Surgical fixation of ipsilateral femoral neck and shaft fractures: a matter of debate?

Abstract

Segmental femoral fractures represent a rare but complex clinical challenge. They mostly result from high-energy mechanisms, dictate a careful initial assessment and are managed with various techniques. These often include an initial phase of damage control orthopaedics while the initial manoeuvres of patient and soft tissue resuscitation are employed. Definitive fixation consists of either single-implant (reconstruction femoral nails) or dual-implant constructs. There is no consensus in favour of one of these two strategies. At present, there is no high-quality comparative evidence between the various methods of treatment. The development of advanced design nailing and plating systems has offered fixation constructs with improved characteristics. A comprehensive review of the existing evidence with a step-by-step description of these different definitive fixation strategies based on three case examples was conducted. Furthermore, the rationale for using single vs dual-implant strategy in its case is presented with supportive references. The prevention of complications relies mainly on the strict adherence to basic principles of fracture fixation with an emphasis on careful preoperative planning, the quality of the reduction, and the application of soft tissue-friendly surgical methods.

Keywords: femur; segmental fractures; trauma.

Figure 1

Case example 1. A 64-year-old male patient presented with multiple injuries following a high-energy motorcycle traffic accident. (A) A 3D CT scan of the left femur shows a transverse acetabular fracture with ipsilateral neck and femoral shaft fractures (FN-FD). (B) Coronal reconstruction of the CT scan shows non-displaced fracture extensions at the subtrochanteric area. (C) Image intensifier views showing the intraoperative preliminary fixation as part of the damage control surgery using K-wire fixation of the femoral neck and application of an external fixator at the femur. (D) Radiographs at 6 months show evident fracture healing at all levels after the definitive management of the FN-FD using a cephalomedullary nail (Long Gamma3® – Stryker®) following the ‘single-implant strategy’ for stabilization of these fractures.

Figure 2

Case example 2. (A) 40-year-old male with an open right segmental femoral fracture in the form of an intertrochanteric fracture AO/OTA 31A1 and a multifragmentary distal diaphyseal-metaphyseal fracture AO/OTA 32C3. (A) Sagittal 2D CT reconstruction capture demonstrating the comminuted distal diaphyseal fracture and the ipsilateral proximal femoral fracture. (B) Sagittal and coronal 2D CT reconstruction captures following the initial damage control with external fixation of the femur. (C) Anterior-Posterior (AP) femoral x-ray post definitive fixation.

Figure 3

Case example 2. (A) Fatigue failure of the plate fixation of the distal femoral diaphysis at 6 weeks after definitive fixation following open reduction, lag screw fixation and neutralizing plate fixation of the diaphyseal segment. (B) Follow-up AP femoral x-ray 6 months after the revision fixation with an orthogonal plating construct.

Figure 4

Case example 3. A 44-year-old female patient with a left open femoral fracture with a fragmented wedge AO/OTA 33-B3 distal to the shaft isthmus and an associated displaced basicervical femoral neck fracture AO/OTA 31-B2-1. (A) Preoperative AP x-ray of this segmental femoral fracture case. (B) AP x-ray of the proximal femur with the bridging hip external fixator as part of the damage control orthopaedic at the early admission phase of this patient. (C) Lateral x-ray of the proximal femur following definitive fixation with two implants (sliding hip screw and retrograde femoral nail). (D) AP x-ray of the distal femur following definitive fixation with two implants (sliding hip screw and retrograde femoral nail). (E) Lateral x-ray of the distal femur following definitive fixation with two implants (sliding hip screw and retrograde femoral nail).

Figure 5

Case example 3. (A) Follow-up AP x-ray of the femur with the dual-implant construct. (B) Alignment views at 3 months. Slow progress of healing of the left diaphyseal femoral fracture. (C) Sagittal 2D CT reconstruction capture of the non-uniting diaphyseal fracture. (D) Follow-up AP femoral x-ray at 5 months following revision surgery to the non-union of the diaphysis with evidence of the progress of healing and pain-free function.