Reamed versus unreamed femoral nails. A randomised, prospective trial

Treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and screw plate

In 2020, the most common treatment for presumed aseptic non-union of the humeral shaft seems to be decortication, often associated with bone autografting, and stabilized by a screw plate. We propose to evaluate an original technique of rigid osteosynthesis combining intramedullary nailing and screw plate. Between January 2004 and January 2020, 45 patients underwent treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and a screw plate. The minimum radio-clinical follow-up was one year postoperatively. The series included 19 men and 26 women with a mean age of 53 years (range 19-84 years). Bone consolidation was achieved in 43 patients, a rate of 95.5%. Comparing patients who achieved bone consolidation with the two failed consolidations did not reveal any statistically significant factor. Interobserver agreement was almost perfect (k=0.93) for the use of the RUST for humeral shaft fractures treated with intramedullary nailing and screw plate. In our study, the treatment of presumed aseptic non- union of the humeral shaft with an osteosynthesis combining intramedullary nailing and screw plate gives, with 95.5% of bone consolidation, results equal to or even superior to the different treatments currently described in the literature.

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures

Objective

To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures.

Design

Retrospective 1:1 matched cohort study.

Setting

Single-level 1 trauma center.

Participants

One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups.

Intervention

Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture.

Main Outcome Measurement

Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores.

Results

Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group.

Conclusions

Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.

Bone intramedullary reaming grafts the fracture site with CD146+ skeletal progenitors and downmodulates the inflammatory environment

INTRODUCTION

Femoral shaft fractures generally occur in young adults following a high-energy trauma and are prone to delayed union/non-union. Novel therapies to stimulate bone regeneration will have to mimic some of the aspects of the biology of fracture healing; however, which are these aspects is unclear. Locked intramedullary nailing is the current treatment of choice for the stabilisation of femur shaft fractures, and it is associated with accelerated healing and increased union rates. These benefits were partially attributed to the reaming procedure, which, regardless of significantly destroying the haematoma, stimulates the healing response. To better understand how reaming influences healing, we evaluated the viability of the nucleated cell fraction and the frequency of CD146⁺ skeletal progenitors, which contain multipotent cells, in the post-reaming haematoma. We also screened the concentrations of inflammatory mediators and growth factors in the fracture site after reaming compared with those in the original haematoma.

METHODS

Pre- and post-reaming haematomas were percutaneously aspirated from the fracture site of 15 patients with closed femoral shaft fractures. Cellular viability and the percentage of CD146+ progenitors were analysed by flow cytometry. The concentrations of cytokines and growth factors were determined by ELISA.

RESULTS

AnnexinV/Pi analysis showed that the viability of the total nucleated cell fraction was decreased in the post-reaming haematoma. However, the procedure increased the percentage of CD146+ skeletal progenitors in the fracture site. Analysis of cytokines and growth factors in supernatants showed a decreased concentration of the inflammatory mediators IL-6, CCL-4, and MCP-1, along with an increase of anti-inflammatory IL-10, and the growth factors bFGF and PDGF-AB.

CONCLUSION

These findings support the view that the positive effects of reaming on fracture healing might result from mechanically grafting the fracture site with a population of skeletal progenitors that contain multipotent cells; transitioning the signalling environment to a less inflammatory state, and enhancing the availability of specific osteogenic and angiogenic factors. A better understanding of the requisite stimuli for optimal bone repair, considering the disturbances made by orthopaedic treatments, will be determinant for the development of innovative treatments for bone repair.

Reamed versus unreamed intramedullary nailing for the treatment of femoral fractures: A meta-analysis of prospective randomized controlled trials

BACKGROUND AND OBJECTIVE

Intramedullary nailing is commonly used for treating femoral shaft fractures, one of the most common long bone fractures in adults. The reamed intramedullary nail is considered the standard implant for femoral fractures. This meta-analysis was performed to verify the superiority of reamed intramedullary nailing over unreamed intramedullary nailing in fractures of the femoral shaft in adults. Subgroup analysis of implant failure and secondary procedure was also performed.

