InternationalOrthopaedics(SICOT) (2005) 29: 245250DOI 10.1007/s00264-005-0661-7ORIGINALPAPERChang-Wug Oh . Jong-Keon Oh . Woo-Kie Min .In-Ho Jeon . Hee-Soo Kyung . Hyung-Soo Ahn .Byung-Chul Park . Poong-Taek KimManagement of ipsilateral femoral and tibial fracturesReceived:13 February 2005 / Accepted: 9 March 2005 / Published online: 1 June 2005# Springer-Verlag 2005Abstract This is a retrospective study of 18 patients whohad ipsilateral femoral and tibial fractures. They were treatedbytheretrogradefemoral andantegradetibial intramed-ullary nail from a single incision in the knee. The averagetime for union of femoral shaft fractures was 27.6 (1840)weeks. One patient required antegrade nailing with a bonegraft duetometal failureafterusingtheshort nail. Twotibial fractures required bone grafting due to bone loss, withan initial open fracture. The average time for union of tibialfractures was 24.5 (1830) weeks. Functional results usingthe KarlstromOlerud criteria were excellent in 14, good inthree, and acceptable in one. The only acceptable result wasinasupra-andinter-condylarfemoralfracture,withpro-trusionofthenail tipintothekneejoint, whichcreatedmoderatelimitationof kneemotion. Simultaneousretro-gradefemoral andantegradetibial nailingwithasingleincision in the knee can achieve satisfactory results in themanagement of these types of fracture.Rsum Etude rtrospective de 18 patients qui avaient unefracturefmoraleettibialeipsilatrales.Ilsontttraitsparenclouagecentromdullairertrogradefmoral et en-clouageantrogradetibial, enutilisantuneseuleincisionsurlegenou.Letempsmoyendeconsolidationdesfrac-tures diaphysaires fmorales tait de 27,6 (1840) semaines.Un malade a ncessit un enclouage antrograde avec greffeosseuse cause de lchec d lutilisation dun clou tropcourt. Deux fractures tibiales ont ncessit une greffeosseuse cause de la perte de substance de une fractureouverte initiale. Le temps moyen de consolidation des frac-tures tibiales tait de 24,5 (1830) semaines. Les rsultatsfonctionnels, avec les critres de KarlstromOlerud taientexcellents dans 14 cas, bon dans trois et mdiocre dans uncas. Le seul rsultat mdiocre tait aprs une fracture sus etintercondylienne fmorale, avec issue de lextrmit ducloudans larticulationdugenou, crant une limitationmodrdelamobilit. Lenclouagesimultanrtrogradefmoral et antrograde tibial avec une seule incision sur legenou peut donner des rsultats satisfaisants dans la gestionde ces fractures.IntroductionTreatment recommendations have varied for ipsilateralfemoral andtibial fractures. Althoughearlier reportsfa-voured non-operative treatment, poor results, such as non-union or malunion, have been reported with such treatment[8, 18]. Aggressive, early stabilisation of both fractures isimportant to prevent systemic complications in polytraumapatients,suchasafloating-kneeinjury[3,8,10].Thisismost commonly achieved via the intramedullary fixation offemur and tibia [18, 19]. Retrograde femoral nailing is ben-eficial in achieving a quicker and easy stabilisation of thefloating-knee injury. The purpose of this study was to de-scribe efficacy and results of ipsilateral femoral and tibialfractures treated by retrograde femoral and antegrade tibialnailing with a single incision in the knee.Materials and methodsPatientsFrom 1January 1999 to December 2003, 19 patients withipsilateral femoral and tibial fractures were treated atKyungpook National University Hospital. With the excep-This study was conductedat Kyungpook National UniversityHospital,Daegu, Korea.C.-W. Oh (*) . W.-K. Min . I.-H. Jeon . H.-S. Kyung .H.-S. Ahn . B.-C. Park. P.-T. KimDepartmentof Orthopedic Surgery,Kyungpook National UniversityHospital,50, Samdok, Chung-gu,Daegu, 700-721, South Koreae-mail:cwoh@knu.ac.krTel.: +82-53-4205628Fax: +82-53-4226605J.-K. OhDepartmentof Orthopedic Surgery,Ehwa UniversityHospital (Dong-DaeMoon),Seoul, South Koreationofonepatient whodiedafteroperation, 18patientswere includedinthis study. Roadtraffic accidents ac-counted for all cases.Surgical proceduresTheprocedureis performedafter adequateresuscitationandstabilisationof theinjuredpatient, especiallyinpa-tientswithahighInjurySeverityScore[2]andotheras-sociatedinjuries. Thepatient isplacedonaradiolucentoperating table, and the injured extremity is placed on theheight-adjustable Mayo-stand table after draping from theiliac wing to the toes.Whenconsideringtheorderofoperation, thegradeoftheopenfractureandthenecessityfor fasciotomyinaswollen leg are the main factors. Otherwise, the tibial frac-ture is usually addressed first, as the surgeons preference.By palpating the subcutaneous anterior border of the tibiaafter reduction, it is relatively easy to check the rotation ofthetibia. However, theruleofthumb(suchascorticalstep sign or diameter different sign) is the only method forchecking the rotation of the femur [9].An incision is made in the mid-line of the palpable pa-tellar tendon. It starts at the inferior pole of the patella andendsat thetopofthetibial