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A COMPARATIVE STUDY OF MANAGEMENT OF FRACTURES OF SHAFT OF FEMUR BY OPEN REDUCTION AND INTERNAL FIXATION WITH INTRAMEDULLARY K-NAIL AND CLOSED REDUCTION AND INTERNAL FIXATION WITH INTRAMEDULLARY INTERLOCKING NAIL. : 

A COMPARATIVE STUDY OF MANAGEMENT OF FRACTURES OF SHAFT OF FEMUR BY OPEN REDUCTION AND INTERNAL FIXATION WITH INTRAMEDULLARY K-NAIL AND CLOSED REDUCTION AND INTERNAL FIXATION WITH INTRAMEDULLARY INTERLOCKING NAIL. SUMIT BHUSHAN SHARMA,PARAMJIT SINGH, DARA SINGH,CHETAN PESHIN DEPARTMENT OF ORTHOPAEDICS, GMC JAMMU

INTRODUCTIONTHE FRACTURES OF FEMORAL SHAFT ARE AMONGST MOST COMMON FRACTURES ENCOUNTERED IN ORTHOPAEDIC PRACTICE. : 

INTRODUCTIONTHE FRACTURES OF FEMORAL SHAFT ARE AMONGST MOST COMMON FRACTURES ENCOUNTERED IN ORTHOPAEDIC PRACTICE. THE INCREASING INCIDENCE AND SEVERITY OF HIGH VELOCITY TRAUMA OF MODERNIZATION IS LEADING TO MORE COMPLEX CONFIGURATION OF FRACTURES OF FEMORAL SHAFT. SINCE FEMUR IS LARGEST AND STRONGEST BONES IN OUR BODY AND BEARS WEIGHT OF ENTIRE LOWER EXTREMITY ITS FRACTURE COULD LEAD TO PROLONGED DISABILITY IF NOT MANAGED APPROPRIATELY. FEMUR IS VERYT VASCULAR AND ITS FRACTURE COULD LEAD TO LOSS OF 2-3 LITRES OF BLOOD.

INTRODUCTION CONTINUED : 

INTRODUCTION CONTINUED SPECTRUM OF THIS INJURY VARIES FROM NON DISPLACED STRESS FRACTURE TO FRACTURE WITH SEVERE COMMUNITION. TREATMENT OF FEMORAL SHAFT FRACTURES IS A COMPLEX PROBLEM.FIXATION MUST TOLERATE HIGH COMBINATION OF AXIAL LOADING AND ANGULATORY STRESS. THE THICK MUSCULAR ENVELOPE PROVIDES IDEAL ENVIRONMENT FOR FRACTURE HEALING.BUT IT SOMETIMES THRAWTS FRACTURE REDUCTION.

INTRODUCTION CONTINUED : 

INTRODUCTION CONTINUED SEVERAL TECHNIQUES ARE NOW AVAILABLE TO TREAT THESE FRACTURS. TREATMENT METHODS INCLUDE:- 1.CLOSED REDUCTION AND SPICA CAST APPLICATION. 2.SKELETAL TRACTION. 3.FEMORAL CAST BRACE APPLICATION. 4.EXTERNAL FIXATION. 5.INTERNAL FIXATION.

INTERNAL FIXATION:- : 

INTERNAL FIXATION:- VARIOUS METHODS AVAILABLE TO TREAT THESE FRACTURES WITH INTERNAL FIXATION ARE:- 1.NAILS 2.PLATES. NAILS OFFER ADVANTAGES OF BEING LOAD SHARING DEVICES. THIS ALLOWS FOR EARLY REHABILITATION FOR FRACTURED EXTREMITY. NAILS COULD BE INSERTED USING AN OPEN TECHNIQUE OR CLOSED TECHNIQUE USING IMAGE INTENSIFIERS. PLATING FOR FEMORAL SHAFT FRACTURES ISN'T WIDELY PRACTISED.

PRINCIPLES OF FIXATION : 

PRINCIPLES OF FIXATION REGARDLESS OF THE METHODS USED FOR FIXING THESE FRACTURES FOLLOWING PRINJCIPLES NEED TO BE FOLLOWED DURING I.F. 1.RESTORATION OF ALIGNMENT, LENGTH&ROTATION. 2.PRESERVATION OF BLOOD SUPPLY TO AID UNION AND PREVENT INFECTION. 3.REHABILITATION OF EXTREMITY AND THEREBY THE PATIENT.

