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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 121-125

Management of floating knees in adults: Experience from tertiary hospital


Department of Surgery, Federal Medical Centre, Birnin Kebbi, Kebbi State, Nigeria

Date of Submission22-Sep-2018
Date of Decision27-Nov-2018
Date of Acceptance05-Feb-2019
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Chikwendu Nwosu
Department of Surgery, Federal Medical Centre, Birnin Kebbi, Kebbi State
Nigeria
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DOI: 10.4103/smj.smj_25_18

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  Abstract 


Background: Floating knee is the term applied to the flail knee joint segment resulting from a fracture of the shaft or adjacent metaphysis of the ipsilateral femur and tibia. The fractures are often a result of high-energy trauma. Objectives: The aim of this study was to determine the pattern and distribution of these fracture types, mechanism of injury, associated injuries, method of treatment, complications, and the challenges encountered during the course of managing these patients. Patients and Methods: This is a retrospective study of all cases of floating knee injuries presenting to the Orthopedic Unit of Federal Medical Center and Surgery Department of Sir Yahaya Memorial Hospital all in Birnin Kebbi, Kebbi State, Northwest Nigeria, from January 2011 to December 2017. Data were extracted from the accident and emergency register, operation register, and patients' case folders. Data collected were analyzed using the Statistical Package for the Social Sciences for Windows version 22 (SPSS Inc. Chicago, Illinois, USA). Results: A total of 29 cases of floating knee injuries presented to the accident and emergency units. Males constituted 27 (93.1%) while females constituted 2 (6.9%). Motor vehicle accident was the most common mechanism of injury in 25 (86.3%) of the patients. The most common fracture type according to Fraser et al. classification is Type I which occurred in 12 (41.4%) of the patients. Conclusion: Floating knee injury occurs mostly in the productive age group. Head injury is the most common associated injury seen. This is mostly caused by motor vehicle accidents.

Keywords: Femur fracture, floating knee, Fraser's classification, multiple injury, tibial fracture


How to cite this article:
Nwosu C, Salawu ON, Mejabi JO, Fadimu AA. Management of floating knees in adults: Experience from tertiary hospital. Sahel Med J 2020;23:121-5

How to cite this URL:
Nwosu C, Salawu ON, Mejabi JO, Fadimu AA. Management of floating knees in adults: Experience from tertiary hospital. Sahel Med J [serial online] 2020 [cited 2020 Aug 4];23:121-5. Available from: http://www.smjonline.org/text.asp?2020/23/2/121/289347




  Introduction Top


Floating knee is the term applied to the flail knee joint segment resulting from a fracture of the shaft or adjacent metaphysis of the ipsilateral femur and tibia.[1] The fractures are often a result of high-energy trauma and may be associated with complex fracture patterns, significant soft-tissue damage, and other life-threatening injuries.[2] This complex injury has increased in proportion due to the population growth, number of motor vehicles on the road, and high-speed traffic.[3] Road traffic accident accounts for majority of the cases, and this is followed by fall from height.[4]

The exact incidence of this type of injury is unknown; however, Akinyoola et al.[5] reported 25 cases in Ife, Southwestern Nigeria, over a 5-year period. According to Fraser et al.,[6] the floating knee includes various patterns: bi-diaphysis fractures (Type I), mixed diaphysis fracture on a bone and epiphyseal fracture on the other (Type IIA and B), and bilateral epiphyseal fracture (Type IIC). In most of the cases, the fractures are open in nature, and the common combination is a closed fracture of femur and an open tibial fracture.[7] Complications, such as compartment syndrome, losing of knee movement, failing to identify knee ligament injury, and also the requirement for amputation, are not unusual.[8] The anterior cruciate ligament is the most affected and it can be associated with other ligamentous structures.[9]

Treatment planning for each fracture in the extremity should be individually considered so as to achieve the optimal result; fewer complications and better results are observed when both fractures are diaphyseal than when either of the fractures are intra-articular.[10] Surgical stabilization of both fractures and early mobilization of the patient and extremity produce the best clinical outcomes. Immediate or early fixation of the femoral fracture stabilizes the patient's condition and permits early mobilization, thus reducing the possibility of adult respiratory distress system, fat embolism and knee stiffness.[11] A thorough secondary survey is mandatory in a trauma patient because of concealed injuries as the deformed limb can be a major distracting factor and it is not unusual to miss the other injuries.[12]

The purpose of this study was to determine the pattern and distribution of these fracture types, mechanism of injury, associated injuries, method of treatment, complications, and the challenges encountered during the course of managing these patients. Necessary solutions toward overcoming these challenges will be proffered. This will provide essential information needed for hospital policy formulation as well as staff and infrastructural development.


