Dr. Mandeep Pathak,MD Dr. Jeremiah Morales,MD Department of Orthopedics Southern Philippines Medical Center • Increasing incidence of high velocity injury patterns. • Winquist et al. studied 521 cases of femoral shaft fracture and showed – 0.9 % infection – 0.9% nonunion rate – 2 % shortening/malunion associated with comminuted fractures. “Thus suggested for interlocking nails for comminuted and segmental fracture” • Weiss et all. Treated 112 comminuted and rotationally unstable fractures of the femur by Grosse-Kempf Nail. – 2.5% angular malunion – 1.7% limb shortening – 7% rotational malalignment – No deep infection or Osteomyelitis Method: • • • • • Patient treated in fracture table Supine position Closed nailing ( using image intensification) Within 1 week None “BONE GRAFTING” • What were the characteristics of patients with comminuted fractures of the lower extremity treated in our institution? • How prevalent are complications associated with intramedullary nailing of the comminuted fracture of the long bone of lower extremity as mentioned in other studies like malunion, nonunion and shortening in our setting? • Is bone grafting necessary for bone healing in comminuted fractures of lower extremity? • Is SIGN nail effective enough to treat the comminuted fracture of lower extremity? • Research Design: – Retrospective study – Looked into the database and evaluated severely comminuted fractures (Winquist III and IV/ Segmental) treated with SIGN intramedullary nails. • Inclusion Criteria: – All pt with comminuted (Winquist III, Winquist IV or Segmental Fracture) fracture of long bone of lower extremity (Femur and Tibia) treated with SIGN nail. – Patient whose record could be gathered from the medical record section. – Patient treated from Jan 2009 to Dec 2012. • Total population identified with Comminuted and segmental fracture of the lower Limb: – 124 • Included in the study – 114 – 10 charts could not be retrieved. • With Follow up data – 61(53.5%) • General Characteristics: 1. Sex Distribution MALE: 89% FEMALE: 11% Mean age: 32.34 with Standard deviation of 11.47. Range:16 yo to 68 yo. Most injured: 15-34 years old ( Cumulative index of 64.91%) 2. • Site – Equal distribution of the fracture site • Left (50 %) • Right (47%) • Bilateral (3%) Cause of Injury: 91 100 90 80 70 60 50 79.8% with VA. 40 30 20 10 0 Type of VA Among the VA , 82.4% from open vehicles like motorcycle/tricycles. 80 70 60 50 40 30 20 10 0 16 4 3 Fall GSW Others VA 75 9 7 Closed Vehicle Open Vehicle Pediastrian Associated injuries: 64 50 70 60 50 40 30 20 10 0 Isolated Fracture 10 9 8 6 4 Multitrauma/ Polytrauma 19 20 6 3 10 2 4 9 0 0 Abdominal Injury Chest Injury Head Injury Bilateral Femur Frequency Floating Knee Other associated fractures • Most of the fracture treated was for Femur (85 %) • Among the Femur Fracture, 73.2% were closed fracture, while 26.8% were Open fracture. • According to the time from injury to admission. 50 47 45 39 40 35 30 28 25 20 15 10 5 0 6 hrs 6-24 hrs >24 hrs • Total of 35 open fractures treated. – 5 Open-I – 12 Open –II – 18 Open-IIIa • 18 cases VA, 16 cases GSW, 1 case Fall Open Fracture Evaluation • Debridement done 9 26% Yes No 26 74% Open Fracture Evaluation • Time from admission to debridement. Frequency 12 10 10 9 8 7 6 4 2 0 <6 Mean duration: 55.15 hrs Range : 2 hrs – 720 hrs 6-24 hrs >24 hrs Management • Initial Management Frequency 85 75% 13 11% Skeletal Traction 16 14% Skin Traction Splint Management • Time from admission to definite management. 40 40 35 32 30 30 25 20 12 15 10 5 0 1 week Mean: 15.49 days Range: 1 day- 78 days 2nd week 2nd week to 4th week > 1month Management • Approach used for surgery. Frequency 80 72 70 60 50 40 25 17 30 20 10 0 Antegrade Femur Retrograde Femur Tibia Management • Reduction Technique Frequency 97 85% 16 14% 1 1% Closed Mini-open Open Management (Intra Operative) • Position Used – Lateral – 70 cases ( all exept one antegrade nailing was supine) – Supine- 42 cases ( all retrograde and Tibial nailing) Management (Intra Operative) • Blood Loss Frequency 40 35% 8 7% 14 12% <200 >1000 52 46% Mean blood loss was 645 cc. 200-500 cc 500-1000cc Management (Intra Operative) • Surgical Time Frequency 40 35% 1 1% 33 29% <1hr >3 hr 40 35% Mean time was 170 mins. 1-2hr 2-3hr Management (Intra Operative) • Bone Grafting Frequency 91 80% 23 20% Yes No Outcome • Union (95.08%) Frequency 58 51% 3 3% No No Follow up Yes 53 46% Outcome • Malalignment Frequency 1 1.64% 54 88.52% 1 1.64% unacceptable shortening With Valgus malalignment 3 4.92% With Varus malalignment Within <2 cm shorteneing None 2 3.28% Outcome • Functional Outcome – Knee ROM Frequency 37 61% >90 flexion Full without any restritions 21 34% 3 5% Less than 90 degrees of flexion Test Variable ϰ2 P value Approach and blood loss 43.705 0.399 Approach and surgical time 115.221 0.606 Approach and knee ROM 18.955 0.004 Bone grafting and Union 39.250 0.000 Injury to admission and Union noted 60.181 0.993 Injury to admission and Malalignment 360.779 0.000 Outcome • There was no Deep infection or Implant failure noted. Case-I (BM,19/M, VA, mini-open) Injury 13 weeks post op Immediate post op 2 yrs after injury 8 wks post op Case-II ( GA, 29/M, VA, Open-II Fx) Injury F/u 25 weeks Immediate post op f/u 8 months f/u 5 weeks Case-III ( NE, 53 yo/M, VA, Segmental Femur) Injury Immediate post op F/U 37 weeks F/U 8 weeks Latest follow up 1.2 yrs post op Case-IV( RF, 29/M, GSI, Open IIIa) Injury F/U 2.3 yrs post-op Immediate post op Squat pic SH, 51/M, VA Case-I post op Injury F/U Case-II CA, 34 M,VA post op Injury F/U Segmental malunion Tibia Non Union Injury Post op Post op 51 wks Post op 15 wks JJ, 22/M, VA,Fx Open III a Femur Injury Post op Post op Post op 13 wks Post op 36 wks Post op 22 wks Discussion • More cases of mal-union and non-union noted in our procedures. • Increased incidence of malunion noted in the cases with delayed presentation. • More patient morbidity in retrograde nailing compared to antegrade nailing in comminuted fractures. • No infection . • No implant complication. SIGN NAIL IS EFFECTIVE ENOUGH* IN TREATING COMMUNITED FRACTURES OF THE LOWER EXTREMITY IN OUR SETTING * With early treatment, with careful intra-op decision, and use of bone graft. Will this fracture unite?# # Emphasize the patient follow up.