METHODS

Electronic literature databases were used to identify relevant publications and included MEDLINE (Ovid interface), EMBASE (Ovid interface), and the Cochrane Central Register of Controlled Trials (CENTRAL; Wiley Online Library). The versions available on January 30, 2016, were utilized. Only human studies, which were designed as randomized controlled clinical trials, were included. Two authors independently evaluated the quality of original research publications and extracted data from the studies that met the criteria.

RESULTS

Around 8 randomized controlled trials involving 1078 patients were included. Reamed intramedullary nailing was associated with shorter time to consolidation of the fracture (SMD = -0.62, 95% CI = -0.89 to -0.35, P < 0.00001), lower secondary procedure rate (OR = 0.25, 95% CI 0.10-0.62, P = 0.003), lower nonunion rate (OR = 0.14, 95% CI = 0.05-0.40, P < 0.01), and lower delayed-union rate (OR = 0.19, 95% CI = 0.07-0.49, P < 0.01) compared to unreamed intramedullary nailing. The 2 groups showed no significant differences in risk of implant failure (OR = 0.50, 95% CI 0.14-1.74, P = 0.27), mortality risk (OR = 0.94, 95% CI 0.19-4.68, P = 0.94), risk of acute respiratory distress syndrome (ARDS; OR = 1.55, 95% CI 0.36-6.57, P = 0.55), or blood loss (SMD = 0.57, 95% CI = -0.22 to 1.36, P = 0.15).

CONCLUSION

Reamed intramedullary nailing is correlated with shorter time to union and lower rates of delayed-union, nonunion, and reoperation. Reamed intramedullary nailing did not increase blood loss or the rates of ARDS, implant failure, and mortality compared to unreamed intramedullary nailing. Therefore, the treatment of femoral fractures using reamed intramedullary nailing is recommended.

The investigation and management of suspected malignant pathological fractures: a review for the general orthopaedic surgeon

The management of malignant pathological fractures necessitates careful diagnostic work-up, pre-operative investigation, planning and multidisciplinary input from specialists in the fields of radiology, pathology, oncology, trauma and orthopaedics. Malignant and non-malignant conditions including metabolic disorders, benign tumours and pharmacological therapies can be implicated. The majority of patients who present with suspected pathological fractures will be managed by general orthopaedic and trauma surgeons rather than specialists in orthopaedic oncology. Skeletal metastases can result in considerable morbidity and predispose to pathological fractures. With advances in the medical management of malignancy, life expectancy in cancer patients is increasing, leading to an increasing risk of skeletal metastasis and the potential for pathological fractures. Conventional modes of trauma fixation for pathological fractures may not be appropriate. The aim of this review is to outline diagnostic and management strategies for patients who present with a long bone fracture that is potentially pathological in nature.

Clinical outcome of ream versus unream intramedullary nailing for femoral shaft fractures

Background

Stabilization of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults; however, to ream or not to ream is still being debated.

Objectives

The primary objective of this study was to determine clinical results following unreamed versus ream intramedullary nailing of femoral fractures.

Patients and Methods

Between January 2008 and August 2009, 50 patients with femoral shaft fractures were treated with unreamed or reamed femoral nails in our clinic. From this prospective single centre study, 16 patients were excluded due to insufficient follow-up data. According to the AO classification, fractures in this study were either type A or B. Dynamic proximal locking was performed in all cases. The remaining 34 patients were divided into two groups of 17 with ream or unream nailing. During and after the operation, we evaluated some variables in whole series.

Results

After statistical analyzes, we found that there were no differences in radiologic union time (P = 1) or full weight bearing time (P = 0.73) between ream and unream nailing. Nail breakage or iatrogenic fractures during nail insertion did not occur and we did not have any fat emboli in both groups but one secondary loss of reduction occurred in the unream group. Superficial infection after the operation was seen in one case which was treated successfully with antibiotics. In the ream group surgical time was about thirty minutes longer and differences were significant (P = 0.000). Patients had to pay more for ream nailing but the difference was not significant. We found no statistical difference between union time with or without reaming; on the other hand, there was significant increased operation length, blood loss and systemic changes in BP or So2 in the ream group versus the unream group.

