Intramedullary nailing of the femur: reamed versus nonreamed

Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults

BACKGROUND

Plate osteosynthesis is the most commonly used technique for the treatment of diaphyseal forearm fractures in adults. However, application of a plate can disrupt the periosteal blood supply and necessitates skin incisions that may be unsightly, and there is a risk of refracture if the implant is removed. The purpose of this study was to assess the early results of the use of a contoured interlocking intramedullary nail to stabilize displaced diaphyseal fractures of the forearm.

METHODS

Between January 2004 and July 2006, a total of thirty-eight interlocking intramedullary nails were inserted into the forearms of twenty-seven adults. Eighteen nails were used in the radius and twenty were used in the ulna to stabilize a diaphyseal fracture. The mean follow-up period was seventeen months. Functional outcomes were assessed with use of the Grace and Eversmann rating system, and patient-rated outcomes were assessed by completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

The average time to fracture union was fourteen weeks. There was one nonunion of an open comminuted fracture of the middle third of the ulna. There were no deep infections or radioulnar synostoses. According to the Grace and Eversmann rating system, twenty-two patients (81%) had an excellent result; three (11%), a good result; and two (7%), an acceptable result. The DASH scores averaged 15 points (range, 5 to 61 points).

CONCLUSIONS

Our experience indicates that the advantages of an interlocking intramedullary nail system for the radius and ulna are that it is technically straightforward, it allows a high rate of osseous consolidation, and it requires less surgical exposure and operative time than does plate osteosynthesis. We suggest that the interlocking intramedullary nail system be considered as an alternative to plate osteosynthesis for selected diaphyseal fractures of the forearm in adults.

Trochanteric nail insertion for the treatment of femoral shaft fractures

OBJECTIVES

This study was designed to evaluate whether the use of a new femoral nail, specifically designed to be inserted through the greater trochanter, could eliminate the complications previously seen with insertion of straight nails through this entry portal for the treatment of femoral shaft fractures.

DESIGN

Prospective, clinical trial.

SETTING

Three level I trauma centers.

PATIENTS

Sixty-one consecutive patients with femoral shaft fractures (50 closed and 11 open fractures) treated with antegrade nailing with insertion through the greater trochanter.

INTERVENTION

All patients were treated in the supine position with a TAN nail (Trigen System, Smith & Nephew, Memphis, TN) inserted through the greater trochanter.

MAIN OUTCOME MEASURE

Union, alignment, complications, and hip function.

RESULTS

Forty-six of 57 (81%) surviving patients were available for follow-up at a minimum of 12 (range, 12-25) months. Union occurred in all but 1 fracture after the index procedure. No patient sustained iatrogenic fracture comminution, and there were no angular malunions. Pain was reported as slight in 6 patients and moderate in 2. Visual and videotaped gate analysis, performed on 24 patients, revealed symmetrical walking in 21.

CONCLUSIONS

This study demonstrates that antegrade nailing of femoral shaft fractures with a specially designed nail inserted through a trochanteric starting point provides predictably high union rates and low rates of complications. Ease of entry and utility in patients with a large body habitus are advantages over conventional piriformis fossa entry techniques. Nailing through the greater trochanter with the patient supine is presently our treatment of choice for patients with femoral shaft fractures.

Pressurization of the Metastatic Femur During Prophylactic Intramedullary Nail Fixation

BACKGROUND

Venting during prophylactic nailing of metastatic femoral lesions may decrease intramedullary pressures and the risk of fat and tumor embolization. This study aimed to quantify maximum intramedullary pressure levels and durations, and to examine tumor displacement during prophylactic reamed intramedullary nailing of vented and nonvented metastatically involved femora.

METHODS

Proximal metastatic defects were simulated in six pairs of cadaveric femora and prophylactically treated using reamed intramedullary nailing with or without proximal and distal vents. Maximum pressures, durations of pressure exceeding embolic threshold levels (25 and 200 mm Hg), and tumor displacement were recorded.

RESULTS

Maximum pressures and durations of pressure exceeding embolic thresholds decreased more than 50% with venting (p < 0.05). Distal pressures surpassed the 25-mm Hg threshold even with venting. Post-test sectioning showed increased tumor disbursement in vented specimens.

CONCLUSIONS

Venting reduces pressurization during prophylactic reamed intramedullary nailing of femoral metastases, but may increase the spread of tumor to extraskeletal tissue if vented tissue is not contained.

The Holland nail: a universal implant for fractures of the proximal femur and the femoral shaft

OBJECTIVE

To study the possibilities and outcomes for hip and femoral fractures treated with the universal Holland nail((R)).

DESIGN

Retrospective study from November 1998 to December 2001.

SETTING

Department of Traumatology, Erasmus Medical Centre, Rotterdam.

SUBJECTS

112 patients with 115 fractures of the proximal femur and/or the femoral shaft, due to traumatic causes or to metastatic disease.

MAIN OUTCOME MEASURES

Implant possibilities of the Holland nail((R)) and observed complications.

