Unreamed intramedullary nailing of femoral fractures

Treatment strategies for intramedullary nailing of femoral shaft fractures

Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).

The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures

INTRODUCTION

Stabilisation of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults. To ream or not to ream is still debated. The primary objective of this study was to determine the incidence of non-union following unreamed intramedullary stabilisation of femoral fractures. Secondary objectives were intra- and postoperative complications and implant failure.

METHODS

Between March 1995 and June 2005, 125 patients with 129 traumatic femoral shaft fractures were treated with as unreamed femoral nail. From this retrospective single centre study, 18 patients were excluded due to insufficient follow up data, including 1 patient who died within 2 days after severe head injury. Sixty-six patients had suffered multiple injuries. 21 fractures were open. According to the AO classification, there were 54 type A, 42 type B, and 14 type C fractures. Dynamic proximal locking was performed in 44 cases (36 type A and 8 type B fractures).

RESULTS

Non-union occurred in two patients (1.9%; one type B and one type C fractures). Intra-operative complications were seen in three patients (2.8%). Postoperative in-hospital complications occurred in 29 patients (27%). Local superficial infection occurred in two patients (1.9%), there were no cases of deep infection. Implant failure occurred in three patients (2.8%): nail breakage was seen in two patients.

CONCLUSION

In this study, the incidence of non-union following unreamed intramedullary nailing is low (1.9%) and comparable with the best results of reamed nailing in the literature.

ENTRY POINT FOR THE ANTEGRADE FEMORAL INTRAMEDULLARY NAIL: A CADAVER STUDY

Objective: To analyze the natural exit of the wire guides in major trochanter through retrograde femoral approach, in cadaver specimens. Material and Method: 100 femurs had been perforated between the femoral condyles, at 1.2 cm of the intercondylar region. A 3-mm straight wire guide was introduced, through retrograde approach, until the proximal extremity of femur was reached. Femurs were assessed for posterosuperior and anterosuperior portions of major trochanter, pear-shaped cavity, and upper median line between the head-neck and the major trochanter. Results: in 62%, the straight wire guides exited at the anterior surface of major trochanter. In the pear-shaped cavity, the median distance found was 1.0 cm and the interquartile range was 0.5 cm, initially expressing, in relation to pear-shaped cavity, better accuracy. Conclusion: the central axis of the medullar canal, at coronal plane, projected better accuracy in the region of the pear-shaped cavity.

Management of open fractures of the tibial shaft in multiple trauma

BACKGROUND

The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients.

MATERIALS AND METHODS

The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8-10 days after the trauma.

RESULTS

The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation.

CONCLUSION

Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8-10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.

Correct anatomical location of entry point for antegrade femoral nailing

Closed intramedullary nailing is a well-accepted method of treatment for femoral shaft fractures. The issue of the correct entry point for antegrade nailing remains a matter of controversy, and the literature is confusing. We reviewed the opinions of 100 orthopaedic surgeons by means of questionnaires. Only four surgeons were able to identify and label their respective entry points for femoral nailing correctly, possibly because of incorrect illustration in publications or errors in terminology. Although the piriformis fossa appears to be the ideal entry point, the importance of exact localisation in the sagittal plane, centered over the axis of medullary canal, cannot be overlooked.

Fat embolism: the reaming controversy

Intramedullary nailing is the preferred treatment method for stabilizing femoral diaphyseal fractures. Despite its superior biomechanical advantages over other implants, its use, particularly in selected groups of patients, has been questioned because of the possible harmful systemic effects of intramedullary reaming. The increase in intramedullary canal pressure during intramedullary nailing can result in intravasation of bone marrow and fat into the venous blood system. The subsequent consequences can be fat embolism syndrome (FES), adult respiratory distress syndrome (ARDS), and multiple organ failure. The lung seems to be the primary target for fat embolization and for the mediated effects primed by inflammatory reactions. In laboratory studies, both reamed and unreamed intramedullary nailing has been shown to alter selected pulmonary variables. Although transient, this effect appears to be more prominent with reamed than unreamed techniques. Additional studies are required to determine whether a subgroup of trauma patients is adversely affected by intramedullary reaming, thus necessitating other fixation techniques.

Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis

The purpose of this study was to use multivariate analysis to evaluate contributing factors affecting deep infection and nonunion of open femoral fractures treated with locked intramedullary nailing (IMN). We examined 89 open femoral fractures (88 patients) treated with immediate or delayed locked IMN in static fashion at the Kitasato University Hospital from 1988 to 2001. Multiple regression models were derived to determine predictors of deep infection and nonunion. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type (I+II or III), fracture grade by AO type (A or B+C), fracture site (proximal site+distal site or middle site), timing or method of IMN, reamed or unreamed nailing (R versus UR), debridement time (< or =6 h or >6 h), existence of polytrauma (ISS<18 or ISS> or =18), and existence of floating knee injury (+ or -). The predictive variables of nonunion selected for analysis were the same as those for deep infection, with the addition of deep infection (+ or -). Five fractures (5.6%) developed deep infections: one Gustilo type II and four type III. Multivariate analysis revealed that only Gustilo type significantly correlated with occurrence of deep infection (p<0.05). Nonunion occurred in 12 fractures (14.1%). Multivariate analysis revealed that only fracture grade by AO type significantly correlated with occurrence of nonunion (p<0.02).

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.

Damage control: extremities

The principles of fracture management in polytrauma patients continue to be of crucial importance. Over the last five decades, various strategies of fracture treatment in the multiply injured patient have evolved. The various new methodologies remain controversial. In the beginning, early surgical fracture treatment of long bone fractures after multiple trauma was not routinely advocated. It was believed that the polytraumatised patient did not have the physiological reserve to withstand prolonged operations. The introduction of standardised, definitive surgical protocols, led to the concept of early total care (ETC) in the 1980s. This concept was subsequently applied universally, in all patient groups, regardless of injury severity and distribution. Later, it became apparent that certain patients did not appear to benefit from ETC. Indeed, extended operative procedures, during the early phase of multiple trauma recovery, were associated with adverse outcome. This applied for patients with significant thoracic, abdominal and head injuries and those with high injury severity scores (ISS). In response, the concept of damage control orthopaedics (DCO) was developed in the 1990s. DCO methodology is characterised by primary, rapid, temporary fracture stabilization. Secondary definitive management follows, once the acute phase of systemic recovery has passed. We explore the processes underlying the systemic biological impact of fracture fixation, the evolution of operative treatment strategies for major fractures in polytrauma and the current trends toward staged management of these patients.

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.

Antegrade femoral nailing: an anatomical determination of the correct entry point

Operative problems in the application of femoral locking nails are frequently related to an unfavourable entry point at the greater trochanter. Especially in more distally located fractures the nail is forced to follow the cortex abutted medullary canal. A wrong defined entry point either in the medio-lateral or dorso-ventral direction inevitably leads to tension between nail and femur. Forceful insertion in this situation may cause disastrous iatrogenic comminution at the fracture side or additional fractures at the proximal femur. To avoid tension between nail and femur the best suited entry point must be defined according to the natural medullary cavity. In 16 human cadaver femora, the natural medullary cavity was opened and after cleaning filled with a radio-opaque substance (barium sulphate). Twelve radiographs where taken from each bone starting with the anterior-posterior view and then turning the bone axially in steps of 15 degrees. From these radiographs, the ideal entry point at the greater trochanter was calculated. In 88% of the specimen the ideal entry point for a straight nail was found constantly at the medial border of the greater trochanter overlaying the tendinous insertion of the piriformis muscle. The axis of the medullary cavity was in average 2.1cm anterior to the dorsal border of the greater trochanter. In a second step the ideal entry point for bend nails was calculated. According to this calculation a bend nail with a radius of 100 cm needs an entry point 0.7 mm anterior to the dorsal edge of the greater trochanter. Overlaying the hook like shape of the posterior part of the trochanter.

