Functional recovery and quality of life after surgical fixation of segmental femoral shaft fractures: a case series from India

INTRODUCTION

Segmental femoral shaft fractures are complex injuries often resulting from high-energy trauma, typically seen in young males between the second and fourth decades of life.¹ These fractures are frequently associated with extensive soft tissue damage and additional traumas, such as craniocerebral, chest, or abdominal injuries.² From presentation to postoperative rehabilitation, managing these fractures presents various challenges.³ Initial assessment should rule out vascular, head, chest, or abdominal injuries, and ensure hemostatic control. Surgery timing, implant choice, and reduction sequence are crucial.^4,5 Intraoperatively, the reduction method must be adapted to the fracture's displacement while preserving surrounding soft tissues to prevent further damage and promote healing.⁶ Complications like delayed union, malunion, nonunion, infections, pulmonary embolism, compartment syndrome, fat embolism, and joint stiffness may arise despite stable fixation.⁷ These complications can lead to increased revision rates and hinder recovery.^8-11 Therefore, managing segmental fractures requires careful preoperative planning, addressing potential complications, and overcoming intraoperative challenges.¹²

CASE SERIES

From October 2022 to March 2023, 12 male patients with segmental femoral shaft fractures presented to our institutions in Tamil Nadu, India. The mean age was 40 years (range: 28-52 years). 50% (6 patients) were manual laborers, 33.3% (4 patients) were drivers, 8.3% (1 patient) was a street food vendor, and 8.3% (1 patient) was unemployed. All fractures resulted from high-energy trauma, primarily road traffic accidents.

Associated injuries were present in 16.7% of cases: one patient (8.3%) had other fractures, and one patient (8.3%) had abdominal trauma who later succumbed to these injuries. 66.6% (8 patients) were closed and 33.3% (4 patients) were open. Details of patient demographics, fracture characteristics, surgical treatment, and functional outcomes are shown in Table 1.

All patients presented with pain, swelling, and inability to bear weight following high-energy trauma. Initial management included a thorough clinical assessment, radiographic evaluation, and ruling out of associated life-threatening injuries. Surgery was performed within 24 hours of injury in 91.6% (11 patients) of cases, with one patient (8.3%) receiving surgery after 24 hours due to delayed presentation.

Despite initial attempts to employ closed reduction techniques, open reduction was ultimately necessary for all patients due to the complexity of fracture reduction and to minimize the risk of additional soft tissue damage. Various implants were used for fixation based on fracture pattern, bone quality, and surgeon preference: 58.3% (7 patients) received intramedullary interlocking nails (Figure 1), 8.3% (1 patient) received a long proximal femoral nail A2 (Figure 2), 25% (3 patients) were treated with locking plates, and 8.3% (1 patient) had a locking plate followed by a nail-plate construct after a fall.

Postoperative management included standardized rehabilitation protocols, pain management, and thromboprophylaxis. Patients were followed up at 1, 3, and 6 months postoperatively.

Functional outcomes were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire for pain, stiffness, and physical function, the EuroQol 5-Dimension 3-Level (EQ-5D-3L) for health-related quality of life, and the short musculoskeletal function assessment (SMFA) for musculoskeletal function.^13-15

The mean WOMAC score showed significant improvement, decreasing from 55.6 (±6.5) at 1 month to 32.8 (±7.1) at 3 months, and further to 18.2 (±5.9) at 6 months (p<0.001). Quality of life, assessed using EQ-5D-3L, improved from a mean score of 0.62 (±0.10) at 1 month to 0.78 (±0.08) at 3 months, and 0.91 (±0.06) at 6 months (p<0.001).

Musculoskeletal function, measured by the SMFA dysfunction index, improved from 41.4 (±5.3) at 1 month to 26.2 (±4.8) at 3 months, and 12.6 (±3.9) at 6 months (p<0.001). Similarly, the SMFA bother index decreased from 36.8 (±4.7) at 1 month to 22.4 (±4.3) at 3 months, and 10.2 (±3.2) at 6 months (p<0.001).

Radiological assessment was done using anteroposterior and lateral views of the femur at each follow-up visit. Radiological union was observed in 33.3% of cases at the 3-month follow-up, and all patients who completed the study (11 patients) achieved union by 6 months without requiring additional interventions. The average time to union was 23.7 weeks (range: 22-24 weeks).