Slide 7: 

K-NAIL WAS INTRODUCED BY GERHARD KUNTSCHER IN 1940 AS METHOD OF I.M. FIXATION. THIS METHOD HAS ACHIEVED A PLACE OF PROMINENCE ESPECIALLY FOR TRANSVERSE AND SHORT OBLIQUE FRACTURES INVOLVING MIDDLE THIRD OF THE FEMORAL SHAFT.IT IS A WIDELY PERFORMED SURGERY FOR FEMORAL SHAFT FRACTURES. HOWEVER A K- NAIL DOES NOT ACHIEVE A DEGREE OF STABILITY SUFFICIENT TO HOLD REDUCTION IN PROXIMAL AND DISTAL THIRD #. ALSO COMMUNITED FRACTURES IN ALL LOCATIONS HAVE A TENDENCY FOR ROTATIONAL MAL-ALIGNMENT.

Slide 8: 

THE INTERLOCKING NAIL WAS INTRODUCED TO OVERCOME THESE PROBLEMS WITH LONGITUDNAL AND ROTATIONAL INSTABILITY BY USE OF SCREWS THAT ARE PLACED THROUGH THE BONE IN PROXIMAL AND DISTAL END. THIS METHOD IS CALLED STATIC INTERLOCKING. IN PROXIMAL AND DISTAL FEMORAL FRACTURES BONE COULD BE STABILIZED BY PLACING SCREWS IN ONLY ONE END OF BONE. THIS IS CALLED DYNAMIC LOCKING. THIS PROCEDURE REQUIRES SOPHISTICATED INSTRUMENTS,IMAGE INTENSIFIERS,COSTLY IMPLANTS, LONGER OPERATING TIME & TRAINED STAFF. AS A RESULT K-NAILING IS STILL BEING PERFORMED IN MAJORITY OF CASES IN J&K. IN OUR STATE IMAGE INTENSIFIER IS AVAILABLE IN LIMITED NO. OF PLACES.AND WE BELIEVE SO TO BE THECASE IN REST OF INDIA.THIS GROUND REALITY PROMPTED US TO TAKE UP THIS SUBJECT.

AIMS AND OBJECTIVES : 

AIMS AND OBJECTIVES TO COMPARE RESULTS OF LOCKED CLOSED INTRAMEDULLARY NAILING WITH THAT OF OPEN K-NAILING. TO COMPARE RESULT OF OUR STUDY WITH THAT OF OTHER SIMILAR STUDIES. TO CONCLUDE & FORMULATE GUIDELINES FOR FUTURE.

MATERIAL & METHODS : 

MATERIAL & METHODS STUDY WAS CONDUCTED IN DEPARTMENT OF ORTHOPAEDICS GOVT. MEDICAL COLLEGE JAMMU BETWEEN MAY 2005 TO MAY2006. 50 PATIUENTS REPORTING TO CASUALITY OF OUR INSTITUTION WERE ENROLLED AFTER PROPER INFORMED CONSENT. PATIENTS WERE ALTERNATIVELY ALLOCATED TO GROUP I AND GROUP II. THOSE IN GROUP I WERE TREATED BY OPEN REDUCTION AND INTERNAL FIXATION WITH A K- NAIL AND IN GROUP II WERE TREATED BY CLOSED REDUCTION AND INTERNAL FIXATION BY INTERLOCKING NAIL.

INCLUSION CRITERIA : 

INCLUSION CRITERIA AGE MORE THAN 18 YEARS WITH FRESH FEMORAL SHAFT FRACTURES. CLOSED FRACTURES OF FEMORAL SHAFT IN MIDDLE THIRD.

EXCLUSION CRITERIA : 

EXCLUSION CRITERIA 1.COMPOUND FRACTUERE. 2.PATHOLOGICAL FRACTURE. 3.COMMINUTED FRACTURE. 4.SUB-TROCHANTERIC FRACTURE. 5.SUPRA-CONDYLAR FRACTURE. 6.ASEPTIC AND INFECTED NON UNIONS 7.IPSILATERAL SHAFT AND NECK FRACTURES. 8.PATIENTS NOT FIT FOR ANAESTHESIA. STUDY DESIGN WAS PROSPECTIVE PARALLEL STUDY DESIGN.

