Clinical and Radiological Outcomes After Surgical Treatment of Lower Limb Fractures in Patients With Spinal Cord Injury

Abstract

Study Design: Retrospective observational study. Objectives: To analyze the clinical and radiological outcomes of lower limb fractures following surgical treatment in patients with chronic spinal cord injury (SCI). Methods: Between January 2003 and December 2015, 102 chronic SCI patients with a lower limb fracture were surgically treated at our hospital. A total of 58 patients met the inclusion criteria and were recruited for final analysis. Patients with 2-stage procedure or incomplete clinical records with lost-to-follow-up were excluded from the study. Patients were divided into 2 groups (group 1= internal fixation; group 2 = external fixation). Primary outcome measures were to identify the number of nonunions via Kaplan-Meier analysis and the time to bone consolidation. The diagnosis of a pseudarthrosis was made after more than 180 days of consolidation time. Considering the Kaplan-Meier analysis, pseudarthrosis was interpreted as treatment failure. Secondary outcome measure was to evaluate the complication rate with special focus on heterotopic ossification. Results: A total of 58 chronic SCI patients with closed bone fractures were included in this study. Fifty-two fractures (88%) were simple and 7 (12%) were complex (type C) fractures according to AO classification. The majority of patients (34 cases, 59%) developed femur fractures followed by 24 tibial fractures (41%). Seventeen patients received an external (29%) and 41 an internal fixation (71%). Bone consolidation was reported in 31 patients (53%) with a mean time interval of bone consolidation after 97 days (range from 45 to 160 days; SD = 30). The reported nonunion (pseudarthrosis) rate was 47%. Comparing the internal group (n = 15 patients) versus the external group (n = 14), we could not find any significant difference ( P = .939) concerning the bone consolidation time. The Kaplan-Meier analysis showed a 75% cumulative survivorship at 120 days (internal group) versus 111 days (external group). Most common postoperative complications occurred in the internal fixation group with Wound infections being predominantly observed (10%), followed by heterotopic ossifications (8%). Conclusions: Our results show that surgical treatment of lower limb fractures in chronic SCI patients is a challenging treatment with a high pseudarthrosis rate in both groups. The complication rate seems to be lower in the patients treated with external fixation. As a clinical recommendation, longer implants should be used for a stable osteosynthesis since SCI patients seem to have a higher load on the osteosynthesis material due to missing sensomotoric feedback.

Bilateral Intertrochanteric Femur Fractures in a Paraplegic Patient: A Case Report

“…Bilateral IT fractures most often arise from high-energy trauma, though this fracture pattern can also be predisposed in patients with a varying degree of superimposed comorbidities. Moreover, spinal cord injuries resulting in paralysis have a well-established detrimental effect on lower extremity bone density and their management requires some unique considerations [ 13 - 17 ].…”

The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury

“…Upwards of half of patients with chronic SCI and a lower extremity fracture [ 60 , 61 ] may develop fracture-related complications. These include infections [ 15 , 182 , 190 ], compartment syndrome from a poor-fitting device for immobilization [ 197 ], heterotopic ossification [ 198 ], pressure injuries [ 60 , 61 , 185 , 199 ], fracture nonunion [ 60 , 155 , 193 ], venous thromboembolism [ 199 ], pain [ 12 ], autonomic dysreflexia and spasticity [ 60 ]. The extent to which depression and anxiety occur after a long bone fracture in patients with a SCI is not clear; affective disorders commonly complicate open lower-limb fractures in the AB population [ 200 ].…”