Conclusions

We advocate that unream nailing in traumatic femoral shaft fractures is a simple, safe and effective procedure with significant advantages, especially in multitrauma patients.

Expandable intramedullary nails in lower limb trauma: a systematic review of clinical and radiological outcomes

This study systematically reviews the evidence-base for the use of expandable nails in the treatment of acute diaphyseal fractures of the lower limb. Both electronic and hand searches were undertaken of the published and grey literature to 1 December 2011. A total of 154 citations were identified, of which 15 were deemed suitable and assessed with the Critical Appraisals Skills Programme tool. A total of 625 nailing procedures were performed in 620 patients: 279 femoral and 346 tibial nails. The expandable nail was found to be significantly quicker to insert than interlocked nails (p < 0.05), and the total incidence of non-union or other complication was 13 and 14 % for expandable femoral and tibial nails, respectively. Notable complications with the expandable nail included fracture propagation on nail inflation in 2.5 % and post-operative shortening in 3.3 %. Device failure secondary to problems with the expansion mechanism was seen in 2.9 %. The rate of non-union and infection following expandable nailing was 3.1 and 1.4 %, respectively. Despite promising initial results, there remains a paucity of good quality studies to support the use of expandable nails over interlocked nails for the treatment of acute diaphyseal fractures of the lower limb.

Infra-isthmal fracture is a risk factor for nonunion after femoral nailing: a case-control study

BACKGROUND

The rates of nonunion after femoral nailing are currently reported to be 4.1-12.5 %. The purpose of this study was to identify the risk factors of noninfected nonunion after femoral nailing, focusing in particular on the effects of the length of the distal main fragment.

METHODS

A case-control study was conducted with 105 patients, with a case (nonunion group)-control (control group) ratio of 1:2. The nonunion group (n = 35) comprised patients with consecutive symptomatic nonunions after femoral nailing who were treated in our institute; the control group (n = 70) were matched by age to the nonunion group. Type of fracture, soft tissue injury, length of femur and nail length, incidence of screw breakage, nail diameter, mean length of distal main fragment, and any episode of dynamization were retrospectively examined. Univariate and multivariate analyses were performed to elucidate the risk factors of nonunion after femoral nailing.

RESULTS

Increased risk of nonunion after femoral nailing was associated with (1) open fracture, (2) screw breakage, (3) shorter length of a distal fragment, and (4) any episodes of dynamization. Receiver operating characteristic analysis showed that a distal fragment length of <43 % of the total femur length was the cutoff level for nonunion after nailing. The odds ratio for nonunion was 6.40 (95 % CI 2.70-15.2) when the length of the distal main fragment was <43 % of the femur length. Multivariate logistic analysis revealed that the risk of nonunion after femoral nailing increased (1) with breakage of locking screws (p = 0.0021), (2) with dynamization (p = 0.0029), (3) with a shorter distal fragment length (p = 0.0379), and (4) with an open fracture (p = 0.0397).

CONCLUSION

The elucidated risk factors of nonunion after femoral nailing were identified as open fracture, infra-isthmal femoral fracture, breakage of locking screw, and inappropriate dynamization. We believe that the surgeon should be consciously aware of the need for additional surgical fixation for the distal fragment when performing femoral nailing of infra-isthmal femoral fractures.

Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review

INTRODUCTION

Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults.

METHODS

Cochrane Central Register of Controlled Trials (October 2010), PubMed (October 2010) and EMBASE (October 2010) were searched. Randomized and quasi-randomized controlled clinical trials were included. After independent study selection by two authors, data were collected and extracted independently. The methodological quality of the studies was assessed. Pooling of data was undertaken where appropriate.

RESULTS

Seven trials with 952 patients (965 fractures) were included. Compared with unreamed nailing, reamed nailing was significantly lower reoperation rate (RR 0.25, 95% CI 0.11-0.59, P = 0.002), lower non-union rate (RR 0.20, 95% CI 0.05-0.77, P = 0.02) and lower delay union rate(RR 0.30, 95% CI 0.14-0.64, P = 0.002). There was no significant difference when comparing reamed nailing with unreamed nailing for implant failure (RR 0.51, 95% CI 0.16-1.61, P = 0.25), mortality(RR 0.94, 95% CI 0.19-4.58, P = 0.94) and acute respiratory distress syndrome(RR 1.53, 95% CI 0.37-6.29, P = 0.55). Unreamed nailing was significantly less blood loss (SMD 119.23, 95% CI 59.04-180.43, P = 0.0001).