OPERATIVE TECHNIQUE FOR I.L. NAILING2nd GENERATION AO NAILS WERE USED IN THIS STUDY : 

OPERATIVE TECHNIQUE FOR I.L. NAILING2nd GENERATION AO NAILS WERE USED IN THIS STUDY NAIL OF APPROPRIATE SIZE WAS CHOSEN PRE-OPERATIVELY BASED ON AP RADIO-GRAPH FOR DIAMETER AND LENGTH OF WAS CHOSEN BY MEASURING DISTANCE BETWEEN G.T. AND JOINT LINE. PATIENT WAS POSITIONED SUPINE ON RADIOLUCENT TABLE AND AFTER PROPER PREPERATION ENTRY PORTAL WAS MADE IN PYRIFORM FOSSA. GUIDE WIRE WAS PASSED THROUGH THE PORTAL AND FRACTURE WAS HELD REDUCED USING IMAGE INTENSIFIER. FEMUR WAS REAMED ON GUIDE WIRE IN 0.5mm INCREMENTS AND NAIL 1mm LESS THAN LAST USED REAMER WAS INSERTED.

Slide 14: 

MARK SHOWN IS IDEAL ENTRY POINT FOR INSERTION OF I.L. NAIL.

Slide 15: 

PROXIMAL AND DISTAL LOCKING WERE DONE USING APPROPRIATE METHODS. PROXIMAL LOCKING WAS DONE USING PROVISIONS IN JIG. DISTAL LOCKING WAS DONE USING FREE HAND TECHNIQUE. QUADRICEPS STRENGTHENING AND ACTIVELY ASSISTED RANGE OF MOTION EXERCISES WERE WERE BEGUN IMMIDIATELY. WEIGHT BEARING WAS INITIATED DEPENDING ON STABILITY OF FRACTURE.

OPERATIVE TECHNIQUE FOR KUNTSCHER'S NAILING. : 

OPERATIVE TECHNIQUE FOR KUNTSCHER'S NAILING. AFTER GENERAL OR SPINAL ANAESTHESIA PATIENT WAS FASTENED TO OPERATING TABLE IN LATERAL POSITION. AFTER APPROPRIATE PREPERATION A POSTERLATERAL APPROACH WAS MADE. ONCE FRACTURE WAS REACHED WE FIRST MOBILIZED THE FRAGMENTS. BOTH FRAGMENTS WERE APPROPRIATELY REAMED. ONCE REAMED, GUIDEWIRE WAS PASSED THROUGH BOTH FRAGMENTS IN ORDER TO KNOW THE MOST APPROPRITE LENGTH OF K-NAIL. NAIL WAS THEN INSERTED KEEPING THE EYE OF NAIL POSTEROMEDIALLY.

Slide 17: 

NAIL WAS PASSED THROUGH FRACTURE AND WAS HAMMERED THROUGH GREATER TROCHANTER WHILE KEEPING LIMB ADDUCTED AND FLEXED AT HIP. AFTER THIS FRACTURE WAS REDUCED AND K-NAIL INSERTED RETROGRADELY. UNIAXIAL MOVEMENTS WERE ALLOWED IN BED FROM NEXT DAY.ROTATIONAL MOVEMENTS WERE AVOIDED. LEG LIFTING WAS ALLOWED FROM 3RD TO 4RTH DAY. AMBULATION WAS ALLOWED AT 3 TO 4 WEEKS POST OP. PARTIAL WEIGHT BEARING WAS ALLOWED AT 6TH WEEK.FOLLOW UP WAS AT 6TH, 12TH, 24TH WEEK.

OBSERVATIONS : 

OBSERVATIONS 5O ADULT PATIENTS WITH FRESH FEMORAL SHAFT FRACTURES WERE TREATEDOPERATIVELY BY O.R.I.F WITH K-NAIL OR C.R.I.F WITH I.L.NAIL IN DEPARTMENT OF ORTHOPAEDICS G.M.C JAMMU.CASES WERE ANALYZED AND FOLLOWING OBSERVATIONS WERE MADE.

