Intramedullary nailing of the femoral shaft: a prospective, randomized study

Outcome after intramedullary nailing of femoral shaft fractures

BACKGROUND

The results of intramedullary nailing of femoral shaft fractures from Australian institutions have not been widely reported. This study examines a consecutive group of patients treated at a major metropolitan trauma centre and reports on the injury statistics and outcome data, and compares this to previously reported results from the literature.

METHODS

A total of 101 fractures in 97 consecutive adult patients were included in the study. Nine patients were excluded. At a minimum of 6 months post injury, 54 patients were interviewed by telephone and 35 patients presented for clinical review and underwent physical examination, computed tomography (CT) scanogram of the lower limbs and Short Form 36 questionnaires.

RESULTS

Road trauma accounted for 81% of injuries and 15% of fractures were open. Of the 54 patients reviewed, 13 (23%) required further surgery for delayed or non-union. Of the 35 who presented for physical examination, there was poor correlation between perceived leg length discrepancy and measured leg length discrepancy on examination or scanogram. Presence of a limp correlated with measured leg length discrepancy of more than 1 cm but did not correlate with rotational abnormality measured on CT scanogram. Pain at the hip, thigh or knee was present in 60% of patients. The Short Form 36 scores for physical functioning, role--physical, bodily pain, general health and vitality were all significantly lower than population norms with P values ranging from <0.001-0.05. Subgroup analysis comparing isolated femur fracture to multi-trauma patients for all five of these parameters revealed significant differences only in the multi-trauma group.

CONCLUSION

The incidence of pain, limp, leg length discrepancy and delayed or non-union is higher in this study than in previously reported results of intramedullary nailing for femoral shaft fractures. This may be due to differences in the patient population, the skill level of the operating surgeon, or incomplete follow up.

Haste bloqueada "Faculdade de Medicina de Ribeirão Preto": experiência clínica no tratamento das fraturas femorais

Uma série de 103 casos de fraturas diafisárias complexas do fêmur foram tratadas com a haste intramedular bloqueada FMRP, no período de maio de 1987 a dezembro 1995. Das 103 fraturas, 67 eram cominutivas, 12 bifocais (segmentar), 4 espirais, 13 proximais e 21 distais, instáveis, rotacionalmente, da diáfise femoral. Do total dos casos, constatou-se 97 bloqueios estáticos e 6 dinâmicos. Dessas 97 estáticas, 7 foram dinamizadas durante a evolução. Clínica e radiográficamente a consolidação ocorreu em 97,09% dos casos, com média de 16,72 semanas e em 3 casos não houve consolidação. Houve 4 casos de infecção suspeita e 3 estabelecidas que foram debeladas e evoluíram para consolidação. Houve 81 casos de encurtamentos que variaram entre 0,5 a 4 cm com média de 1 cm. O encurtamento menor ou igual a 2 cm ocorreu em 73 casos. Desvio de alinhamento em qualquer plano acima de 10 º e igual a 15º foi observado em 8 pacientes. Houve 10 casos de deformidades rotacionais, porém nenhum caso acima de 10º. A incidência de infecção foi baixa e a de consolidação alta. A estabilização dessas fraturas complexas permitiu imediata mobilização do paciente, reabilitação precoce do membro e diminuição da permanência hospitalar, excetuando os politraumatizados. A haste FMRP permitiu o tratamento dessas fraturas sem o uso de intensificador de imagens e de fresas flexíveis com baixo custo operacional. Os resultados foram semelhantes aos obtidos com as hastes intramedulares bloqueadas que necessitam de aparelhagem técnica mais sofisticada, porém com vantagens para o paciente e a equipe cirúrgica.

Reamed intramedullary nailing of the femur: 551 cases

BACKGROUND

The care of the patient with the fractured femur entails a multiple surgical team approach. Healing of the fracture and expediency in the operating room are both important. We sought to determine the results of the treatment of fractures of the femoral shaft with interlocking femoral nails inserted with closed techniques, and to compare the outcomes of fractures nailed by using a fracture table with those stabilized with the leg draped free on a radiolucent table.

METHODS

Eight hundred eighty-two consecutive patients with fractures of the femoral shaft treated with a first-generation intramedullary nail at the authors' institution during the years 1986 to 1996 were identified. Five hundred fifty-one fractures in 515 patients met the inclusion criteria.

RESULTS

Treatment with an intramedullary nail led to a union rate of 98.9%. There were six infections, all occurring in closed fractures. Thirty-eight percent of the fractures had hardware removed, most commonly because of pain. One nail and 13 locking bolts broke. Four hundred eighteen fractures had adequate radiographs available to assess fracture alignment. No fracture healed with more than 10 degrees of angulation in either plane. Forty-four fractures healed with more than 5 degrees of angulation. A distal third fracture was found to be associated with an increased incidence of malalignment. There were no differences in outcomes between fractures stabilized with or without a fracture table.