CONCLUSION

Reamed intramedullary nailing has better treatment effects than unreamed intramedullary nailing for shaft fracture of femur in adults.

Open grade III fractures of femoral shaft: Outcome after early reamed intramedullary nailing

BACKGROUND

Open grade III fractures of femur are a challenging therapeutic problem as most of them are associated with multiple trauma. Method used for skeletal stabilization of these fractures should limit further soft tissue damage, bacterial spread and morbidity in addition to its ease of application, providing mechanical support and restoring normal alignment.

METHODS

Forty-six patients with open grade III fractures of femoral shaft were included in the study. There were 10 grade IIIA, 34 grade IIIB and two grade IIIC fractures that were treated with early reamed intramedullary nailing with adequate management of soft tissue. Patients were reviewed retrospectively.

RESULTS

Mean time of union was 27 weeks. Infection rate was 4% and non-union rate was 9%. There were two cases (4%) with limb shortening. No case of angular or rotational deformity was noted.

CONCLUSION

Early reamed intramedullary nailing for open grade III fractures of femoral shaft, after giving due respect to the soft tissue injury, gives satisfactory results with proper alignment, good range of motion, short rehabilitation period and low infection rate.

LEVEL OF EVIDENCE

Level IV. Retrospective therapeutic study.

Management of femur shaft fractures in obese patients

Given the ongoing epidemic of obesity, femoral fracture management in the population affected by this condition is likely to become more frequent. Fracture treatment in obese patients poses a special challenge given greater difficulty in establishing an accurate diagnosis and confirming associated injuries. Adequate intraoperative positioning and obtaining accurate reduction and stable fixation may require special considerations. Obese patients have a high predisposition for complications such as compartment syndrome, nerve injuries, and pressure ulcers, and are at increased risk for medical complications given the high prevalence of comorbidities. A thorough understanding of the risks associated with obesity and the diagnostic and therapeutic challenges involved with femoral shaft fractures in this setting is paramount to achieve adequate results.

Comparison of RIA and conventional reamed nailing for treatment of femur shaft fractures

INTRODUCTION

The standard of care for femoral diaphysis fractures is sequentially reamed, locked, intramedullary nails. However, in the polytraumatized patient perioperative complications such as fat embolism syndrome (FES) and acute respiratory distress (ARDS) are well chronicled. The reamer irrigator aspirator (RIA)has been theorized to minimize such phenomena.

METHODS

A retrospective study comparing conventional reamed nailing for femur fractures versus those treated with the RIA was conducted. From January 2005 to September 2006, 156 patients treated at our institution with an intramedullary nail met inclusion criteria. There were sixty-six patient treated with conventional reaming (group A) and ninety patients treated with the RIA (group B). The main outcome measures included length of hospital stay, rate of ARDS, pneumonia, ventilatory failure, overall pulmonary complications, healing rate and death.

RESULTS

No significant differences were found between groups with regard to patient demographics, injury severity and the incidence of head/chest trauma. In addition, no differences were found in length of hospital stay, length of ICU stay or mechanical ventilation. Overall pulmonary complications occurred in 11% (group A) and 16% (group B) respectively (p = 0.48). No fatalities were found in group A while there were four in group B, 4% (p = 0.14). No significant differences were found in delayed union versus nonunion rate between groups, while overall healing complications were seen in 7% and 14% of patients (p = 0.35) in groups A and B respectively.

CONCLUSION

No statistical significance was reached with regard to pulmonary complications, healing rates or death. However, we were unable to demonstrate favorable physiologic lung parameters with RIA use compared to conventional reaming as has been described in previous animal studies. We found a trend toward more healing complications in the RIA group, but this was not statistically significant. Further study is warranted.