Treatment of femoral shaft fractures with a titanium intramedullary nail

Ninety-nine femoral shaft fractures were treated with locked intramedullary nails made from titanium alloy. One of the distal interlocking screws failed in six fractures (6%) and both screws failed in two fractures (2%). Delayed union was associated with all of the eight fractures that had locking screw failure. Young, heavier patients who had nails of small diameter had an increased risk of screw failure. Additional surgery was needed when both screws failed. The authors still use this nail, but currently prefer to ream the medullary canal more so that larger nails can be inserted. Decisions concerning weightbearing are made on an individual basis for each patient, and currently full weightbearing is delayed for young, active, and heavy patients. Two distal interlocking screws should be inserted for treatment of femoral shaft fracture when a Ti locked intramedullary nail is used.

The Marchetti-Vicenzi elastic locked nail for the treatment of femoral shaft fractures: a review of 100 consecutive cases

A total of 100 hundred femoral fractures in 97 patients were treated with the Marchetti-Vincenzi universal bundle elastic nail; six of the fractures were open. Closed fractures were classified according to AO and Winquist; open fractures were classified according to Gustilo. A total of 91 fractures united (average 12 weeks) and six led to non-union. There were two deep and one superficial infections. In three cases, the secondary nails protruded from the anterior cortex of the femoral condyle; in two cases intraoperatively and in the third case 2 months postoperatively, due to severe osteoporosis. The cylindrical part of the nail did not fail, whereas all the secondary nails failed in one patient as well as one secondary nail in another patient at the level of the fracture; these two cases exhibited non-union. We consider the absence of distal screws the major advantage of this particular nail, followed by position of the entry point and the limited reaming. We believe that the absence of a pin guide is a disadvantage. The elasticity of the nail has a positive effect in certain cases while in other cases it acts negatively, resulting in a relatively high proportion of non-unions as in our series. Therefore our conclusion is that this nail is not appropriate for the treatment of femoral shaft fractures.

Unreamed femoral nailing

Sixty one femoral fractures treated with ACE unreamed titanium nail (AIM femoral nail, ACE Medical, Los Angeles, CA) were studied. Ten patients died before bony union and three were lost to follow up. Forty eight fractures were followed up for an average of 11.2 months (4-31 months). All fractures united except one in which plating and bone grafting was performed at 6 months due to failure of progression of union. The mean time to bony union was 6.2 months. There was no implant failure but one distal interlocking bolt broke at 6 weeks. No incidence of adult respiratory distress syndrome (ARDS) was observed. Malunion was seen in one patient whereas three cases had shortening of more than 2 cm. Our results show that unreamed femoral nailing using titanium nail is a safe and effective procedure for the treatment of femoral shaft fractures.

The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device

We present the clinical and radiographic results of a prospective study with the Orthofix tibial nailing system. The ease and safety of distal locking with the use of an improved targeting system was also evaluated. Sixty fresh tibial fractures in 60 patients with a mean age of 37.3 years (range 17-73 years) were treated. Eighteen of the fractures were grade I open fractures. All operations were performed in a conventional operating theatre on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site. Hand reaming was then performed to ensure, where possible, the insertion of a nail of at least 9 mm in diameter. Fracture healing was observed at a mean of 17 weeks (12-28 weeks). No tibial non-unions occurred in our series, and only three fractures, two segmental and one severely comminuted, showed delayed union. No infection, either superficial or deep, was found and no cardio-pulmonary complications were recorded. Following surgery, all patients gained a full range of pain-free movement of the ankle and knee joints and only six patients (10%) complained of mild anterior knee pain. All patients returned to their previous jobs one month after fracture healing had been confirmed clinically and radiographically. Following nailing, no deviation from normal tibial alignment was detected. No mechanical failure of either the nails or the locking screws was recorded. The mean duration of operation (skin to skin) was 30 min (range 20-45 min) and the mean total theatre time was 55 min (range 40-75 min). The mean total intensification time was 5 s. In total, 120 distal locking screws were inserted using the external targeting device. All attempts at distal locking except five (4.2%) were successful with two failures in the same patient being a result of inappropriate use of the system. We conclude that this nailing system is clinically effective and that distal locking can be performed easily, without exposure to radiation.

