| Abstract|| |
Context: Floating knee injuries are uncommon and complex injuries. Management of this injury has been variously described in the literature. Aims: We present the outcome of the intramedullary nailing using a single knee incision for treatment of extraarticular floating knee. Materials and Methods: We report a retrospective series of nine patients with extraarticular floating knee. Results: There were seven men and two women with an average age of 35 years. At least one of the fractures was open in three cases. The average Injury Severity Score was 17. According to Fraser's classification, 100% of the cases are type I. All our patients were treated by the intramedullary nailing using a single knee incision. The mean operating time was 146 min. The mean follow-up is 19 months. According to the Karlstrφm criteria, the end results were excellent in two cases, good in four, acceptable in two, and poor in one. Bone union was achieved in eight cases with an average period of 93 days. Conclusions: The intramedullary nailing using a single knee incision has shown in this series better results.
Keywords: Femur fracture, floating knee, intramedullary nailing, single knee incision, tibia fracture
|How to cite this article:|
Dahmani O, Elrhazi A, Elidrissi M, Shimi M, Elibrahimi A, Elmrini A. The intramedullary nailing using a single knee incision for treatment of extraarticular floating knee (nine cases). J Emerg Trauma Shock 2014;7:322-6
|How to cite this URL:|
Dahmani O, Elrhazi A, Elidrissi M, Shimi M, Elibrahimi A, Elmrini A. The intramedullary nailing using a single knee incision for treatment of extraarticular floating knee (nine cases). J Emerg Trauma Shock [serial online] 2014 [cited 2022 Jan 20];7:322-6. Available from: https://www.onlinejets.org/text.asp?2014/7/4/322/142774
| Introduction|| |
The floating knee is a concept defined by Blake and Mcbryde  to describe the ipsilateral fractures of the femur and the tibia, the most often encountered aspect is the extraarticular floating knee. It often results from high-energy trauma and is usually accompanied by other potentially vital lesions. ,
If the surgical treatment is favorable, the osteosynthesis techniques have evolved with the generalization of the anterograde than retrograde locked nailing, so the goal of our retrospective study is to highlight the long-term outcomes of the double nailing with single incision technique, which mean retrograde for the femur and anterograde for the tibia in the treatment of extraarticular floating knee.
| Materials and Methods|| |
This was a retrospective study of 11 patients treated between 2008 and 2011 for ipsilateral femoral and tibial diaphyseal fractures. Two patients were excluded from the study (lost of view), so only nine patients were included. The inclusion criteria were referring to the existence of extraarticular floating knee (type I classification Fraser et al., ) treated by the technique of double nailing all by the knee. Joint floating knee (type II classification of Fraser et al., ) and floating knees treated by other techniques were excluded.
Locoregional examination looked for skin opening (classified according to the classification Cauchoix et al., ), vascular or nerve damage, impairment of the central pivot of the knee, and other lesions. The general examination sought for associated lesions. The severity of the floating knee was evaluated using the Injury Severity Score (ISS) defined by Baker et al.
The radiological analysis of the lesions was made using the classification of Winquist and Hansen  for bone comminution and classification of Fraser et al., for histological types [Figure 1].
The fixation of the fractures consisted of a double nailing retrograde for the femur and anterograde for the tibia. This surgery was performed on an ordinary table, with a single internal parapatellar incision and a single installation [Figure 1]. The assessment criteria were surgical technique, operative time, per and postoperative complications, measuring the total operative bleeding (that was based on the calculation of the cell volume lost  which was difficult due to the emergency), and finally the length of hospitalization.
The clinical results were evaluated with the score Karlström and Olerud  [Table 1]. The radiological results were judged by the time of consolidation, the occurrence or not of the nonunion, and the presence or absence of the malunion.
| Results|| |
During the trauma, the average age was 35 years (19-52years). The gender distribution was predominantly male with seven men and two women. The fracture concerned the right side in five cases and the left in four cases.
The floating knee was closed in six patients. The femoral fracture was open in one case (stage I) and the tibial fracture was open in two cases (one case stage I and one case stage II). No vascular nerve or central pivot damage has been found. The association with other lesions was common: Two head injuries, one case of abdominal trauma, and other one of maxillofacial trauma. The mean ISS score was 17. Three patients had a score superior than 18 considered as a polytrauma.