CONCLUSION

Reamed intramedullary nailing of femoral shaft fractures results in a low rate of nonunion, malunion, infection, and hardware failure. There is no difference in the outcomes of fractures treated with and without the use of a fracture table. This is particularly useful in the patient with multiple injuries for whom transfer to a fracture table may not be time effective.

Length of operative procedures: reamed femoral intramedullary nailing performed with and without a fracture table

OBJECTIVES

To determine whether performing reamed intramedullary nailing of the femur without the use of a fracture table decreases the length of operation.

DESIGN

Retrospective.

SETTING

Level 1 trauma center, Nashville. Tennessee.

PATIENTS/PARTICIPANTS

Consecutively treated patients with fractures of the femoral shaft were treated with intramedullary nails from June 1986 to March 1996.

INTERVENTION

Reamed intramedullary nailing of the femoral shaft was performed with the use of a fracture table or with the leg draped free on a radiolucent table.

MAIN OUTCOME MEASUREMENTS

Length of anesthesia time, prep and drape time (from the point the anesthetized patient is turned over to the surgeons until incision), and intramedullary nailing time (from incision until end of surgery) for reamed intramedullary nailing of the femoral shaft performed with and without the use of a fracture table were compared.

RESULTS

Univariate analysis showed statistically significant decreases in the length of prep and drape time, operative time, and anesthetic time when fractures were treated without the use of a fracture table. Multivariate analysis showed that use of a fracture table prolongs prep and drape time (plus twenty minutes), operative time (plus seventeen minutes), and anesthesia time (plus seventy-three minutes) when the covariates of age, sex, fracture location, learning curve, position of the patient, nail brand, and number of distal bolts are controlled.

CONCLUSIONS

Reamed intramedullary nailing of the femoral shaft performed without the use of a fracture table is significantly faster than when the procedure is performed with a fracture table.

Mechanical characteristics of eight femoral intramedullary nailing systems

OBJECTIVE

There are few nonproprietary papers addressing the mechanical strength of intramedullary nails; none address the characteristics of the proximal and distal ends of these devices. Our objective was to provide such data.

DESIGN

Independent testing of eight femoral intramedullary nail systems at the proximal, middle, and distal regions was undertaken to evaluate strength and flexural rigidity (stiffness).

METHODS

Each device, usually a reconstruction nail, was forty-two to forty-six centimeters in length. Four or five nails of each available size (range 9 to 13 millimeters in diameter) were tested for each system. The nails were cut into proximal, middle, and distal thirds. Each nail section was loaded to failure using a four-point bend test on a custom fixture (modification of the American Society of Testing Materials standard test).

RESULTS

Significant variations (p < 0.05) were found in strength and stiffness between the middle and the proximal or distal aspects of some rods. A significant difference (p < 0.05) was observed when comparing the properties of earlier designs with the properties of more recent designs. Newer rod designs all performed in a similar manner with regard to strength. Strength and rigidity increased with increasing rod diameter in some but not all systems.

CONCLUSIONS

Although none of the newer designs appeared to have superior static strength, the individual systems had significant variations in their mechanical properties (bending rigidity), particularly in the proximal and distal sections. It is important that the surgeon become familiar with the individual characteristics of strength and rigidity for the particular devices available and how these might impact fracture healing. Consideration of this information could alter the decision to select one system over another in a complex fracture situation.

The rationales of interlocking nailing of the femur, tibia, and humerus

Interlocking nailing has been increasingly used to treat acute and chronic afflictions of long bones. Although the interlocking construct is similar, regardless of the anatomic area of application, the results and complications of this type of fixation in the femur, tibia, and humerus differ. This review compares the anatomy, biologic response to injury, and functional expectations of these 3 distinct long bones with respect to interlocking nailing. Final results seem related more closely to the bony anatomy and soft tissue injury than to any inherent success of interlocking techniques.

Locked Femoral Nailing

Locked intramedullary nailing has become the standard of care for most femoral fractures. Originally designed to prevent rotation and shortening in comminuted fractures of the midshaft, its application has been extended proximally and distally to nearly all femoral fractures from the lesser trochanter to the supracondylar area. Achieving a closed reduction and selecting the proper starting point in the piriformis region are crucial to a successful result. Following the proper surgical technique for the specific nail used is more important than nail material or design. Large-diameter reamed nails provide greater strength than unreamed nails. Static locking has been shown to yield nearly the same high union rates as dynamic locking and is now the accepted standard. Distal targeting of the interlocking screw remains the most difficult aspect of the surgical technique; most surgeons prefer freehand targeting with a sharp trocar. Second-generation (reconstruction) nails, with screws directed toward the femoral head, has extended the indications for locked nailing proximally to subtrochanteric fractures and combined femoral neck-shaft fractures.