JBJS -- Letters to the Editor for Mithoefer et al., 88 (4) 729-737

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Letters to the Editor to:

Scientific Articles:
Kai Mithoefer, David W. Lhowe, Mark S. Vrahas, Daniel T. Altman, Vanessa Erens, and Gregory T. Altman
Functional Outcome After Acute Compartment Syndrome of the Thigh
J Bone Joint Surg Am 2006; 88: 729-737 [Abstract] [Full text] [PDF]

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Electronic letters published:

Dr. Mithoefer et al. reply to Dr. Satpathy: Kai Mithoefer, M.D., David W. Lhowe, M.D., Mark S. Vrahas, M.D., Daniel T.Altman, M.D., Gregory T. Altman, M.D., and Vanessa Erens, DPT (13 June 2006)

Femoral Shaft Fractures Without Acute Compartment Syndrome Can Also Lead to Functional Deficit: Jibanananda Satpathy (17 May 2006)

Dr. Mithoefer et al. reply to Dr. Satpathy 13 June 2006

Kai Mithoefer, M.D.
Harvard Vanguard Orthopedics & Sports Medicine, Brigham & Women's Hospital, Boston, MA,
David W. Lhowe, M.D., Mark S. Vrahas, M.D., Daniel T.Altman, M.D., Gregory T. Altman, M.D., and Vanessa Erens, DPT
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Re: Dr. Mithoefer et al. reply to Dr. Satpathy

kmithoefer{at}partners.org Kai Mithoefer, M.D., et al.

We thank Dr. Satpathy for his interest in our study (1). We recognize the high prevalence of knee injuries associated with femur fractures as one of our investigators is also the senior author of an article quoted by Dr. Satpathy (2). However, functional deficits from concomitant knee injuries can be ruled out as a cause of the long-term functional deficits seen in our patients since no patient showed clinical evidence of ligamentous instability or meniscal pathology on the knee examinations routinely performed as part of our follow-up evaluations.
Quadriceps weakness and decreased knee range of motion has been associated with isolated femur fracture in several studies (3-6). However, careful review of the literature on muscle function after femur fracture shows that non-operative treatment including traction, casting, or bracing was used in up to 72% of patients in some of these studies (3). Prolonged muscle weakness and knee stiffness was primarily observed in patients with non-operative treatment and attributed to delayed treatment and muscular rehabilitation.(3, 4). In contrast, fracture fixation with intramedullary rodding and early rehabilitation resulted in minimal limitation of knee motion and quadriceps strength (3-6). Isokinetic testing demonstrated permanent quadriceps weakness in only 27-39% of patients with femur fracture without associated compartment syndrome treated with intramedullary nailing (5, 6). In fact, Staepperts and coworkers reported no significant difference between the intact leg and operated leg treated with intramedullary nailing (5).
Since fracture fixation in our study was achieved by intramedullary nailing in all but one patient with a femur fracture, low long-term morbidity would have been predicted. However, compared to the age and severity-matched historic controls, 83% of patients with combined femur fracture and acute thigh compartment syndrome presented with persistent thigh muscle weakness in our study. Therefore, the significant prevalence of functional limitations observed in our patients with combined femur fracture and thigh compartment syndrome cannot be attributed to the femur fracture alone as suggested by Dr. Satpathy, but rather to the associated acute compartment syndrome.
Thus, we conclude that isolated femoral fracture without associated injury does not produce the same level of long-term functional impairment as femur fracture combined with acute thigh compartment syndrome. Rather, the increased prevalence of long- term functional deficits in our study suggests that thigh compartment syndrome and femur fracture act synergistically in augmenting muscular injury and increase the incidence of permanent functional deficits.
References:
1. Mithoefer K, Lhowe DW, Vrahas MS, Altman DT, Erens V, Altman GT. Functional Outcome After Acute Compartment Syndrome of the Thigh. J Bone Joint Surg Am 2006; 88: 729-737
2. Dickson KF, Galland MW, Barrack RL, Neitzschman HR, Harris MB, Myers L, Vrahas MS. Magnetic resonance imaging of the knee after ipsilateral femur fracture.J Orthop Trauma. 2002 Sep;16(8):567-71.
3. Mira AJ, Markley K, Greer RB 3rd. A critical analysis of quadriceps function after femoral shaft fracture in adults. J Bone Joint Surg Am.1980; 62:61 -7. 4. Finsen V, Harnes OB, Nesse O, Benum P. Muscle function after plated and nailed femoral shaft fractures.Injury . 1993;24:531 -4.
5. Stappaerts KH, Broos P, Willocx T, Aelvoet C. Factors determining quadriceps function recovery following femoral shaft fractures. Unfallchirurg.1986; 89:121 -6.
6. Hennrikus WL, Kasser JR, Rand F, Millis MB, Richards KM. The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old. J Bone Joint Surg Am. 1993;75:508 -13.

Femoral Shaft Fractures Without Acute Compartment Syndrome Can Also Lead to Functional Deficit 17 May 2006

Jibanananda Satpathy,
Orthosurgeon
Oxford Radcliffe NHS Trust (Horton) UK
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Re: Femoral Shaft Fractures Without Acute Compartment Syndrome Can Also Lead to Functional Deficit

jibnapgi{at}hotmail.com Jibanananda Satpathy

To the Editor:
I read with interest the article by Mithoefer, et al, "Functional Outcome after Acute Compartment Syndrome of the Thigh�. I would note that there are other possible explanations for a residual functional deficit in these patients. For example, six of eight patients with long term functional deficits (Limp, patello-femoral pain, sensory deficit, limited knee ROM and gait) had femur fractures which underwent operative intervention. A fracture of the femoral shaft without thigh compartment syndrome can produce limp or knee pain. There is a high incidence of associated knee injuries with femur shaft fractures that can produce functional deficit(1,2).
Associated shortening following femur fractures can produce limp, and femoral shaft fractures have been associated with weakness of the quadriceps and decreased knee range of motion(3,4,5,6), as has been noted by the author.
It seems logical to conclude that an isolated femoral fracture without the associated complication of a compartment syndrome, could have produced the long term functional deficits reported in this study. Femoral shaft fractures, with or without compartment syndrome, can adversely affect long term functional outcome.
References:
1.Walking AK, Seradge H, Spiegel PG. Injuries to the knee ligaments with fractures of the femur. J Bone Joint Surg Am.1982;64(9):1324-7
2.Dickson KF, Galland MW, Barrack RL, Neitzschman HR, Harris MB, Myers L, Vrahas MS.Magnetic resonance imaging of the knee after ipsilateral femur fracture.J Orthop Trauma. 2002 Sep;16(8):567-71.
3.Mira AJ, Markley K, Greer RB 3rd. A critical analysis of quadriceps function after femoral shaft fracture in adults. J Bone Joint Surg Am.1980; 62:61 -7.
4.Stappaerts KH, Broos P, Willocx T, Aelvoet C. Factors determining quadriceps function recovery following femoral shaft fractures. Unfallchirurg.1986; 89:121 -6.
5.Finsen V, Harnes OB, Nesse O, Benum P. Muscle function after plated and nailed femoral shaft fractures.Injury . 1993;24:531 -4.
6.Hennrikus WL, Kasser JR, Rand F, Millis MB, Richards KM. The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old. J Bone Joint Surg Am. 1993;75:508 -13.