Rinkd in Great Britain
G. Anastopoulos’
A. Assimakopoulos’
E. Exarchou’ and Th. Pantazopoulosz
‘The 2nd Orthopaedic Department of the General Hospital of Athens and ZOrthopaedic Department of University of
Athens K.A.T. Hospital, Kifissia-Athens, Greece
From October 1987 lo September 1990 32 patient s with ipsilateral
fractures of fhe emurand the tibia were k&d. There were 20 menand 12
women with a mean age of 2 7 years (range18-75 years).All were caused
by road accidents.
There were 7
the fracture5 was partially the same.
The fibialfiacfures were m&d and stabilized by a unilateral external
fixator, while in
nailingwasperformed.I remaining threepatients with an opengrade III
fracture were initially treated by extemal jixation, with two of them
converted nto nailing.
Thefemoral @ctms healed in an averageof 15.5 weeks, while thetibia1
fractures healed in 18.5 weeks. ‘The evaluation of our resuhs was made
according to kdstrom and Olerd’s cderia. We achieved 81 per cent
excellent orgood
femur and tibia, an injury also known as ‘floating knee’
(McBryde and Blake, 1974), are rather uncommon but very
severe trauma. It is generally caused by a high-velocity
accident and for this reason it is usually associated with
many other injuries (Omer et al., 1968; Karlstrom et al.,
1974).
these usually multiply-injured patients rather d&ult.
All the relevant reports in the literature emphasize the
importance of early mobilization of these patients to
facilitate their better care and quick respiratory recovery.
This can only be achieved by good stabilization of the
fractures of the leg, which also promotes a successful and
good functional result of the adjacent joints of the injured
limb (Ratliff, 1968; Karlstrom and Olerud 1977; Edwards,
1979, 1980; Browner et al., 1981; Veith et al., 1984).
However, there is no generally accepted guideline in
treating these fractures. The recommended methods of
treatment vary very widely (Ratliff, 1968; Kadstrom et al.,
1977, Hojer et al., 1977; Winston, 1972; Delee 1978; Fraser
et al., 1978).
0020-1383/92/07043+03
The purpose of this paper is to report our method of
managing these fractures in our department and to present
the final functional results of this treatment in our series of
patients.
Another three patients with the same injury died from
severe additional injuries within 24 h of their admission and
are excluded from this series. There were 20 men and 12
women with an age range of 18 to 75 years (mean 27 years).
The highest incidence was in the 2nd and 3rd decades of life.
All fractures were caused by traffic accidents and 80 per
cent of the patients were on motorcycles. Out of 32 fractures
of the femur, 7 were open (two grade I, two grade II, and
three grade Ill) according to the Gustilo and Anderson
(1976) classification. The types of femoral fractures are
shown in Tublel.
There were 22 open tibial fractures (five of grade I, IO of
grade II, and seven grade Ill), and six out of the remaining 10
closed fractures had skin friction burns. The types of tibia1
fractures are shown in TizbIelI.
Out of 32 patients in this series, 19 had associated injuries
as shown in TableIll.
Management of the fractures in 29 out of the 32 patients
was partially the same. On admission, the tibia1 fracture was
reduced and stabilized by the external fixator using the
unilateral HofIinann device. In the case of closed and stable
fractures, the external fixation was converted to a Sarmiento
functional brace 3-4 weeks later.
Table I. Type of femoral shaft fractures
Fractures
No.
(1992)
Fractures
No.
mobilized within the first 2 days after fixation of their
fractures, while the remaining and more severely injured
patients were mobilized when their general condition
allowed. The follow-up time ranged from 12 to 36 months
(mean 19.5 months).
reasonable period of time.
Table III. Associated injuries
The time required for the femoral fractures to heal was
14-20 weeks (mean 15.5 weeks) and for the tibial fractures
16-24 weeks (mean 18.5 weeks), except for the three
patients operated on for non-union 4 months after their
injury.
