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  • Title: [Ipsilateral fractures of the proximal femur and the femoral shaft].
    Author: Douša P, Bartoníček J, Pavelka T, Luňáček L.
    Journal: Acta Chir Orthop Traumatol Cech; 2010 Oct; 77(5):378-88. PubMed ID: 21040649.
    Abstract:
    PURPOSE OF THE STUDY: The aim of the study was a retrospective evaluation of the surgical treatment of 171 fractures of the proximal femur and the femoral shaft. MATERIAL AND METHODS: Between the years 1994 and 2008, 171 ipsilateral fractures were operatively treated in 169 patients with an average age of 56 years (range, 21-97 years). The group comprised 108 men and 61 women. The fracture was fixed by the long Gamma nail (Howmedica) in 18 cases, by the long PFN (Synthes) in 147 cases and by the long PFH (Medin) in three cases. In two patients with a bilateral fracture, a reconstruction nail was used on one side and a combination of DHS and condylar plate on the other. External fixation was used in a patient with severe burns. In one case the fracture was fixed by a LCP Proximal Femoral Plate. Types of fractures were evaluated on the basis of the authors' own classification of 1998. Type I (concomitant femoral neck and femoral shaft fractures) accounted for 13 %, Type II (pertrochanteric fracture and femoral shaft fracture) for 23 %, Type III (complex fracture of the proximal femur extending from the femoral neck base to the femoral shaft) for 21 %, Type IV (high subtrochanteric fracture extending from the tuberculum innominatum to the femoral shaft) for 40 % and Type V (Type I or II with a fracture of the distal femur) for 3 % of fractures. In 68 % of cases the injury was caused by high-energy trauma. In Types I and V it involved all the patients, in Type II 95 % of them. These fractures occurred primarily within a polytrauma or as an associated injury (91 %). Types III and IV included mainly monotrauma cases (78 %). The minimum follow-up period was 12 months (1-15 years). RESULTS: Of 129 fractures, 127 (98 %) healed within 12 months after the injury. In one patient, non-union healed after re-nailing 15 months after the injury. In another case, infected non-union healed 18 months after the injury. In the whole group, 14 intraoperative and 9 early postoperative complications (14 %) were encountered. In the group of 129 patients followed up minimally for 1 year, 16 late complications (12 %) were recorded. In 125 cases treated with a reconstruction nail there were 13 complications (10 %) and in four patients treated by another method, complications occurred in three cases. The highest number of complications was recorded in Type V fractures (3 of 5). Excellent results were achieved in 63 %, good in 29 %, fair in 6 % and poor results in 2 % of the patients. DISCUSSION: There is no generally accepted classification of ipsilateral fractures of the femur. Therefore, we used our own classification that proved useful in evaluation of the group of patients.We only slightly modified it in terms of the findings. Type III and type IV fractures have a number of characteristic features in common and so we decided to cover them by one type of complex fractures extending from the femoral neck base as far as the femoral shaft. There is no consensus concerning the treatment. In addition, the percentage of complications is quite high. The group was treated almost exclusively with the reconstruction nail. In 2 % we used another method of internal fixation. Our results do not differ from those reported by other authors. CONCLUSIONS: In case of fractures of the femoral shaft, in high-energy trauma particularly, it is necessary to check the patient for a potential proximal femur fracture. The diagnosis should be made on the basis of a radiograph of the pelvis in internal rotation and axial projection and CT scans for evaluation of the proximal femur, including 2D CT reconstructions. Prior to nailing of the femoral shaft, sciascopic examination must be made of the hip in both projections. Fixation by a reconstruction nail is a suitable method for treatment of ipsilateral fractures.We consider the risk of complications adequate to the mechanism of injury and its severity.
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