  Patients and Methods Top


Study design:

This is a retrospective study carried out in the Orthopedic Unit of Federal Medical Center and Surgery Department of Sir Yahaya Memorial Hospital all in Birnin Kebbi, Kebbi State, Northwestern Nigeria, from January 2011 to December 2017.

Sampling technique

All cases of floating knee injuries presenting to the unit were studied. Data were extracted from the accident and emergency register, operation register and patients' case folders on biodata, diagnosis, mechanism of injury, fracture pattern, associated injuries, type of surgical procedure, date of surgery, time between presentation and surgery, and postoperative complications.

The floating knee injuries were classified according to Fraser et al.[6] classification using information got from the operation notes. Only files of patients with complete medical records were included in this study.

Data analysis

Data collected were analyzed using the Statistical Package for the Social Sciences for Windows version 22 (SPSS Inc., Chicago, Illinois, USA) after cross-checking for wrong data entry. Results were presented as percentages while data analysis included use of simple descriptive statistics and tables of frequency distribution.

Ethical consideration

All information obtained was treated with strict confidentiality to protect patients' identity. Ethical clearance was obtained from the hospital's Research Ethical Committee (FMC/BK/HP/045/P/517/Vol III) on 5th October 2018.


  Results Top


A total of 29 cases of floating knee injuries presented to the accident and emergency units. All had complete medical records. Males constituted 27 (93.1%) while females constituted 2 (6.9%). The male-to-female ratio was 13.5:1. The age range was from 21 to 66 years with a mean of 31 years. The 20–39 age group constituted 17 (58.6%) [Table 1]. Mean duration of hospital stay was 18 days. Motor vehicle accident was the most common mechanism of injury in 25 (86.3%) of the patients [Table 2].
Table 1: Age distribution

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Table 2: Mechanism of injury

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The most common fracture type according to Fraser et al.[6] classification is Type I which occurred in 12 (41.4%) of the patients [Table 3]. Ten (34.5%) patients presented with closed femoral and open tibial fractures; 9 (31%) patients presented with closed femoral and tibial fractures; 7 (24.2) patients presented with open femoral and tibial fractures, while 3 (10.3%) patients presented with open femoral and closed tibial fractures. Head injury was the most common associated injury and presented in 6 (20.7%) patients. One patient presented with ipsilateral posterior hip dislocation, which was reduced at the time of surgery [Table 4].
Table 3: Fracture type according to the Fraser's classification

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Table 4: Associated injuries

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Among these patients, 1 (3.4%) died as a result of severe head injury, 2 (6.9%) left against medical advice due to financial constraints, 3 (10.3%) were referred with severe head injuries for neurosurgical management, while 23 (79.4%) patients had surgical intervention. Among those that underwent surgery, 9 (39.2%) had locked intramedullary nailing for both tibia and femur, while 7 (30.5%) had locked intramedullary nailing for the femur and external fixation for the tibia [Table 5]. This is due to the open nature of the injury. The external fixator was replaced after callus formation by patella tendon bearing cast, with commencement of graduated weight bearing till union was achieved. K-wires were used to fix open distal femoral fractures. Knee joint stiffness occurred in 7 (30.5%) patients postoperatively followed by wound infection 4 (17.4%) [Table 6]. Nonunion of the tibia occurred in 2 patients following external fixation. These later had locked intramedullary nailing of the tibia. All the surgeries were performed by a consultant orthopedic surgeon.
Table 5: Surgical interventions

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Table 6: Postoperative complications

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  Discussion Top


The floating knee is a significant therapeutic challenge for the whole medical staff involved in multiple trauma patients' care.[13] The grossly deformed limb that one encounters in the floating knee can act as a major distracting factor, and it is not unusual to miss other significant injuries.[14] A careful evaluation of these injuries and resuscitation of the patient must precede the definitive management of specific fractures.[12]

This study showed a male preponderance. This is similar to the findings of other related studies.[1],[4],[5],[13],[14],[15],[16],[17],[18] This is due to the fact that males are the more active of the sexes, being breadwinners, and are more involved in trauma. The highest number of patients is in the productive age group. This is similar to the findings of Hegazy,[3] Nouraei et al.,[4] Akinyoola et al.,[5] Khawar S et al,[17] and Dwyer AJ et al.[19] This is indicative of the loss in productive time both to the patients and the society in general.