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%).

[Unreamed intramedullary nailing]

Reaming and non-reaming of intramedullary nails in long bone fractures was a controversial and even emotional topic in recent decades. This article gives an historical overview of the development in this field and presents the background to the need for unreamed nailing. Furthermore, the current state of knowledge is illustrated by describing the results of a series of randomised controlled trials. Before the year 2000 nearly all German handbooks on orthopaedic and trauma surgery recommended unreamed intramedullary nailing as a more "biological" treatment that causes less harm to vascularity with equal or even better results. Unreamed nailing was in particular advocated for the treatment of open fractures. The tide turned as randomised controlled trials conducted since 2000 gave evidence that unreamed nailing leads to a higher rate of delayed or non-union, while the advantages to blood supply and infection rate could not be proven. According to evidence based medicine isolated femur and tibia fractures should be nailed in a reamed procedure. In a severe multiple injury setting it is safer to stabilize long bone fractures with external fixators, as adverse events are described for reamed and unreamed nailing.

How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe

BACKGROUND

The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA).

METHODS

Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05).

RESULTS

Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values.

CONCLUSIONS

Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.

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.

Innovations in osteosynthesis and fracture care

Over the years giant steps have been made in the evolution of fracture fixation and the overall clinical care of patients. Better understanding of the physiological response to injury, bone biology, biomechanics and implants has led to early mobilisation of patients. A significant reduction in complications during the pre-operative and post-operative phases has also been observed, producing better functional results. A number of innovations have contributed to these improved outcomes and this article reports on the advances made in osteosynthesis and fracture care.

Intramedullary nailing in femoral shaft fractures. Evaluation of a group of 101 cases

The Authors analyse the results of intramedullary nailing in a group of 101 femoral shaft fractures. Used nails: Universal Synthes (62 cases), Russel-Taylor (14), Gamma long (10), uncannulated femoral nail (9), cannulated femoral nail (4) and proximal femoral nail (2). Stabilisation of the femoral shaft fracture was possible using a reamed technique in 91 cases, unreamed in 10. All nails were locked. Dynamisation was performed in 35 cases and was not in 66. The fracture heal was faster with the reaming and dynamisation technique. Ten fractures were open (5 Gustilo I, 5 Gustilo II) and stabilisation with Universal Synthes nail (8 cases), Russel-Taylor nail (1) and Gamma long nail (1) was performed. No infection was detected. Lung embolism (6) and deep vein thrombosis (3) occurred only in the case of reamed nails. All results confirm the locking nail system as the best treatment in the shaft fractures, especially with new-generation nails.

Growth factor release following femoral nailing

The aim of this study was to investigate whether growth factors essential for fracture healing are substantially increased in the immediate aftermath following reaming of the intramedullary cavity for stabilisation of femoral shaft fractures. Consecutive adult patients whose femoral shaft fractures stabilised with either reamed (10 patients) or unreamed (10 patients) intramedullary nailing were studied. Peripheral blood samples and samples from the femoral canal before and after reaming and nail insertion were collected. Serum was extracted and using Elisa colorimetric assays the concentration of Platelet Derived Growth Factor-BetaBeta (PDGF), Vascular Endothelial Growth Factor (VEGF), Insulin-like Growth Factor-I (IGF-I), Transforming Growth Factor beta 1 (TGF-beta1) and Bone Morphogenetic Protein-2 (BMP-2) was measured. The mean age of the twenty patients who participated in the study was 38 years (range 20-63). Reaming substantially increased all studied growth factors (p<0.05) locally in the femoral canal. VEGF and PDGF were increased after reaming by 111.2% and 115.6% respectively. IGF-I was increased by 31.5% and TGF-beta1 was increased by 54.2%. In the unreamed group the levels of PDGF-BB, VEGF, TGF-beta1 remained unchanged while the levels of IGF-I decreased by 10%. The levels of these mediators in the peripheral circulation were not altered irrespectively of the nail insertion technique used. BMP-2 levels during all time points were below the detection limit of the immunoassay. This study indicates that reaming of the intramedullary cavity is associated with increased liberation of growth factors. The osteogenic effect of reaming could be secondary not only to grafting debris but also to the increased liberation of these molecules.

Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation

Large bony defects and non-unions are still a complication in trauma and orthopedic surgery. Treatment strategies include the use of autogenous materials (iliac crest), allogenic bone, bone substitutes, and currently stimulation with growth factors such as BMP-2, BMP-7 or the growth factors containing platelet-rich plasma (PRP). Another source of bone graft material might be the cuttings produced during intramedullary reaming. The aim of this study was to compare the quantity of various growth factors found within iliac crest, bony reaming debris, reaming irrigation fluid, and platelet-rich plasma. Iliac crest and reaming debris and irrigation samples were harvested during surgery. PRP was prepared from blood. The growth factors in the bony materials (iliac crest or reaming debris) and of the liquid materials (platelet-poor plasma (PPP), platelet-rich plasma (PRP) or reaming irrigation) were compared. Elevated levels of FGFa, PDGF, IGF-I, TGF-beta1 and BMP-2 were measured in the reaming debris as compared to iliac crest curettings. However, VEGF and FGFb were significantly lower in the reaming debris than from iliac crest samples. In comparing PRP and PPP all detectable growth factors, except IGF-I, were enhanced in the platelet-rich plasma. In the reaming irrigation FGFa (no measurable value in the PRP) and FGFb were higher, but VEGF, PDGF, IGF-I, TGF-beta1 and BMP-2 were lower compared to PRP. BMP-4 was not measurable in any sample. The bony reaming debris is a rich source of growth factors with a content comparable to that from iliac crest. The irrigation fluid from the reaming also contains growth factors.

Grading the evidence: levels of evidence and grades of recommendation

Evidence-based medicine is using the best available evidence in order to make accurate and knowledgeable treatment decisions. It is not the automatic gainsay of "low quality" evidence and acceptance of randomized controlled trials (RCT's). To be able to make a sound recommendation for a therapy based on the best available evidence, it is necessary to follow steps in acquiring literature, appraising it for study design and quality, and to assess its results, as well as look at the net benefits and net harms.

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).

Reaming during anterograde femoral nailing: is it worth it?

A systematic review was performed to assess the relative merits of reamed and unreamed antegrade femoral nailing. To be included, a study had to be prospective, randomised or pseudorandomised, comparing reamed and unreamed antegrade femoral nailing in adults. Where more than one study from the same institution was available, only the study with longest follow-up was included. A literature search found 2044 possible articles. Of these, eight studies compared reamed and unreamed femoral nailing. The methodology of these articles was independently assessed by all the three authors. Five studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, the data were not combined. If there was no significant heterogeneity, a combined odds ratio or weighted mean difference was calculated using a fixed effects model, and a Z-test was performed to test the overall effect. Six hundred and forty-seven femoral fractures (315 reamed; 332 unreamed) were entered into the included studies. Unreamed nailing was quicker and associated with significantly less blood loss (P < 0.00001). Reaming significantly reduced the time to union (P = 0.00001), non-union (P = 0.002), delayed union (P = 0.005), technical problems (P = 0.01) and reoperation rate (P = 0.001). The use of reamed femoral nails gives significant advantages over unreamed femoral nails.