Intramedullary nailing of the femur: reamed versus nonreamed

All intramedullary nailing creates some loss of endosteal blood supply and an increase in intramedullary pressure, resulting in marrow embolization. In laboratory studies, both reamed and nonreamed intramedullary nailing have led to alteration in selected pulmonary variables. This effect, although transient, appeared more pronounced with reamed techniques than with nonreamed techniques. Concern about the systemic pulmonary effects of reamed intramedullary nailing has led to an increase in the use of nonreamed nailing. The authors of most clinical studies have reported that reamed intramedullary nailing has not been associated with a concomitant increase in pulmonary complications in multiply injured patients, although this point is still controversial. Femoral shaft fractures treated with nonreamed nailing have been shown to have slightly higher rates of delayed union and nonunion compared with those treated with reamed nails. Reamed interlocking intramedullary fixation remains the treatment of choice for femoral shaft fractures in adults. Further study is required to determine whether an identifiable subgroup of trauma patients is adversely affected by intramedullary reaming, which would suggest the need for alternative fixation techniques.

Reamed versus nonreamed anterograde femoral nailing

OBJECTIVE

To compare reamed femoral nailing with unreamed femoral nailing.

DESIGN

Prospective, randomized.

SETTING

Two Level One trauma centers.

PATIENTS

One hundred seventy patients with 172 femur fractures were randomized to an unreamed or reamed group. MAIN OOUTCOME MEASURES: Data included demographics, Injury Severity Score (ISS), operative time, blood loss, blood and fluid requirements, technical complications, time to callus formation, time to union, and complications.

RESULTS

There was no statistical difference in operative time, transfusion requirements, or hypoxic episodes between the groups. Intraoperative blood loss was greater in the reamed group. The time to union was 80 +/- 35 days for the reamed group and 109 +/- 62 days for the unreamed group (p = 0.002). This difference was most dramatic in the distal femur, with union in the reamed group occurring in 80 days compared with 158 days in the unreamed group (p = 0.012). There were more technical complications and delayed unions in the unreamed group.

CONCLUSIONS

There is no advantage to the routine use of nailing without reamed insertion. Fractures treated with reamed nails heal faster than those treated with unreamed nails, especially distal fractures.

Intramedullary pressure and bone marrow fat extravasation in reamed and unreamed femoral nailing

This study was designed to investigate whether intramedullary pressure and embolization of bone marrow fat are different in unreamed compared with conventional reamed femoral nailing in vivo. In a baboon model, the femoral shaft was stabilized with interlocking nailing after a midshaft osteotomy. Intramedullary pressure was measured in the distal femoral shaft fragment at the supracondylar region. Extravasation of bone marrow fat was determined by the modified Gurd test (range: 0-5) with blood samples from the vena cava inferior. Data were monitored in eight unreamed and eight reamed intramedullary femoral nailing procedures. Intramedullary pressure increased in the unreamed group to 76 +/- 25 mm Hg (10.1 +/- 3.3 kPa) during insertion of 7-mm nails and in the reamed group to 879 +/- 44 mm Hg (117.2 +/- 5.9 kPa) during reaming of the medullary cavity. Insertion of 9-mm nails after the medullary cavity had been reamed to 10 mm produced an intramedullary pressure of 254 +/- 94 mm Hg (33.9 +/- 12.5 kPa) (p < 0.05). Fat extravasation in the unreamed group was recorded with a score of 2.9 +/- 0.4 for the Gurd test during nailing with 7-mm nails, whereas in the reamed group significantly more fat extravasation was noticed during the reaming procedures, with a score of 4.6 +/- 0.1. Liberation of fat during insertion of 9-mm nails after reaming was recorded with a score of 3.5 +/- 0.4. In both groups, a positive correlation of fat extravasation with the rise in intramedullary pressure was found (reamed group: r(s) = 0.868; unreamed group: r(s) = 0.698), resulting in significantly less liberation of bone marrow fat in the unreamed stabilized group than in the reamed control group (p < 0.05). The data indicate that fat embolization during nailing procedures after femoral osteotomy increases with increasing intramedullary pressure and occurs in a lesser degree in unreamed than in reamed intramedullary femoral shaft stabilization.