According to the classification of Fraser et al., , all our patients have a type I floating knee [Figure 2]. For the femur fracture we had five cases of distal third, four cases of middle third. Concerning the tibia fractures, we found four cases of the middle third, three cases of proximal third and two cases of distal third. According to the Winquist and Hansen's classification,  we noted three type I fractures, four type II fractures, and two type III fractures.
|Figure 2: (a) Floating knee type I (b) Double nailing technique all by the knee (c) 11 months follow-up|
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The period of management was an average of three days (1-8 days). The nailing with single knee incision was performed in all cases. The mean operating time was 146 min (110-215 min). The operating time for femur was 70 min on average (35-120 min). Operative time for the tibia was 60 min (30-100 min). Open fractures treated with recommended antibiotics. No vascular or muscular action was necessary. The treatment of lesions has been carried out by multidisciplinary teams and intensive care was needed in one case.
The measurement of cell volume lost was difficult, but operative bleeding seems less than other surgical techniques (no cases of transfusion requirements have been reported). No septic or thrombotic complications have been found. There were no deaths in our series. The average hospital stay was 7 days with extremes of 4 and 21 days.
The average follow-up was 19 months (range: 4-40 months). The clinical results were evaluated with the score Karlström and Olerud  [Table 1]. It was excellent for two, good for four, medium for two, and bad for one (related to nonunion). Two patients showed a flexion deficit of the knee but still greater than 90°, but none had an extension deficit. We also noted a case of intermittent knee pain.
No rotational disorder has been reported. No anteroposterior instability of the knee or meniscal tear was diagnosed.
A favorable evolution with consolidation was noted in eight cases with 93 days as average time.
Aseptic nonunion of the femur occurred in one case [Figure 3], which was treated by decortication and graft.
|Figure 3: (a) In the immediate postoperative period (b) Aseptic nonunion of the femur after 8 months|
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The radiological evaluation of the nonunion showed axial deviations distributed as follows:
- The femur: Two varus (maximum 10°), one valgus (6°), a flexum (8°), and no recurvatum;
- The tibia: One varus (5°), no valgus, flexum none recurvatum.
No patient presented clinical repercussions requiring osteotomy. No difference in length of the lower limbs was noted.
| Discussion|| |
The relative scarcity of floating knee found in the literature ,,, should not obscure the severity of these injuries in the context of polytrauma.
In general terms, the floating knee most often occurs in polytrauma patients requiring multidisciplinary care. In our series, three patients were polytrauma. Schiedts et al.,  reported a 100% polytrauma rate. Mortality on arrival is reported with a rate of 5.6%  to 8.6%.  The skin wound is a common complication, 69% had at an open fractures. ,,,,,,,,,, Neurological involvement is reported in about 10% of cases and vascular in 6.4% of cases. ,,,,, The association of meniscal-ligamentous injury to a floating knee is a concept gained, though in our series no meniscal and none ligament injuries were found. McAndrew and Pontarelli  reported the lowest rate (7%). In most studies, ,,,,, the diagnosis of ligament damage is done at the stage of laxity. We believe that the search for knee ligament injuries was the rule after internal fixation of both fractures. Extraarticular type I floating knees are much more common than type II in all nonexclusive series. ,,, Note that our series focuses on the floating knee type I (100%).
Due to the scarcity of floating knees and their variability, the study of literature does not provide therapeutic guidelines especially for type II.  However, most authors recommend surgical treatment for both type I and for type II; ,,,,, and in the most recent series, the treatment of floating knee type I made the maximum use double nailing ,,,,, with two methods: Single versus double incision nailing technique. Comparing these two techniques, double nailing with single incision can make only one installation on ordinary radiolucent table with a significant time savings in both operative skin-to-skin time and the overall time including intervention and installation. , This interest of single incision has been pointed out by Ríos et al.,  for which the functional outcome is better. The criticism of this technique is mainly focused on the ligament problem. ,, Indeed, it seems difficult to make a repair center pivot or ligament with nails in place,  but we believe that ligament injuries are rare in type I floating knee, they are mostly confined in types II. Also, Gregory et al.,  has not found any case in the series, and so is in our study. In addition, all secondary intraarticular gestures, according Piétu et al.,  have been made only for the type II floating knee.
