[Femoral shaft fractures in the elderly treated by intramedullary nailing].

PURPOSE OF THE STUDY

Little work has been devoted to femoral shaft fractures in the elderly, contrasting with the data available for proximal neck or trochanteric fractures. The purpose of this study was to determine the epidemiological and clinical features of femoral shaft fractures in the elderly from a retrospective series of 58 patients who underwent locked intramedullary nailing procedures with Grosse and Kempf (GK) or long gamma (GL) nails.

MATERIAL AND METHODS

The series included 38 women and 20 men, mean age 83.6 years, who suffered a fracture of the femoral diaphysis due to a fall at home (49 fractures), a traffic accident (8 fractures) or a high-energy fall (1 fracture). Prior to the fracture, 10 patients had homolateral osteoarthritis and two had a contralateral hip arthroplasty. Twenty-six patients were in very good health, 19 had a history of cardiovascular disease, 9 had diabetes and 12 suffered parkinsonian syndromes or dementia. The ASA score was I in 24, II in 23 and III in 11. The diaphyseal fracture was isolated in 31 cases and associated with trochanteric involvement in 27. The upper third of the femur was involved in 37 cases, the middle third in 7 and the lower third in 14. Generally there was a simple spiroid subtrochanteric fracture line (36 cases), or a torsion wedge with or without a proximal extension. Mean delay to surgery was 1.9 days. Subtrochanteric fractures with a proximal line were stabilized with a GL (34 nails) and diaphyseal fractures with a GK (24 nails). Mean duration of the procedure was 1.9 for GL and 2 hours for GK. In 22 cases (17 GL and 5 GK), a minimally invasive access was needed to achieve reduction or stabilization during reaming and insertion of complementary fixation (3 screw fixations, 7 cerclages).

RESULTS

Six patients died before six months, 4 during the initial hospitalization. Twenty patients experienced general complications: 7 cases of phlebitis and 5 "end-of-life" syndromes. Infection occurred in 3 cases including one septic arthritis leading to a bedridden situation. A new fracture beyond the ends of the implant occurred in 2 others. The upright position was achieved within 31 days and total weight bearing within 69 days. Bone fusion was achieved at 4 months (mean). Six patients died between 6 and 12 months, giving a 20.6% mortality at 1 year. Clinical outcome at 12 months was available for 42 living patients: 21 were walking without assistance, 7 used a cane, 8 required crutches or another assistance device and 6 were bedridden.

DISCUSSION

The general and functional prognosis of femoral shaft fractures in the elderly is the same as for proximal fractures. These diaphyseal fractures can be individualized due to their characteristic mechanical and anatomic features: composite fracture with a rotation element involving the distal portion of the trochanter and the proximal quarter of the diaphysis. Several types of ostheosynthesis have been proposed for fixation. Locked intramedullary nailing has been found to be effective despite the difficulty in reduction, especially for particularly proximal fractures. There is a risk of iterative fracture in the transition zones between the femoral component and the osteoporotic bone.