Improved results in treatment of femoral shaft fractures with the unreamed femoral nail? A multicenter experience

OBJECTIVES

The first studies of intramedullary nailing with the Arbeidsgemeinschaft fur Osteosynthesefragen (AO) unreamed femoral nail in selected clinics showed favorable results. Daily practice, however, is that femoral fractures are treated in a variety of clinics by a mixture of surgeons. To evaluate whether similar results could be obtained in general practice, a prospective multicenter trial was undertaken, involving a variety of university and general hospitals in one country.

METHODS

Between August of 1994 and June of 1996, 122 patients with 129 traumatic femoral shaft fractures treated with the unreamed femoral nail in eight hospitals were included in this study. Patients who had a reoperation with an unreamed femoral nail or patients with a pathologic fracture of the femur were excluded from this part of the study. Of these patients, 58 patients had multiple injuries, and 33 of the fractures had open soft-tissue injury.

RESULTS

Postoperative infection occurred in four patients; the nail broke in one patient. In total, nine patients (6.6 %) sustained general complications, five of which developed adult respiratory distress syndrome (3.6%). Non-union occurred in seven patients (5.1%) and delayed union occurred in four cases (2.9%) with a reintervention rate of 6.6%.

CONCLUSION

In this study, a decrease in the number of patients who develop adult respiratory distress syndrome through the use of a thin unreamed nail could not be demonstrated. The promising early callus formation and good consolidation mentioned in previous studies could not be confirmed. We find that the technical and clinical results in this study of unreamed femoral nailing in a mixture of clinics and by a variety of surgeons are comparable to the results of reamed nailing in the literature and are not as favorable as in the previous reports.

Intramedullary pressure and bone marrow fat intravasation in unreamed femoral nailing

OBJECTIVE

To investigate whether intramedullary pressure and bone marrow fat embolization are different in unreamed compared with conventional reamed femoral nailing. The null hypothesis is that there is no difference between the two techniques.

DESIGN

A prospective consecutive nonrandomized clinical trial.

METHODS

Intramedullary pressure was measured in the distal femoral fracture fragment at the supracondylar region. Bone marrow fat intravasation was measured by means of the modified Gurd-test. Monitoring was carried out in 31 unreamed and eight reamed intramedullary femoral nailing procedures.

RESULTS

Intramedullary pressure increased in the unreamed group to 82 +/- 11 mm Hg during the insertion of 9-mm and 10-mm nails and in the reamed group to 396 +/- 85 mm Hg during reaming of the medullary cavity. Insertion of nails after reaming led to an increase in intramedullary pressure of 79 +/- 13 mm Hg. A positive correlation between fat intravasation and intramedullary pressure was found in each group (rs = 0.73), resulting in less liberation of bone marrow fat in the unreamed group than in the reamed group.

CONCLUSIONS

Intramedullary pressure increased significantly in the reamed more than in the unreamed group. Bone marrow fat intravasation depended on the rise in intramedullary pressure, and occurred less frequently in unreamed than in reamed intramedullary femoral fracture stabilization.

The treatment of femoral shaft fractures using intramedullary interlocked nails with and without intramedullary reaming: a preliminary report

OBJECTIVE

To compare operative and postoperative variables in the treatment of femur fractures using interlocked intramedullary nails with and without reaming.

DESIGN

Prospective and randomized.

METHODS

81 consecutive patients with femur fractures treated with a stainless steel statically locked intramedullary nail. Whether or not reaming was done was randomized. There were 42 nails placed without reaming and 39 placed with reaming. There were no demographic differences between the two groups. Intraoperative and postoperative variables were studied. Interval healing was assessed by one observer on bimonthly radiographs.