Functional results after ipsilateral fracture of the femur and tibia are difficult to assess given the diversity of evaluation criteria. In the series using criteria Karlström and Olerud, the rate of satisfactory results varies from 28%  to 83%.  In our series, the rate of satisfactory results is about 90%. The literature review showed that the functional level, age,  vascular involvement, joint or not floating knee,  opening fractures, and their complexity and their seat (distal femur)  appear to predominate as well as the involvement of the central pivot. The ISS does not appear to influence the functional result  and the detrimental role of smoking could not be assessed.  As a result, the floating knee type I has a better outcome that type II. , And according to our study, we can also deduce that the floating knee type I treated by nailing with single incision become better than those treated by t other osteosynthesis resources, because we found less intraoperative complications (less bleeding, less need for transfusion, less fat embolism) and even less postoperative complication (less risk of infection and less hospital stay), although functional outcomes, mobility, and patella syndrome are comparable.  This interest has been pointed out by Ríos et al.,  for which the functional outcome is better if single incision nailing technique is used.
The nonunion is a relatively rare complication in our series with a femoral nonunion in one case. Although with nailing the nonunion rate has decreased, it varies in the series of 4%-11% for the femur and 3%-30% for the tibia.  The factors included in the consolidation are age, sex, type of floating knee, seat, comminution, and open fractures. Malunions are relatively common and underline the difficulty to give a correct axis in case of floating knee. Karlström and Olerud  and McAndrew and Pontarelli  reported this complication in respectively 3% and 17.8% of cases. In our series, malunion was noted in three cases, neither is symptomatic. There was no significant difference in the incidence of nonunion or malunion between anterograde and retrograde nailing series.
| Conclusion|| |
Currently, double nailing is recommended in floating knee type I specially with single incision technique because it is more preferable: We used a single approach, a single installation, less bleeding, less risk of systemic complications (fat embolism), less operative time, less hospital stay, less risk of infection, but with a restriction due to the possible associated damage of central pivot. For satisfactory results, it is recommended to select patients (floating knee type I).
| References|| |
Blake R, Mcbryde A. The floating knee: Ipsilateral fractures of the tibia and femur. South Med J 1975;68:13-6.
Kao FC, Tu YK, Hsu KY, Su JY, Yen CY, Chou MC. Floating knee injuries: A high complication rate. Orthopedics 2010;33:14.
Rethnam U, Yesupalan RS, Nair R. Impact of associated injuries in the floating knee: A retrospective study. BMC Musculoskelet Disord 2009;10:7.
Fraser RD, Hunter GA, Waddell JP. Ipsilateral fracture of the femur and tibia. J Bone Joint Surg Br 1978;60-B:510-5.
Cauchoix J, Duparc J, Boulez P. Treatment of open fractures of the leg. Mem Acad Chir 1957;83:811-22.
Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-96.
Yokoyama K, Tsukamoto T, Aoki S, Wakita R, Uchino M, Noumi T, et al
. Evaluation of functional outcome of the floating knee injury using multivariate analysis. Arch Orthop Trauma Surg 2002;122:432-5.
Winquist RA, Hansen ST Jr. Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop Clin North Am 1980;11:633-48.
Brecher ME, Monk T, Goodnough LT. A standardized method for calculating blood loss. Transfusion 1997;37:1070-4.
Karlström G, Olerud S. Ipsilateral fracture of the femur and tibia. J Bone Joint Surg Am 1977;59:240-3.
Rethnam U, Yesupalan RS, Nair R. The floating knee: Epidemiology, prognostic indicators and outcome following surgical management. J Trauma Manag Outcomes 2007;1:2.
Mazas F, Capron M, De la Caffinière JY. The factors of severity in fractures of the lower femur. Rev Chir Orthop Reparatrice Appar Mot 1973;59:415-26.
Rööser B, Hansson P. External fixation of ipsilateral fractures of the femur and tibia. Injury 1985;16:371-3.
Schiedts D, Mukisi M, Bouger D, Bastaraud H. Ipsilateral fractures of the femoral and tibial diaphyses. Rev Chir Orthop Reparatrice Appar Mot 1996;82:535-40.