tubercle. Thetibial nail (un-reamed tibial nail, Mathys, Switzerland) is then introducedin standard unreamed fashion. After manual reduction, thenail is passed across the fracture site. Two locking screwsare placed proximally and distally.With the knee flexed approximately 40, a guide pin isinserted in the mid-line through the distal femoral cartilage,just abovetheintercondylarnotch. Thepinischeckedbylateral fluoroscopy to ensure that it is just above Blumensaatsline. A rigid reamer is used to open the distal femoral meta-physis. An unreamed femoral nail (Mathys, Switzerland) or aretrograde nail (Zimmer, United States) is used without ream-ing of the diaphysis. Caution is given to the distal end so that itis not over the articular surface. The nail is locked statically.The knee incision is irrigated, and a suction drain is frequentlyplaced into the knee.Post-operativecareItisimportanttouseearlyrangeof motion(ROM)exer-cises or a continuous passive motion machine in the earlypost-operative period. Weight bearingprogresses as thefemoralandtibialcallusincreases.Routinefollow-upra-diographs (anteroposterior, lateral and oblique) are obtainedevery4weeks until theyshowsolidcontinuous callusformation.All patients undergoadetailedclinical follow-upex-amination using the Karlstrom and Olerud grading system[8].ResultsThere were four women and 14 men with an average ageof 34.1 (range, 1964) years. The average Injury SeverityScore [2] was 18.8 (range, 938). Fifteen patients had as-sociated injuries, and 12 patients had other fractures in thelower extremities. Two patients had bilateral femoral frac-tures, and three had bilateral tibial fractures.Seventeen patients had full knee motion (Figs. 1 and 2).Onepatientwhohadasupracondylarintercondylarfem-oral fracture had moderate limitation in knee motion. Thenail tip extruded over the articular surface in this case. Thepatient obtainedkneeflexionto100 andregainedfullrangeofmotionafternail removal. UsingtheKarlstromandOlerudratingsystem[8], thispatient wasgradedashavinganacceptableresult. Theother 17patientsweregraded as having good (3) or excellent (14) results (Table 1).Using the system of AOOTA classification [14] of thefemoral fractures, there were six type A, three type B andnine type C fractures. According to the WinquistHansenclassification [19], there were four type 0, four type I, sixFig. 1 a A 24-year-old womanwith ipsilateralfemoral and tib-ial shaft fractureson the rightside. b She also had a posteriorhip dislocation on the same sideand a contralateralfemoralfracture.Retrogradenailingofthe femur and unreamed tibialnailingwere performed.246type II, one type III and three type IV fractures. There werethree grade 1 open fractures [5]. Fifteen fractures were inthe middle one-third area, one was in the distal one-third,one was supracondylar and intercondylar and one was sub-trochanteric. Thesubtrochantericfracture requiredaddi-tional percutaneous plating to aid stability at the time of thenailingprocedure. Seventeenofthe18femoral fracturesunited. The average time to union of the femoral shaft frac-tures was 27.6 (range, 1840) weeks.Ofthetibialfractures,threewereintheproximalone-third, 12 were in the middle one-third and three were in thedistal one-third. According to the AOOTA classification,Fig. 2 a Bone union of bothfemur and tibiaoccurred, withgood alignment. b Three yearslater, she had excellentkneefunction.Table 1 Ipsilateral femoral andtibial fractures treated withret-rograde and antegrade nailings from knee. ISS Injury Severity Score,AOOTAfracture classification according to AOOTA, NAnotavailableinthecalculationof uniontime, KneefunctionclinicalevaluationaccordingtoKarlstromOlerudcriteria, KneeLOMinthis patient, the tip of the retrograde femoral nail extruded over thearticularsurface, which caused limited kneeflexion of 100Number Age ISS Femur fracture Tibia fracture KneefunctionComplicationitstreatmentOpen AOO TA Union time Open AOOTA Union time1 19 9 A 24 2 B 28 Excellent2 30 38 A 32 3c C NA Good Tibiabonegraft3 26 34 A 20 A 20 Excellent4 30 19 A 18 A 18 Excellent5 24 14 A 28 A 24 Excellent6 32 17 A 28 1 B 28 Excellent7 45 22 B NA B 22 Excellent Femur nail failurenailchange and bonegraft8 22 22 1 B 30 2 B 30 Excellent9 29 14 B 20 A 20 Excellent10 23 27 1 C 24 1 A 20 Excellent LLD; 7 mm11 37 27 C 40 1 C 22 Excellent12 38 22 C 36 3b B 28 Excellent13 64 9 C 32 1 A 22 Acceptable Knee LOM14 54 10 C 28 B 28 Good15 26 13 C 36 B 30 Excellent16 47 10 C 26 1 C 26 Good17 34 13 C 20 2 B NA Excellent Tibiabonegraft18 35 19 1 C 28 3a B 26 ExcellentMean 34.1 years 18.8 27.6 weeks 24.5 weeks247there were six type A, nine type B, and three type C frac-tures. There were seven closed and ten open tibial fractures.Opentibial fracturesweregradedasgrade1(fivefrac-tures), grade 2 (three), grade 3A (one), grade 3B (one) andgrade3C(one). Onepatient requiredanarterial bypassgraft, and one patient required a gastrocnemius muscle flapfor coverage. Sixteentibial