Eccentric Hexapod external fixator assisted closed reduction and intramedullary nail fixation for the treatment of femoral shaft fractures

OBJECTIVE: Closed reduction and intramedullary nail (IMN) fixation remains the gold-standard treatment for femoral shaft fractures (FSFs). However, technical challenges persist in achieving and maintaining anatomical alignment during the closed reduction process. This study aimed to evaluate the clinical efficacy of Hexapod external fixator (HEF)-assisted closed reduction and IMN fixation in the management of FSFs. METHODS: A retrospective cohort study was conducted on 25 patients undergoing closed reduction and IMN fixation with eccentric HEF assistance between June 2021 and January 2023. Operative parameters, including operative duration, blood loss, fluoroscopy frequency, reduction time, radiographic union time, and complication rates, were systematically recorded. Functional outcomes were evaluated at the final follow-up using the Liu et al. criteria, a validated scoring system for FSFs rehabilitation. RESULTS: All 25 patients underwent postoperative follow-up for 18-24 months (mean: 23.5 months). Closed reduction was achieved in all cases without requiring conversion to open reduction. The final radiographic evaluation confirmed radiographic union at the fracture site in all patients. A single case (4%) of delayed union (defined as incomplete bridging callus at 6 months) was managed by transitioning from static to dynamic interlocking screw fixation, achieving radiographic union at 9 months postoperatively. No instances of neurovascular injury, implant failure, deep infection, or nonunion were observed. The mean operative duration was 76.5 min (range: 46-102), with an average blood loss of 110.0 mL (range: 60-180). Fluoroscopy frequency averaged 8.4 exposures (range: 4-17), while reduction time and radiographic union averaged 9.5 min (range: 7-13) and 5.9 months (range: 3-9), respectively. According to the Liu et al. criteria, 21 cases (84%) achieved excellent outcomes and 4 (16%) were graded as good, resulting in a 100% excellent-to-good rate. CONCLUSION: The use of eccentric Hexapod external fixator assisted closed reduction and intramedullary nail fixation for the treatment of FSFs offers a reliable solution. Its ability to minimize soft tissue damage, reduce radiation exposure, and achieve high union rates positions it as a promising alternative to existing technologies.