Dwyer AJ, Paul R, Mam MK, Kumar A, Gosselin RA. Floating knee injuries: Long-term results of four treatment methods. Int Orthop 2005;29:314-8.
Anastopoulos G, Assimakopoulos A, Exarchou E, Pantazopoulos T. Ipsilateral fractures of the femur and tibia. Injury 1992;23:439-41.
Gregory P, DiCicco J, Karpik K, DiPasquale T, Herscovici D, Sanders R. Ipsilateral fractures of the femur and tibia: Treatment with retrograde femoral nailing and unreamed tibial nailing. J Orthop Trauma 1996;10: 309-16.
Elmrini A, Elibrahimi A, Agoumi O, Boutayeb F, Mahfoud M, Elbardouni A, et al
. Ipsilateral fractures of tibia and femur or floating knee. Int Orthop 2006;30:325-8.
Hee HT, Wong HP, Low YP, Myers L. Predictors of outcome of floating knee injuries in adults: 89 patients followed for 2-12 years. Acta Orthop Scand 2001;72:385-94.
Van Raay JJ, Raaymakers EL, Dupree HW. Knee ligament injuries combined with ipsilateral tibial and femoral diaphyseal fractures: The "floating knee". Arch Orthop Trauma Surg 1991;110:75-7.
Veith RG, Winquist RA, Hansen ST Jr. Ipsilateral fractures of the femur and tibia. A report of fifty-seven consecutive cases. J Bone Joint Surg Am 1984;66:991-1002.
Paul GR, Sawka MW, Whitelaw GP. Fractures of the ipsilateral femur and tibia: Emphasis on intra-articular and soft tissue injury. J Orthop Trauma 1990;4:309-14.
Piétu G, Jacquot F, Féron JM, et les membres du GETRAUM. The floating knee: A retrospective analysis of 172 cases. Rev Chir Orthop Reparatrice Appar Mot 2007;93:627-34.
McAndrew MP, Pontarelli W. The long-term follow-up of ipsilateral tibial and femoral diaphyseal fractures. Clin Orthop Relat Res 1988:190-6.
Szalay MJ, Hosking OR, Annear P. Injury of knee ligament associated with ipsilateral femoral shaft fractures and with ipsilateral femoral and tibial shaft fractures. Injury 1990;21:398-400.
Bohn WW, Durbin RA. Ipsilateral fractures of the femur and tibia in children and adolescents. J Bone Joint Surg Am 1991;73:429-39.
Hung SH, Lu YM, Huang HT, Lin YK, Chang JK, Chen JC, et al
. Surgical treatment of type II floating knee: Comparisons of the results of type IIA and type IIB floating knee. Knee Surg Sports Traumatol Arthrosc 2007;15:578-86.
Hegazy AM. Surgical management of ipsilateral fracture of the femur and tibia in adults (the floating knee): Postoperative clinical, radiological, and functional outcomes. Clin Orthop Surg 2011;3:133-9.
Oh CW, Oh JK, Min WK, Jeon IH, Kyung HS, Ahn HS, et al
. Management of ipsilateral femoral and tibial fractures. Int Orthop 2005;29:245-50.
Ostrum RF. Treatment of floating knee injuries through a single percutaneous approach. Clin Orthop Relat Res 2000:43-50.
Ríos JA, Ho-Fung V, Ramírez N, Hernández RA. Floating knee injuries treated with single-incision technique versus traditional antegrade femur fixation: A comparative study. Am J Orthop 2004;33:468-72.
Grimme K, Gosling T, Pape HC, Schandelmaier P, Krettek C. Fracture of the medial femoral condyle as a complication of retrograde femoral nail removal. Unfallchirurg 2004;107:532-6.
Rethnam U. Single incision nailing of the floating knee - do we ignore the knee ligaments? Int Orthop 2006;30:311.
Yokoyama K, Nakamura T, Shindo M, Tsukamoto T, Saita Y, Aoki S, et al
. Contributing factors influencing the functional outcome of floating knee injuries. Am J Orthop 2000;29:721-9.
Bansal VP, Singhal V, Mam MK, Gill SS. The floating knee. 40 cases of ipsilateral fractures of the femur and the tibia. Int Orthop 1984;8:183-7.
Dr. Omar Dahmani
Department of Orthopaedics (B4), University Hospital Hassan II, Fez
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]