Motor vehicle accident is the most common mechanism of injury in these patients. This is similar to the findings of Elmrini et al.,[2] Nouraei et al.,[4] Feron et al.,[18] and Aher et al.[20] However, it contrasts with the findings of Akinyoola et al.,[5] Khawar S et al.,[12] and Dwyer et al.[19] who all reported motorcycle-related accidents as the most common mechanism of injury. The most common fracture type according to Fraser's classification [6] is Type I. This is in line with the findings of Elmrini et al.,[2] Akinyoola et al.,[5] Khawar S et al.,[12] Feron et al.,[18] and Aher et al.[20]

Locked intramedullary nailing for both the femur and tibia was the most common form of fixation. This is similar to the findings of Rethnam et al.,[1] Elmrini et al.,[2] Hegazy,[3] Feron et al.,[18] Dwyer et al.,[19] and Aher et al.[20] However, it contrasts with the findings of Nouraei et al.,[4] who reported plate and screws as the most common fixation method for both the femur and tibia. Intramedullary nailing of both femoral and tibial fractures has been preferred to external fixation, which is a more demanding method and has more complications.[12] Plating should be used in cases of intra-articular involvement of the distal femur, proximal tibia, and in Type IIC injuries, according to the Fraser classification.[21] The reduction of the articular surface is of paramount importance and cannot be overemphasized.[16] Additional benefits of plating include the simultaneous management of concomitant intra-articular soft-tissue pathology such as lateral meniscal tear through the same surgical incision.[15] External fixation of open tibial fracture is an acceptable form of treatment, but intramedullary implants should be opted for all closed and type 1 open injuries(Gustillo and Anderson).[11] Head injury is the most common associated injury in this study. This is in line with the findings of Rethnam et al.[1] and Elmrini et al.[2] However, it is at variance with the findings of Khawar S et al,[12] Feron et al.,[18] and Dwyer et al.[19] who all reported long bone fractures as the most common associated injury. Nouraei et al.[4] and Rahul et al.[22] reported pelvic injury and polytrauma, respectively, as the most common associated injury. The most common presenting injury type in this study is a combination of closed femoral fracture and open tibial fracture. This is similar to the findings of Dwyer et al.[19] and Aher et al.[20] It is in contrast with the findings of Khawar S et al.,[12] who reported closed femoral and closed tibial fracture as the most common presenting injury.

Stiffness of the knee joint is the most common postoperative complication in this study. It is similar to the findings of Elmrini et al.,[2] Hegazy,[3] and Khawar S et al.[12] However, it is at variance with the findings of Dwyer et al.[19] and Aher et al.[20] who reported delayed union and infection, respectively, as the most common postoperative complication.

Limitations

The limitation of this study lies in the fact that it is a retrospective study with limited information. The sample size in this study is small. This is in line with the findings of Rethnam et al.,[1] Elmrini et al.,[2] Hegazy,[3] and Aher et al.[20] This is an indication of the low prevalence of this condition. Further studies are needed to determine the functional long term outcome of management in these patients.


  Conclusion Top


Floating knee injuries occur more in males in the productive age group. Motor vehicle accident was the most common mechanism of injury. Fraser Type I fracture was the most common presenting type. Closed fracture of the femur and open fracture of the tibia were the most common presenting patterns. Head injury was the most common associated injury. Locked intramedullary nailing of both the femur and tibia was the most common form of fixation. Knee joint stiffness was the most common postoperative complication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rethnam U, Yesupalan RS, Nair R. The floating knee: Epidemiology, prognostic indicators; outcome following surgical management. J Trauma Manag Outcomes 2007;1:2.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
4.
Nouraei MH, Hosseini A, Zarezadeh A, Zahiri M. Floating knee injuries: Results of treatment and outcomes. J Res Med Sci 2013;18:1087-91.  Back to cited text no. 4
    
