Purpose

The timing of definitive fixation for major fractures in polytrauma patients is controversial. To clarify this aspect of trauma management, we randomised patients with blunt multiple injuries to either initial definitive stabilisation of the femur shaft with an intramedullary nail or an external fixator which was converted to an intramedullary nail at a secondary procedure and documented the post-operative clinical condition.

Introduction: Joint sparing is a prerequisite for biologic reconstructions allowing for permanent healing in bone tumors. The physis not crossed by vessels in children can provide a safe margin for tumor resection. In selected patients we have performed joint sparing procedures either by transepiphysial resection or by epiphysial distraction as introduced by Canadell and San Julian.

Patients and methods: 8 children (1 ewing tumor, 8 osteosarcomas [1 multiple localizations]) with open physes 3 distal femurs, 6 proximal tibiae) were treated for metaphysial tumor localizations touching but not crossing to the physis. In 4 localizations epiphysial distraction was used, in the others transepiphysial resection. Reconstructions were performed with vascularized fibula alone in 4 cases, with vascularized fibula transfer and allograft in 1 patient, in the others only intercalary allografts were used.

Results: F/u is 3 to 12 years. No local recurrence occurred. One intercalary allograft failed for infection after irradiation; this was salvaged by a modified rotation plasty. One patient with fibula reconstruction of the femur needed reosteosynthesis due to lack of fusion with a finally excellent result at 3 years f/u, in one the fractured allograft needed be replaced by autologous bone following temporary cement spacer, but the epiphysis could be retained. All patients have excellent joint function. Shortness due to loss of the physis is corrected by contralateral epiphysiodesis and/or lengthening.

Conclusion: Epiphysial sparing tumor resection can be successful oncologically if patients are properly selected and surgery is respecting the tumor margins.

Patients with bilateral femur shaft fractures are known to have a higher rate of complications when compared with those who have unilateral fractures. Many contributing factors have been considered responsible, however due to the heterogeneity of the studied populations solid conclusions cannot be substantiated. Patients included in our study were separated according to the presence of a unilateral (group USF) (n=146) versus bilateral femur shaft fracture (group BSF) (n=19)Endpoints of the study included the incidence of systemic (SIRS, Sepsis, Acute Lung Injuries) complications. The perioperative assessment included documentation of clinical and laboratory data assessing blood loss, coagulopathy, wound infection, and pneumonia. Local (wound infection, compartment syndrome etc.) and systemic complications (ALI, MOF, Sepsis) were documented. Statistical analyses were conducted to examine the relation between the occurrence of unilateral versus bilateral femoral fractures and variables indexing patient demographic characteristics and other indicators of initial injury severity. Independent sample t-tests were used to examine treatment group differences for variables that approximated a Gaussian distribution. For non-normal indicators of injury severity Mann-Whitney tests were performed. Pearson chi-square tests were performed for binary indicators of injury severity, except when expected cell counts did not exceed 5 participants. When this occurred, the Fisher exact test was used Evidence indicated that patients who suffered a bilateral femoral fracture were significantly more likely to have hemothorax and receive a blood transfusion upon admission to the hospital in comparison to patients who suffered a unilateral femoral fracture. Bivariate analyses also indicated that patients with bilateral femoral fractures exhibited a longer clinical recovery time and were more likely to experience clinical complications in comparison to those with unilateral fractures. However, there were no significant differences between the fracture groups in terms of the number of hours spent on a ventilator or the occurrence of pneumonia, acute lung injury, acute respiratory distress, sepsis, and multiple organ failure following surgery. Patients in borderline condition spent significantly more time in the ICU in comparison to those in stable condition. The high incidence of posttraumatic complications in poly-trauma patients with bilateral femur shaft fractures is caused by the accompanying injuries rather than by the additional femur fracture itself. It also documents that a thorough preoperative assessment can help differentiate those who have a high like hood of developing systemic complications from those who do not.