The average age of the patients was 31, 44 years (range 16 to 61 years). Nine of 59 patients were female (15.3%) and 50 of 59 patients were male (84.7%). 34 out of 59 patients had been operated for right femur fractures (57.6%), 21 out of 59 patients (35.6%) had been operated for left femur fractures and 4 patients had been operated for bilateral femoral fractures (6.8%). Patients being operated for bilateral femoral fractures were included only for one side because the other side was inappropriate for our study (fixation by plate or external fixator) (Table 1). Femur shaft fracture was classified according to AO/OTA Classification System and W-H Classification System. 42 of 59 fractures were AO 32-B (71.2%) and 17 of 59 fractures were AO 32-C (28.8%) according to AO/OTA Classification System. 22 of 59 fractures were T4 (37.3%), 17 of 59 were T3 (28.8%), 15 of 59 were T2 (25.4%) and five of 59 were T1 (8.5%) according to W-H Classification System (Table 1).
38 of 59 patients had non-reverse type fractures (64.4%) and 21 of 59 patients had reverse type fractures (35.6%) (Table 1). The average size of the butterfly fragment was 76.1 mm (range 18 to 250 mm, SD=52,99). 21 of 59 fractures were small fragment (35.6%). 38 of 59 fractures were in large fragment (64.4%) (Table 2).
According to gap distance; 22 of 59 fractures had small gap (37.3%) and 37 had large gap (62.7%). Average gap size in large gap group and small gap group were 23.4 mm (range 11 to 62 mm) and 7.05 mm (range 4 to 10 mm) respectively (Table 2).
The distribution of IM nail type was as follows: Antegrade intramedullary nail via trochanteric portal – 33 cases (56%), antegrade intramedullary nail via piriformis fossa portal – 14 cases (23.7%) and retrograde intramedullary nail - 12 cases (20.3%) (Table 1).
Mean union score of 59 patients at 3th month was 7.68 (range 4 to 12), mean union score at 6th month for 58 patients was 10.09 (range 4 to 12) and mean union score at the end of 12th month for 49 patients were 11.84 (range 9 to 12) according to RUSF scale (Table 2).
There were two implant failures, three non-union and all had been treated by exchange nailing. There were five delayed union. One delayed union case was treated by plating+ grafting (Figure 4), one delayed union was treated by repositioning and cerclage wiring of the fragment and three delayed unions was treated by dynamization between six to 12 months. Ten of the 59 patients had re-operation. Four out of ten patients were in non-reverse group and six were in reverse group. But there was not statistically significant difference between two groups in terms of reoperation (p=0.144).
We determined implant failure in two patients. Both were in the reverse group. There isn’t statistically significance between reverse and non-reverse groups related to implant failure (p=0,144). However, we thought that this was due to the low number of implant failure.
The union scores at the 3rd month (p=0,011) and 6th month (p=0,039) were lower in reverse group than the non-reverse group and it was statistically significant. However, when the union scores of two groups at the 12th month were compared, there was no statistically significant difference (p=0.819) (Table 3).
In comparison of union rates in related to gap size and fragment size, there wasn’t any statistically significant difference between groups at 3rd, 6th and 12th months (Table 4,5). Although two patients could not get the perfect healing RUSF score at 12th month follow-up period. They don’t have pain during weight-bearing. We didn’t plan any intervention. When the union rates were compared in related to fracture type classified according to AO Classification and W-H Classification, we didn’t’ find any statistically significant difference between groups at 3rd, 6th and 12th months (Table 6,7).
Mean RUSF score of 31 isolated femur fractures (8 ± 1.15) was higher than that of 24 cases with additional extremity trauma (6.96 ± 1.81). It was statistically significant (p=0.048). In comparison of union rates in related to IMN type, there was no statistically significance difference. Evaluation of continuous variables by Spearman Correlation Analysis has shown that there was a direct correlation between the fragment size and age. In addition, there was an indirect correlation between age and mean RUSF score at 12th month (Table 8).