Surgical treatment of ipsilateral multi-level femoral fractures

BACKGROUND Concurrent ipsilateral fractures of the proximal and shaft of the femur are rare complex fracture combinations. In this prospective cohort study, we evaluated clinical and radiological long-term results after operative treatment using several surgical strategies: the so-called "rendezvous" surgical technique, e.g., the combination of retrograde intramedullary nailing and dynamic hip screw (DHS) osteosynthesis, or the all-in-one device technique, e.g., long cephalomedullary nail, compared with two non-overlapping implants (e.g., conventional technique). METHODS In a 10-year-period from 2004 to 2013, we treated 65 patients with complex ipsilateral multi-level femoral fractures. Median age was 45 years (range 19-90 years). Fractures were classified according to the AO/OTA classification. Four patients died during intensive care unit treatment due to multi-organ failure prior to definitive osteosynthesis. Clinical long-term outcome using the functional system of Friedman/Wyman as well as radiological outcome was evaluated 2 years after trauma (range 13-42 months). RESULTS All-in-one device was used in 36 patients, "rendezvous" technique in 9 patients, and the conventional technique in the remaining 16 patients. Two years after trauma, complete fracture healing was found in 57 out of 61 patients ("rendezvous": 9, all-in-one device: 33, conventional: 15; p-value: 0.66). There was no significant difference regarding the complication rate in the cohort groups ("rendezvous": 3, all-in-one device: 13, conventional: 5; p-value: 0.94). Using the functional assessment system of Friedman/Wyman 2 years after trauma, a good clinical result was found in 77.7% in the "rendezvous" group, in 77.8% in the all-in-one device group, and in 75% in the conventional group. CONCLUSION The indication for operative stabilization of ipsilateral multi-level femoral fractures is considered an urgent and emergency procedure. Based on the successful long-term results of this study, we prefer the "rendezvous" technique with fracture stabilization from distally to proximally. Both fracture components require stable fixation. It is advisable to stabilize the shaft fracture primarily using external fixation (damage control orthopedics) and the proximal femoral fracture using early definitive internal fixation. In a second and staged operation, the external fixator is removed and the shaft fracture is stabilized using retrograde nail osteosynthesis with overlapping of the DHS and nail implants.