Incidence of deep infection, union and malunion for open diaphyseal femoral shaft fractures treated with IM nailing: A systematic review

doi:10.1016/j.surge.2018.08.003

The Surgeon

Volume 17, Issue 5, October 2019, Pages 257-269

https://doi.org/10.1016/j.surge.2018.08.003 Get rights and content

Abstract

Background

and purpose: We have undertaken a systematic review to evaluate the clinical results of intramedullary nailing (IMN) for open diaphyseal femoral fractures on the rates of union, delayed union, malunion, superficial and deep infection and bone grafting.

Methods

We searched the electronic databases of EMBASE, MEDLINE, from their inception until December 1st, 2017 with no language restrictions. The reference lists of all included articles and relevant reviews were also examined for potentially eligible studies. Hand search using electronic database of recent major orthopaedic journals was also carried. Two reviewers working independently extracted study characteristics and data to estimate the diagnostic odds ratio and 95% confidence interval for each result.

Results

Seventeen studies were eligible. Pooled estimate of effect size for union rate was 97% (95% CI: 94–99%). Deep infection rate was 6% (95% CI: 3–9.3%) and more prominent in Gustilo type III injuries; superficial infection was 5.6% (95% CI: 3–9.3%). Delayed union rate 3% (95% CI: 1–5.6%) while, malunion rate was 8.4% (95% CI: 5.7–11.6%). The need for bone grafting ranged from 0 to 9%.

Conclusions

IMN remains the treatment of choice for open femoral diaphyseal fractures with very good union rates. Gustilo grade III injuries demonstrate a distinct higher deep infection rate and strict adherence to established surgical debridement and fixation protocols is advocated. The need for bone grafting can be as high as 9% and patients should be made aware of the possibility of requiring this additional procedure.

Introduction

Femoral shaft fractures occur following high energy trauma and are often seen in the context of polytrauma.1, 2 The vast majority of them present as closed injuries. Recently, their worldwide annual incidence resulting from motor vehicle collisions has been estimated to range from 1.0 to 2.9 million.³ Open femoral shaft fractures constitute a discrete subset of these long bone injuries. In a recent cohort study from the nationwide population-based prospective database in Germany, open femoral shaft fractures accounted for 23.2% of all femoral shaft fractures encountered in adult, polytrauma patients who survived until primary admission.⁴ In the same cohort, when compared to closed counterparts, open fractures were associated with higher overall in-hospital complication rates mainly associated to increased hospital and intensive care stay as well as increased incidence of Multiple Organ Failure.⁴

Intramedullary Nailing (IMN) has long been the gold standard of management of diaphyseal femoral fractures.⁵ Despite the fact that the safety and efficacy of IMN in the management of closed fractures have been extensively studied and reviewed,6, 7, 8 this level of evidence is lacking for open fractures. To shed more light into the use of IMN in open femoral diaphyseal fractures we have undertaken a systematic review of the literature to evaluate the clinical results on the rates of and superficial infection, nonunion and malunion. We also sought to investigate the need for a scheduled bone grafting (secondary outcome).

Section snippets

Materials and methods

The systematic review carried out adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.9, 10

Literature search

The initial electronic search yielded 4523 results, and another 7 records were obtained from the screening of the bibliographies of relevant published studies. After removal of duplicates, 210 abstracts and abstract titles were available for further screening. By applying the eligibility criteria, 17 articles5, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 were identified and constituted the primary studies of our analysis (Fig. 1, PRISMA Flowchart).

The majority of them were retrospective

Discussion

This systematic review indicates that IMN fixation of open femoral fractures results in similar union rates compared to IMN for closed fractures.5, 23, 35, 36 Similarly, reasonably low levels of infection rate were documented, despite the fact that the majority of the recruited open femur fractures were Gustilo grade III. On the other hand, the calculated summarized estimate for malunion rate lay in rather high levels. For the aforementioned outcomes, no statistically significant differences

Conclusion

IMN for the management of open femoral fractures results in satisfactory union and acceptable infection rates comparable to those observed in the management of closed counterparts. Scheduled secondary grafting, when needed due to traumatic bone loss, should be promptly addressed and, if so, satisfactory healing should be expected. Gustilo grade III injuries demonstrate a distinct higher deep infection rate and strict adherence to established surgical debridement and fixation protocols is