5
fractures of the femur using a GrosseKempf rod, 1-14 days
after admission to the hospital, depending on the general
condition of the patient. In the latter approach 17 nails were
static and 12 dynamic. The remaining three patients in the
series, those with open grade III fractures of the femur, were
treated initially by external fixation of their femoral fracture
using the Hoffman device. Two of these patients had a
closed intramedullary nailing when their femoral wound
was healing uneventfully. In the third patient, the external
fixation of the femoral fracture was continued as the main
method of treatment because of severe soft tissue trauma.
Evaluation of the final functional results was made
according to Karlstrom and Olerud criteria (1977). In 26
patients (81 per cent) these were excellent or good, and in
the remaining six patients (19 per cent) acceptable or poor,
but in three of them this was because of knee instability after
severe ligamentous injury needing late reconstruction. Of
the other three patients, two had an amputation, one, in
75-year-old lady, of the contralateral fractured tibia because
of circulatory problems, and the other of the femur of the
affected limb because of severe infection, the only one in the
whole series, in a 52-year-old man with an open grade III
comminuted fracture of the tibia, and the third patient had a
20” varus deformity of the femur with 3 cm shortening
because of technical complications of nailing.
Discussion
In all the closed and open grade I fractures, a second
generation cephalosporin (cephamandole) was given for
36-48 h, while for the open grade II and III fractures the
same antibiotic combined with an aminoglycoside (netil-
micin) was administered for I week.
The treatment of patients with ipsilateral fractures of the
femur and tibia represents a difficult problem, as this injury is
caused by high-energy accidents, and so it is usually
followed by extensive soft tissue trauma and other severe
associated injuries.
In our series, seven out of 32 femoral and 22 out of 32
tibial fractures were open and 19 patients had associated
injuries.
Complications
The oldest patient of the series, a 75-year-old female, also
had a fracture of the controlateral tibia with extensive
degloving of the skin. A tibial amputation was carried out 10
days after injury because of severe circulatory problems in
the leg. In another 52-year-old man with an open grade III
fracture of the tibia, a widespread leg infection and septicae-
mia developed and a femoral amputation was performed 15
days after injury. Another case, an osteoporotic lady,
resulted in a 20” varus deformity of the femur and 3 cm
shortening because of technical complications of nailing.
Early mobilization of these usually multiply-injured
patients and of their injured limbs is imperative in order to
avoid complications and to achieve the best functional end
result (Edwards, 1979; Browner et al., 1981).
However, there is no definite therapeutic regimen recom-
mended in the literature for the best management of these
fractures. Non-operative treatment by plaster cast and
traction or braces proposed by Winston (1972) and DeLee
(1977) was mainly suggested in order to avoid the high
incidence of osteomyelitis after surgical procedures.
Three tibial fractures had no
 
Anastopoulos et al.: Ipsilateral rahres of the femur and tibia
441
reported series of this injury (Hojer et al., 1977; Fraser et al.,
1978; Jongersen, 1980; Rooser and Haqon, 1985).
In our series, a
fractures, either closed or open, was performed by a
unilateral Hoffmann external fixator device immediately
after admission of the patient to the hospital. This is a
well-known and widely accepted method for treating tibia1
fractures (Bumy, 197 Lawyer and Lubbers, 1980). It
provides stable fixation with minimum surgical trauma,
while allowing inspection of the extremity and knee and
ankle movements.
was performed within the first few days after admission or
when the general condition of the patient permitted; in all
but three of our patients in whom the fracture was open
grade III, and in two of whom the initially applied external
fixation was converted to a nailing as soon as the local
trauma had healed uneventfully.
We think that the end results of this treatment are quite
satisfactory since 26 out of 32 patients of this series
recovered completely and returned to their previous occu-
pation within I year of their injury.
In three out of the remaining six patients, the unsatisfac-
tory result was due to a severe ligamentous injury of the
knee resulting in instability and was not a complication of
the applied treatment of the fractures.
Finally, the complications in the series are very limited if
we consider the severity of many of the fractures of the
femur and especially of the tibia, the majority of which were
open and con-minuted or segmental.
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Requests for reprints should be aa essed to: Antonios Assimakopoulos,
12 Doridos Str., 155 62 Holargos, Athens, Greece.