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Akinyoola AL, Yusuf MB, Orekha O. Challenges in the management of floating knee injuries in a resource constrained setting. Musculoskelet Surg 2013;97:45-9.  Back to cited text no. 5
    
6.
Fraser RD, Hunter GA, Waddell JP. Ipsilateral fracture of the femur and tibia. J Bone Joint Surg Br 1978;60-B: 510-5.  Back to cited text no. 6
    
7.
Prasad VK, Satyanarayana J, Narasimha RT, Satish P, Moorthy GV. A prospective study of 97 cases to arrive at treatment protocols for floating knee. J Evol Med Dent Sci 2015;4:3608-13.  Back to cited text no. 7
    
8.
Lundy DW, Johnson KD. “Floating knee” injuries: Ipsilateral fractures of the femur and tibia. J Am Acad Orthop Surg 2001;9:238-45.  Back to cited text no. 8
    
9.
Reis AC, Scattolini BB, Santos MG, Carvalho NA, Fukuda TY. Rehabilitation program in type 1 floating knee. A case report. J Appl Res 2011;11:49-54.  Back to cited text no. 9
    
10.
Shobha HP, Idris K, Lingaraju K, Rahul B. Functional outcome of surgical management of floating knee injuries in adults (Ipsilateral femoral and tibia fractures) and its prognostic indicators. Int J Orthop Sci 2017;3:305-8.  Back to cited text no. 10
    
11.
Johnson KD, Cadambi A, Seibert GB. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early stabilization of fractures. J Trauma 1985;25:375-84.  Back to cited text no. 11
    
12.
Khawar S, Rana DA, Ajmal Y. Floating knee injuries: postoperative complications and outcome. Journal of Pakistan Medical Association 2015;65:195-201.  Back to cited text no. 12
    
13.
Marco FA, Rozim AZ, Piedade SR. Knee joint stability in a floating knee condition. Acta Ortop Bras. 2008;16:32-6.  Back to cited text no. 13
    
14.
Singaravadivelu V, Jagannath PG, Mugundhan MS. Floating Knee Injury Associated with Patellar Tendon Rupture: A Case Report and Review of Literature. Case Reports in Orthopedics 2012:1-6.  Back to cited text no. 14
    
15.
Oh CW, Oh JK, Min WK, Jeon IH, Kyung HS, Ahn HS, et al. Management of ipsilateral femoral and tibial fractures. Int Orthop 2005;29:24550.  Back to cited text no. 15
    
16.
Muñoz VJ, Bel JC, Capel AA, Chana RF, Palomo TJ, Schultz LM, Tosounidis T. The floating knee: a review on ipsilateral femoral and tibial fractures. EFORT Open Rev 2016;1:375-82.   Back to cited text no. 16
    
17.
Jamali AA, Lee MA, Donthineni R, Meehan JP. Minimally invasive management of a floating prosthesis injury with locking plates. J Arthroplasty 2007;22:928-33.  Back to cited text no. 17
    
18.
Feron JM, Bonnevialle P, Pietu G and Jacquot F. Traumatic Floating Knee: A Review of a Multi-Centric Series of 172 Cases in Adult. The Open Orthopaedics Journal. 2015;9:356-60.  Back to cited text no. 18
    
19.
Dwyer AJ, Paul R, Mam MK, Kumar A, Gosselin RA. Floating knee injuries: long-term results of four treatment methods. International Orthopedics (SICOT) 2005;29:314-8.  Back to cited text no. 19
    
20.
Aher D, Sonkar D, Sharma P, Maravi D S. Functional Outcome of Operatively Treated Floating Knee Injuries in Adults. OrthopJMPC 2016;22:11-5.  Back to cited text no. 20
    
21.
Kumar A, Mam MK, Rajesh P. Ipsilateral Fracture of Femur and Tibia, Treatment and Functional Outcome. Journal of Medical Education and Research 2006;8:42-4.  Back to cited text no. 21
    
22.
Rahul NB, Sanjay SM. A study of associated injuries with fracture shaft of femur and tibia. MedPulse International Medical Journal, 2016;3:182-4.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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