fracturesunitedwithout anysecondary procedures. Two patients withinitial bone lossrequired a bone graft in order to achieve union. The averagetime for the tibial fractures to unite was 24.5 (range, 1830)weeks.Non-uniondevelopedinonefemoral fractureandtwotibialfractures.Inthecasewithfemoralnon-union,therewas metal failure with breakage of the nail. It was treatedwith bone grafting and antegrade nailing (Figs. 3, 4). Thetibial non-unions occurred in open fractures with bone loss.They were treated with early bone grafting. In three tibialfractures, there was breakage of the locking screws, but thepatients did not have clinical symptoms. One patient had afemoral shortening of 7 mm. There was no mal-union ex-ceeding10 of angulationor rotationineither fracture.Therewasnodeepinfection.Buttwopatientswithopentibial fracturesexperiencedasuperficial infection, whicheventually healed.DiscussionConcomitant ipsilateral fractures of the femur and tibia, theso-calledfloatingknee, areimportant becauseof highmortalitywithassociatedinjuries[16, 18]. Themortalityrates from floating knees range between 5% and 15%, andamputations are reported in approximately 25% of patients[16, 17]. In this study, there was one death and one vascularinjury. The average Injury Severity Score was 18.8, whichissimilar tothosereportedpreviously. ThehighrateofopenfracturesinthecurrentseriesalsoshowsthattheseFig. 3 a This patient hadipsi-lateralfemoral and tibialfractures withintra-articularextension. b Retrograde femoralnailingand antegrade tibialnailingwere performed, but thedistance from the fracture to theproximal locking screw was tooshort.Fig. 4 a Nine months after theoperation, although the tibia waswell healed, b the femoral nailwas broken with non-union.c Exchange nailingwith a bonegraft was performed.248combinedfracturesweremoreseverethanjust thebonyinjuries.Operative treatment has bothsystemic andmusculo-skeletal benefits, and has resulted in fewer systemic com-plications and better functional outcomes than conservativetreatment [4, 6]. Immediate or early fixation of the femoralfracture stabilises the patients condition and permits earlymobilisation, thusreducingthepossibilityofadult respi-ratorydistresssystem(ARDS)orfat embolism[7]. Thisallows for the early assessment of the knee joint and pre-ventskneestiffness. It isnoteworthythat therewerenocases of post-operative fat embolism in our series.Intramedullarynailingofbothfemoral andtibial frac-tureshasbeenpreferredtoexternal fixation, whichisamore demanding method and has more complications. Theseverity of soft-tissue injury in the tibia is known as one ofthe important predictive factors of the outcome [20]. Usingun-reamednailing, theunionrateof tibial fractureswasexcellent in our series and the complication rate low, nev-ertheless with a high percentage of open fractures. We thinkthat intramedullary nailing has certain advantages overexternal fixation. It providesbetter reduction, allowsforearlyweight bearing, andrequires fewer secondaryop-erations, without increasing the risk of infection.Standard antegrade nailing is generally accepted in fem-oral fractures. The floating-knee injury, which has a higherincidence of associated injuries, benefits from a quick pro-cedure thathas noadverse effects from positionalchangetothechest, spineor abdominal area. Fromthis view-point, the retrograde femoral nailing technique used in ourstudywouldseemtobeattractiveinthemanagement ofipsilateral fracturesofthefemurandtibia[11, 15], asitreduces intra-operative patient manipulationandoveralloperativetime. Wefoundnoresidualsymptomsorfunc-tional impairment after retrogradenailingalthoughtherehadbeenconcernsregardingimpairedkneefunctionduetopossibledamagetothearticular surfaceof theknee[12].The final outcome of ipsilateral femoral and tibial frac-tures of earlier studieshaveshownmanyun-favourableresults [10, 16, 18]. In this study, however, 94% of the pa-tients had good or excellent results. This is similar to otherstudies using intra-medullary nailing of both fractures, re-gardless of whether the femoral nailingis done by anantegrade or retrograde technique [4, 15].In the contributing factors to the functional outcome offloating-knee injuries, involvement of the knee joint is animportant factor [16, 20]. Theonlyresult that wasclas-sified as acceptable in our study also had an intra-articularfracture of the distal femur. We think that retrograde nailingisnotsuitablefortheverydistalfemoralfracture, whichwaspartlyresponsibleforthepooroutcome. Otherwise,our study has shown thatthistechnique can providepos-itive results for diaphyseal femoral fractures and confirmsother reports [1, 4].In this study, most femoral and tibial fractures had pri-mary union without a secondary procedure. Only one fem-oral fracturehadnon-unionduetometallicfailure. Thiswas one of the earlier cases of our study, which was thoughtto include the technical mistake of using a short nail. 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