RESULTS

There were more intraoperative technical complications in the group without reaming. There was no statistical difference in operative time, transfusion requirement, or time to union between the groups. In the reamed group callus formation occurred faster and there was slightly more blood loss (247 cc vs. 396 cc) (p < 0.05). However, when distal fractures were analyzed separately, the time to union was faster in the reamed group (< 0.05). Two patients in the unreamed group and none in the reamed group developed delayed unions. Pulmonary complications occurred in two patients, one in each group and did not appear to be related to the nailing.

CONCLUSION

Reamed canal preparation led to faster healing of distal fractures treated with statically locked intramedullary nails. Blood loss was greater in the reamed group but this did not translate into increased transfusion requirements. In this series, there was no advantage to nail insertion without reaming.

Reamed against unreamed nailing of the femoral diaphysis: a retrospective study of healing time

In order to assess the results of the AO unreamed femoral nail (URFN), and specifically its effects on healing, 147 consecutive patients treated were reviewed. These included 50 reamed femoral nails (RFN) and 97 unreamed femoral nails. Exclusion of pathological fractures, revisions and fractures outside the femoral diaphysis left 51 procedures in which the healing process could be studied. Twenty-four unreamed and 27 reamed femoral nails in patients with diaphyseal fractures AO (32) were followed up by clinical review and radiographically until union or death. There were two deaths from multiple injuries (one in each group) and two non-unions (at 52 weeks), one in each group. There were no cases of infection, angular deformity of leg length discrepancy; two cases required early rotational correction. There was a single broken distal locking screw in the URFN group but no other implant failures. The fractures in the URFN cases took longer to heal with a mean of 26.9 weeks as opposed to 20.5 weeks in the RFN group (P = 0.009). This did not cause a significant clinical problem. The URFN proved easy to use with a much shorter operation time.

Entry sites for antegrade femoral nailing

Dissections on 42 anatomic specimen hips were performed to study proximal femoral anatomy as it pertains to entry sites for intramedullary nailing. The precise relationships of muscle insertions on the greater trochanter were documented, as were the boundaries of the digital fossa. Measurements of trochanteric bony anatomy were made on a separate group of 30 dry bone unpaired proximal femora. Finally, possible clinical insertion sites were studied radiographically by placing a series of guidewires at various locations in the proximal femur. Two areas tended to align well with the longitudinal axis of the proximal intramedullary canal: the digital fossa, which is the site of the insertion of the obturator externus; and the posterior aspect of the superior border of the trochanter. This second area is the tip of the trochanter posterior to the piriformis fossa. This study suggests that either location may be suitable for an insertion point for intramedullary nailing. Precise sagittal plane localization of the entry site, which can be made on lateral views with an image intensifier, is recommended.

Unreamed intramedullary nailing of femoral shaft fractures: operative technique and early clinical experience with the standard locking option

Nailing techniques have changed in recent years in ways which are not just limited to omitting the reaming process. These changes concern positioning patients, techniques of reduction and selecting implants. Techniques of approach and exposure have been modified to new, less-invasive procedures to fulfill technical, functional and cosmetic requirements. In addition, techniques have been developed to avoid fragment diastasis, rotational and sagittal malalignment, and leg-length discrepancy. Finally, simple algorithms have been elaborated for the management of specific fracture patterns (bilateral shaft fractures, ipsilateral tibial fractures or associated femoral neck fractures) and to determine the number and location of locking bolts. We developed these algorithms, techniques and procedures in a series of 133 femoral shafts, which were stabilized with the AO unreamed femoral nail (URFN) in a prospective study between 1991 and 1994. Of these, the first 57 cases with a mean follow-up of 17.9 months (range, 5-44) after injury were reviewed. Fractures were classified according to Müller's 1990 system: 12 type A, 29 type B and 16 type C. Closed soft-tissue injuries were classified by our classification of 1982: 17 type C 0/I, 42 type C II. Of 15 open fractures, six were OI, six OII, two OIIIA and one was OIIIB by Gustilo's classification of 1984. The major complications were two broken locking bolts, one nail breaking after 9 weeks, one case of osteitis and one of intra-operative lung embolism.