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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This work aimed at answering the following research questions: (1) What is the incidence of femoral shaft fractures in the geriatric population in the U.S.? (2) What is the rate of mortality, mechanical complications, nonunion and infection, and what are the associated risk factors?
In this cross-sectional study, femoral shaft fractures occurred between January 1, 2009, and December 31, 2019, were identified from Medicare records. Rates of mortality, nonunion, infection, and mechanical complications were calculated with the Kaplan-Meier method with Fine and Gray sub-distribution adaptation. Semiparametric Cox regression was applied with twenty-three covariates to determine risk factors.
Between 2009 through 2019 the incidence of femoral shaft fractures decreased by 12.07% to 40.8/100,000 inhabitants (p = 0.549). The 5-year mortality risk was 58.5%. Male sex, age over 75 years, chronic obstructive pulmonary disease, cerebrovascular disease, chronic kidney disease, congestive heart failure, diabetes mellitus, osteoporosis, tobacco dependence, and lower median household income were significant risk factors. The infection rate was 2.22% [95%CI: 1.90–2.58] and the union failure rate 2.52% [95%CI: 2.17–2.92] after 24 months.
An early assessment of individual patient risk factors may be beneficial in the care and treatment of patients with these fractures.
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To optimize patients' functional external rotation outcomes, reverse total shoulder arthroplasties (rTSAs) including a latissimus dorsi tendon transfer were undertaken with promising early results and no significant increase in complications in comparison to traditional rTSAs. This was especially utilized for patients with a pronounced combined loss of elevation and external rotation. The purpose of this study is to evaluate and synthesize the findings of all relevant publications assessing the outcomes of rTSAs with associated latissimus dorsi transfer.
We thoroughly searched the literature within the PubMed database using a standardized methodology. For our inclusion criteria, we included any study regarding rTSAs that contained functional outcome scores for postoperative range of motion (such as elevation, external rotation, etc.) or postoperative outcomes such as complications (reoperation, infection, etc.) and patient satisfaction. For the extraction of data, we used pilot-tested Google Forms to record extracted data. These data were then converted to spreadsheets (Microsoft Excel [Microsoft, Redmond, WA, USA]). This was done on 2 separate scenarios by 2 authors to ensure accuracy. We used the modified Coleman Methodology Score to assess the methodological quality of the studies in our samples. Meta-analysis mathematics and statistical analysis were performed using Stata software 17 (StataCorp, College Station, TX, USA).
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Citation Excerpt :
Our reoperation rate was 47% for both study groups. When excluding reoperations for locking screw removal due to local irritation, the reoperation rate is 22%, which is similar to reported rates in the literature on high energy femoral fractures [19,21]. RFN is classically described for several indications such as multiple injuries, floating knee, bilateral femoral fractures and obesity, while generally avoided in treating severe open fractures [8,9].
Treatment of severe open femoral fractures with retrograde intramedullary nailing, raises concerns of septic arthritis of the knee due to its intra-articular entrance point. There is little evidence concerning the safety of retrograde femoral nailing (RFN) usage in these cases, and what evidence there is does not necessarily include severe open fractures. Furthermore, the outcome of ballistic injuries treated in this manner and a comparison with antegrade femoral nailing (AFN), is yet to be established. The aim of this study was to examine the outcome of primary retrograde femoral nailing in high-grade open fractures and compare our results with similar fractures treated with AFN.
A retrospective analysis of treated high-grade open femoral fractures, was performed at an academic level one trauma centre between 2006 and 2016. Included were all open femur shaft fractures treated with either RFN or AFN as primary fixation. We analysed both patient groups and compared outcomes including the infection rate, non-union rate and secondary interventions. Presence of knee pain and long-term function, was evaluated using the Short-Form 12 (SF-12) questionnaire.
Forty-nine patients with open femoral shaft fractures whose primary treatment was intramedullary nailing (IMN), were included in the cohort. Thirty patients were treated with RFN and 19 with AFN. No septic arthritis of the knee was detected in either group. One patient in the RFN group and two in the AFN had a deep surgical wound infection. Excluding reoperations for locking screw removal due to local irritation, the reoperation rate was 22% with two patients treated for non-union in the RFN group and two in the AFN. When comparing outcome measures, including SF-12 scores and the reported knee pain rates of AFN and RFN groups, no significant differences were observed.
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Prevalence of surgical wound infection and related factors in patients after long bone surgery: A systematic review and meta-analysis
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Determination of intramedullary nail based on centerline adaptive registration
2023, Frontiers in Bioengineering and Biotechnology
Bone Defect Due to Open Fracture and/or Infection After Osteosynthesis
2022, The Art of Intramedullary Nailing for Femoral Fracture

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Incidence of deep infection, union and malunion for open diaphyseal femoral shaft fractures treated with IM nailing: A systematic review

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Literature search

Discussion

Conclusion

Declaration of interest

Injury

Orthop Traumatol Surg Res

Injury

Injury

Optimal timing of femur fracture stabilization in polytrauma patients: a practice management guideline from the Eastern Association for the Surgery of Trauma

J Trauma Acute Care Surg

The role of secondary brain injury in determining outcome from severe head injury

J Trauma [Internet]

Epidemiology of orthopedic fractures and other injuries among inpatients admitted due to traffic accidents: a 10-year nationwide survey in Taiwan

Sci World J

Classification of soft-tissue injuries in open femur fractures

J Trauma Acute Care Surg

Intramedullary nailing of femoral shaft fractures: current concepts

J Am Acad Orthop Surg

Interventions for treating femoral shaft fractures in children and adolescents

Evidence-Based Child Heal A Cochrane Rev J

Reamed versus unreamed intramedullary nailing for the treatment of femoral fractures

Medicine (Baltimore)

Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and meta-analysis

Can J Surg [Internet]

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration

BMJ

Reprint--preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Phys Ther

Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group

Scand J Med Sci Sports

The combination of estimates from different experiments

Biometrics [Internet]

Measuring inconsistency in meta-analyses

BMJ Br Med J

Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases

J Bone Joint Surg Am

Immediate nailing of open fractures of the femoral shaft

J Bone Joint Surg Am

Intramedullary nailing of open fractures of the femoral shaft

J Bone Joint Surg Am

Intramedullary nailing of the femur: reamed versus nonreamed

J Am Acad Orthop Surg [Internet]

Early complications in the management of open femur fractures: a retrospective study

J Orthop Trauma

Interlocking nailing for the treatment of femoral fractures due to gunshot wounds

J Bone Joint Surg Am

Femoral shaft fracture open grade III early reamed with intramedullary nailing and the outcome of the fixation