One patient succumbed to associated abdominal injuries during the follow-up period. No other mortality was reported. None of the patients developed implant failure, non-union, malunion, or infection during the follow-up period. Functional outcomes at 6 months indicated that all patients who completed follow-up had returned to their daily activities with minimal to no pain and significantly improved quality of life. The patients are currently being followed up as per our institutional protocol to assess long-term outcomes and detect any late complications.

IMIL=Intramedullary Interlocking; PFNA2 = Proximal Femoral Nail Antirotation-2, *Patient 12 did not complete follow-up as he succumbed to his abdominal injuries.

DISCUSSION

Segmental femoral shaft fractures, caused by high-energy trauma, present challenges from stabilization to rehabilitation. Our study showed a male predominance (100%), consistent with previous research, Dave et al reported 73.3%, Liu et al, 71.7%, and Wu et al a 3:1 male-to-female ratio. Road traffic accidents were the primary injury mechanism, common across all reviewed studies.^3,6,12

The mean age of our patients was 40 years, slightly older than those of Dave et al (35.85 years) and Liu et al (37.8 years).^3,6 Wu et al, reported a wider age range of 19–81 years. Occupationally, manual laborers comprised 50% of our patients, with drivers accounting for 33.3%, and street food vendors and unemployed each representing 8.3%, which was not reported in other studies.^3,6,12 Associated injuries in our cohort included fractures (8.3%) and abdominal trauma (8.3%). Liu et al reported a wider range of injuries, while Dave et al and Wu et al did not specify.^3,6,12 In our study, 66.6% of fractures were closed, and 33.3% open, similar to Dave et al (76.7% closed, 23.3% open) and Liu et al (72.2% closed, 27.8% open).^3,6 All patients in this case series required open reduction.

Dave et al, reported 22% with open nailing, while Liu et al used a combined plating and nailing approach.^3,6 Implant choices in our study were based on fracture patterns and surgeon preference: 58.3% intramedullary interlocking nails, 8.3% long proximal femoral nail A2, 25% locking plates, and 8.3% had a locking plate followed by a nail-plate construct after a fall.

Functional outcomes, assessed using WOMAC, EQ-5D-3L, and SMFA scores, showed significant improvements over 6 months. WOMAC scores decreased from 55.6 to 18.2, EQ-5D-3L improved from 0.62 to 0.91, and SMFA indices reflected enhanced musculoskeletal function and quality of life (p < 0.001). Dave et al used Harris hip and knee society scores, reporting 54% with excellent outcomes, while Liu et al and Wu et al did not evaluate functional recovery.⁶ Notably, ours was the only study in the literature review to assess functional outcomes following segmental femur fractures involving the shaft.

Radiological union was observed in 33.3% of patients at 3 months and 100% at 6 months, with an average time to union of 23.7 weeks. No interventions were required. Dave et al reported an 82% union rate at 4 months, with nonunions managed by dynamization and cancellous bone grafting.⁶ Liu et al, had a shorter healing time (18.9 weeks) due to their use of nail-plate constructs. Wu et al had a 78.6% union rate, with 21.4% requiring dynamization or bone grafting.^3,12 Cho et al, studying fragmentary segmental fractures, reported higher non-union rates (27%) due to severe soft tissue damage and alignment issues.⁷ Our superior union rates might be attributed to careful soft tissue handling, stable fixation techniques, and appropriate post-operative protocols.

The early surgical intervention in 91.6% of our cases, combined with our choice of implants and surgical technique, may have contributed to the favorable outcomes observed in our study. These results suggest that a standardized approach to timing, implant selection, and surgical technique could optimize outcomes in segmental femoral fractures. Furthermore, our comprehensive functional assessment provides valuable insights into the recovery timeline, which can help in patient counseling and rehabilitation planning.

The study's primary limitation is its small sample size and single-center design, affecting generalizability. Variations in fracture patterns, implant choices, and the short follow-up period also limit the analysis. Larger cohorts and longer follow-up periods would provide more robust insights.

CONCLUSION

Optimized treatment of segmental femoral shaft fractures depends on proper timing, implant selection, and surgical technique, which when paired with standardized postoperative care and rehabilitation, significantly enhance functional recovery and quality of life. While these fractures present challenges in reduction that may necessitate open reduction, individualized implant selection and multidisciplinary management can effectively achieve radiological union within six months, demonstrating the value of a tailored treatment approach.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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