Slide 20: 

THE AVERAGE AGE OF PATIENTS WAS 38.88 YEARS.MOST OF PATIENTS WERE IN 3rd OR 4th DECADE. THERE WERE 21(84%)MALES IN AND 4(16%) FEMALES IN GROUP I. THERE WERE 22(86%) MALES IN AND 3(12%)FEMALES IN GROUP II. MALE TO FEMALE RATIO WAS ALMOST SIMILAR IN BOTH GROUPS.

SEX INCIDENCE GRAPHIC : 

SEX INCIDENCE GRAPHIC

GRAPHIC SHOWING MODE OF INJURY : 

GRAPHIC SHOWING MODE OF INJURY MOST FREQUENT MODE OF INJURY WAS RTA IN 21 PATIENTS IN GROUP I AND 23 PATIENTS IN GROUP II

AS SEEN IN THIS GRAPHIC RIGHT SIDE IS PREDOMINANTLY INVOLVED IN BOTH GROUP I AND GROUP II.

MORPHOLOGY OF FRACTURE : 

MORPHOLOGY OF FRACTURE IN THIS STUDY 100% OF FRACTUTES IN GROUP I WERE A(A1,A2,A3) IN GROUP 2 1 PATIENT WAS IN C2 PATTERN. RED COLUMN REPRESENTS I.L GROUP AND PALE GREEN COLUMN K- NAIL GROUP.

DURATION BETWEEN TRAUMA AND SURGERY : 

DURATION BETWEEN TRAUMA AND SURGERY

Slide 26: 

QUADRICEPS STATUS

SHORTENING AT TIME OF HEALING : 

SHORTENING AT TIME OF HEALING

Slide 29: 

THANK YOU

ROTATION : 

ROTATION HIGHER PROPORTION OF PATIENTS IN GROUP I(K-NAIL) HAD ROTATIONAL DEFORMITY COMPARED TO GROUP 2

ANGULATION : 

ANGULATION

INFECTIONS : 

INFECTIONS THERE WAS NO INCIDENCE OF SUPERFICIAL OR DEEP INFECTION IN GROUP 2

TIME OF UNION : 

IN THIS STUDY TIME OF UNION WAS 18 WEEKS AVERAGE IN GROUPI AND 16 WEEKS IN GROUP II TIME OF UNION

Slide 34: 

DISCUSSIONRANGE OF KNEE MOTION IN THIS STUDY THE RANGE OF KNEE MOTION WAS 60-90° IN ALL CASES IN GROUP I AFTER 8 WEEKS AND 21 CASES (84%) IN GROUPII AFTER 12 WEEKS R.O.M. WAS BETWEEN 60-90° IN 8 CASES(32%) AND IN 17 CASES IT WAS BETWEEN 90-120° IN GROUP I . IN GROUP II 20 CASES HAD R.O.M B/W 90-120° AFTER 24 WEEKS R.O.M THE R.O.M WAS B/W 90- 120° IN ALL 25 CASES IN GROUP I AND IN GROUP II 22 CASES HAD KNEE RANGE OF MOTION BETWEEN 90-120°.3 CASES HAD KNEE R.O.M MORE THAN 120°

PREOP AND POST OP X-RAYS A MALE TREATED WITH A K NAIL. : 

PREOP AND POST OP X-RAYS A MALE TREATED WITH A K NAIL.

CALLUS FORMATION AFTER 24 WEEKS. : 

CALLUS FORMATION AFTER 24 WEEKS.

54 YEAR OLD PATIENT WITH FRACTURE SHAFT OF FEMUR TREATED BY A K-NAIL. : 

54 YEAR OLD PATIENT WITH FRACTURE SHAFT OF FEMUR TREATED BY A K-NAIL.

Union in a closed fracture in a young man : 

Union in a closed fracture in a young man

PRE OP AND POST OP X RAYS IN GROUP II PATIENTS : 

PRE OP AND POST OP X RAYS IN GROUP II PATIENTS

RADIOGRAPHS AT 16 WEEKS : 

RADIOGRAPHS AT 16 WEEKS SOLID UNION AT 16 WEEKS

ILLUSTRATIONS : 

ILLUSTRATIONS FRACTURE SHAFT OF FEMUR IN A YOUNG MALE.