RESULTS

110 patients presented for primary fracture treatment. Two patients were treated secondarily. In three patients, both femora were fractured. Nineteen patients suffered a pathological (impending) fracture. During operation we dealt with 27 minor difficulties. Postoperatively, in 80% of the cases full weight-bearing was allowed. Three patients developed wound infection. In follow-up, 14 patients were lost and two died. The remaining 77 patients (80 fractures) were available for follow-up with regard to fracture healing. Overall consolidation was achieved in 89% of the patients within 12 months. Two patients developed perforation of the femoral head, necessitating removal of the hip screws, and in two patients failure of the nail was seen. Overall, 19 patients needed a non-planned secondary intervention, of which 12 were deemed a minor procedure (e.g. 'dynamisation by distal screw removal').

CONCLUSION

The Holland nail((R)) is technically easy to use for any type of hip and femoral-shaft fracture.

Bone formation following intramedullary femoral reaming is decreased by indomethacin and antibodies to insulin-like growth factors

OBJECTIVE

We aimed to: 1). compare rates of in vitro bone formation following reamed and nonreamed intramedullary fixation in a murine model of femoral fracture healing; and 2). examine whether antibodies to insulin-like growth factor (IGF) I, IGF II, or indomethacin (an inhibitor of the inflammatory process) affect bone formation following intramedullary reaming.

DESIGN

Experimental study.

PARTICIPANTS

Twenty-four C57 black mice were randomized to two groups: reamed ( = 12), and nonreamed intramedullary nail insertion ( = 12).

INTERVENTION

In the reamed group, the femoral canals were successively reamed with 30-, 27-, 25-, and 23-gauge stainless steel pins and stabilized with a 27-gauge pin. In mice randomized to the nonreamed group, a 27-gauge pin was inserted. An external three-point bending force created a midshaft transverse femoral fracture. Seven days postsurgery, each mouse was killed, and the right femur was removed. Following pin removal, the callus was minced, the bone marrow was removed, and both were ultracentrifuged at 1200 rpm for 5 minutes. The supernatent was cocultured with 3-day-old murine calvarial cells in culture media. At day 5 of culture, reamed plasma and calvarial cell cocultures were exposed to either 1.0 micro g/mL of anti-IGF I, 1.0 micro g/mL of anti-IGF II, 2 micro M indomethacin, or served as controls (calvarial cells only). The cells were cultured for a total of 21 days.

MAIN OUTCOME MEASUREMENTS

The number of bone nodules was quantified by light microscopy.

RESULTS

Reamed pin insertion resulted in 4.1-fold and 8.9-fold increases in the mean number of bone nodules compared to pins inserted without reaming and controls, respectively (399 +/- 40.0 vs. 97.0 +/- 21.0, < 0.001). The positive effect of intramedullary reaming on bone nodule formation was reversed with the administration of antibodies to IGF I and IGF II. The addition of anti-IGF I or anti-IGF II to calvarial, or osteoblastlike, cells treated with supernatent from the callus and bone marrow of mice with prior intramedullary reaming resulted in significant declines in the mean number of bone nodules ( < 0.001). Specifically, treatment of osteoblastlike cells with anti-IGF I or anti-IGF II resulted in 7.0-fold and 5.4-fold declines in mean bone nodule formation compared to cells without such treatment.

CONCLUSIONS

Intramedullary reaming prior to pin insertion resulted in a significantly greater number of bone nodules than pin insertion only. Antibodies to IGF I, IGF II, and indomethacin reversed the stimulatory effect of reaming on bone nodule formation, suggesting their role in modulating the course of fracture healing following intramedullary reaming.

Early weight-bearing after statically locked reamed intramedullary nailing of comminuted femoral fractures: is it a safe procedure?

BACKGROUND

The purpose of this study was to determine the safety of early weight-bearing after statically locked reamed nailing of comminuted fractures of the femoral diaphysis, and to assess the rate of implant failure and fracture healing.

METHODS

Thirty consecutive patients with comminuted diaphyseal femur fractures (Winquist type II, III, and IV) were treated with statically locked reamed intramedullary nailing. Six patients were lost to follow-up, and the remaining 24 patients were followed at least 1 year. Early weight-bearing was allowed and encouraged in the first 2 weeks after the operation. The nail diameters were 13 mm in 16 patients, 12 mm in 6 patients, and 14 mm in 2 patients.

RESULTS

Most of the patients could start weight-bearing between the first 2 and 4 weeks postoperatively. None of the patients, except one, were using any walking aids at the second month postoperatively. All the fractures healed without any significant complications. Nail bending or breakage did not occur in any patients, but there was slight bending in one distal interlocking screw and one proximal interlocking screw. The fractures of the patients with bent screws healed uneventfully.

CONCLUSION

This study showed that early weight-bearing after reamed static interlocking nailing of Winquist type II, III, and IV femoral fractures is a safe and effective method, and the risk of implant failure does not preclude the procedure.