b061a72


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