SAME CASE AFTER CRIF WITH A INTERLOCKING NAIL : 

SAME CASE AFTER CRIF WITH A INTERLOCKING NAIL

DISCUSSION : 

DISCUSSION THE MAIN AIM OF TREATMENT OF MIDDLE THIRD FRACTURES OF FEMUR IS PREVENTION OF SHORTENING, KNEE STIFNESS,MUSCLE WASTING AND RESTORATION OF FUNCTION IN SHORTEST POSSIBLE TIME. SEVERAL STUDIES HAVE SHOWN THAT CLOSED INTRAMEDULLARY NAILING IS TREATMENT OF CHOICE FOR SUCH FRACTURES. CLASSICAL INDICATION IS A CLOSED FRACTURE OF FEMORAL SHAFT IN MIDDLE 1/3RD. PERIOSTEAL BLOOD SUPPLY ARE MINIMALLY DAMAGED BY THIS METHOD. TO AVOID CHANCES OF MALUNION INTERLOCKING NAIL WAS INTRODUCED.IT PROVIDES IMMEDIATE STABILITY AND RESTORES LENGTH.

IN OUR STUDY A MAJORITY OF FRACTURES WERE TYPE A(AO CLASSIFICATION), AND A FEW C TYPE. TIME OF UNNION IN OUR STUDY WAS ON AVERAGE 18 WEEKS IN GROUPI AND 16 WEEKS IN GROUP II. RANGE OF KNEE MOTION AFTER 8 WEEKS WAS 60-90° IN ALL CASES IN GROUP I AND 84% CASES IN GROUP II. R.O.M WAS 90-120° IN ALL CASES IN GROUP I AND >120° IN 3 CASES IN GROUP II. REDUCED KNEE RANGE OF MOTION IS DUE TO:- 1.PATELLOFEMORAL ADHESIONS. 2.FIBROSIS FOLLOWING POST TRAUMATIC CAPSULAR ADHESIONS. 3.ADHESIONS BETWEEN CALLUS AND INJURED MUSCLE MASS. NO PATIENT HAD ANY EXTENSOR LAG IN ANY GROUP.

Slide 47: 

IN THIS SERIES 20 CASES HAD NO SHORTENING, IN 3 CASES THERE WAS SHORTENING UPTO 1 cm. AND IN 2 CASES HAD SHORTENING UPTO 2 cm IN GROUP II ONLY 2 CASES HAD SHORTENING UPTO 2 cm. I.L NAILS PROVIDE IMMEDIATE LENGTH AND ROTATIONAL STABILITY. 21 CASES HAD NO DEFORMITY WHEREAS 3 CASES HAD ANGULATORY DEFORMITY BETWEEN 0-5°IN GROUP I. ANGULATION IS MORE OF A PROBLEM IN THOSE PATIENTS TREATED BY CONSERVATIVE MEANS. INFECTION WAS SEEN IN FORM OF SUPERFICIAL ABSCESSES IN 2 CASES IN GROUP I AND NO CASE OF INFECTION WAS SEEN IN GROUPI II. NO REFRACTURE WAS NOTED IN OUR SERIES. WE DID NOT SEE ANY NON UNION IN OUR SERIES. THERE WAS NO CASE OF FAT EMBOLISM IN PRESENT STUDY

CONCLUSIONBASED ON OUR EXPERIENCE WE CONCLUDE:- : 

CONCLUSIONBASED ON OUR EXPERIENCE WE CONCLUDE:- REAMED CLOSED INTERLOCKING IS AN EXCELLENT TECHNIQUE FOR TREATMENT OF FEMORAL DIAPHYSIS FRACTURES. ALL FRACTURES BETWEEN L.T AND FEMORAL CONDYLES COULD BE STABILIZED WITH I.L NAILS. IT DOES NOT EXPOSE PATIENT TO AN UNDUE INFECTION. AS I.L DOES NOT DISTURB FRATURE HEMATOMA IT LESSENS TIME OF UNION. IT REDUCES RATE OF MALUNION. MINIMAL SOFT TISSUE INJURY DURING SURGERY APPRECIABLY AIDS REHABILITATION. INTERLOCKING IS EXCELLENT METYHOD TO AID TRANSPORT OF T MULTIPLY INJURED PATIENT.

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