Embolia gordurosa: uma revisão para a prática ortopédica atual

A embolia gordurosa (EG) é a oclusão de pequenos vasos por gotículas de gordura, geralmente originadas nas fraturas do fêmur, tíbia e bacia, e nas artroplastias do joelho e quadril. Normalmente não causa danos aos órgãos atingidos, a menos que seja maciça. Em poucos casos a EG evolui para a "síndrome da embolia gordurosa" (SEG) a qual afeta principalmente os pulmões e o cérebro, embora qualquer órgão ou estrutura do organismo possa ser afetada. A gordura embolizada é hidrolizada pela lipase, originando os ácidos graxos livres (AGL) que agem toxicamente sobre o endotélio capilar e que intensificam a ação das integrinas as quais acentuam a adesividade dos neutrófilos às células endoteliais, facilitando a ação das enzimas proteolíticas dos lisossomas desses neutrófilos sobre o endótelio. O resultado dessas reações é a ruptura da rede capilar seguida de hemorragia e edema nos órgãos afetados. A SEG apresenta desde insuficiência respiratória e alterações neurológicas variadas até convulsões e coma profundo. O diagnóstico da SEG é puramente clínico, não existindo nenhum exame laboratorial que o confirme. Dentre os exames de imagens, apenas a ressonância magnética cerebral demonstra claramente as áreas do edema perivascular e dos infartos. O tratamento da EG com inúmeras drogas não apresentou resultados positivos; no entanto, a medida mais requisitada para a SEG é a assistência ventilatória. A mortalidade é quase de 100% nas formas fulminantes; aproximadamente de 20% nas formas sub-agudas e não há mortalidade na forma sub-clínica. Para prevenir a SEG é fundamental evitar o choque e a hipóxia desde a cena do acidente, e proceder à fixação precoce das fraturas, o que diminui a incidência de SARA e a mortalidade pós-trauma.

Human reaming debris: a source of multipotent stem cells

The biological characteristics of human reaming debris (HRD) generated in the course of surgical treatment of long bone diaphyseal fractures and nonunions are still a matter of dispute. Therefore, the objective of the present investigation has been to characterize the intrinsic properties of human reaming debris in vitro. Samples of reaming debris harvested from 12 patients with closed diaphyseal fractures were examined ultrastucturally and were cultured under standard conditions. After a lag phase of 4-7 days, cells started to grow out from small bone fragments and established a confluent monolayer within 20-22 days. The cells were characterized according to morphology, proliferation capacity, cell surface antigen profile, and differentiation repertoire. The results reveal that human reaming debris is a source of multipotent stem cells which are able to grow and proliferate in vitro. The cells differentiate along the osteogenic pathway after induction and can be directed toward a neuronal phenotype, as has been shown morphologically and by the expression of neuronal markers after DMSO induction. These findings have prompted interest in the use of reaming debris-derived stem cells in cell and bone replacement therapies.

[Why do osteosyntheses fail? The problem with biomechanics and biology]

Avoidance of complications in the course of fracture treatment is of essential importance not only for patients but increasingly from an economic point of view. In the past 15 years emphasis has been placed on the development and fine-tuning of minimally invasive reduction techniques with suitable implants. The main objectives were avoidance of surgical site infection and uneventful fracture healing. This facilitated the solving of long-standing problems but created new sources of error. Minimally invasive, dynamic forms of osteosynthesis were found to fail with extensive open reduction or neglect of biomechanics. Additionally, it appeared that some traditional techniques and basic rules of operative fracture treatment fell into oblivion. The majority of complications are determined already preoperatively by the choice of treatment or implant. After exact analysis of the biomechanics and biological etiology, nonunion is dealt with by an imperative increase in mechanical stability. Additional procedures, i.e., bone graft or debridement, are incorporated into the therapeutic regime. Increasing mechanical stability should be attempted with a minimum of added trauma to avoid local biological impairment. Further improvement of outcome depends on innovative and adapted teaching concepts. Training exclusively with one implant, even under the guidance of the producing company, is insufficient to grasp the various fundamentals of operative fracture treatment indispensable for a successful day-to-day routine.

Femoral shaft fractures

Femoral shaft fractures are not only significant injuries in their own right but also often a marker for multiple, serious injuries elsewhere. The treatment in adults is usually surgical. The results are for the most part good, but are dependent on the degree of injury to the local soft tissues and on the presence or absence of other distant injuries.

Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery

BACKGROUND

The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture.

METHODS

In a retrospective cohort study performed at a Level I trauma center, the patient's injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I degrees intramedullary nailing [I degrees IMN]; I degrees external fixation [I degrees EF]; I degrees plate osteosynthesis [I degrees plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981-December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990-December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993-December 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to intramedullary nailing in patients at risk of organ failure.

RESULTS

The patient groups were comparable regarding age, gender distribution, and the mechanism of injury. Primary external fixation was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups compared with the ETC group (16.6%) ( = 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I degrees EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I degrees IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdominal injuries accounted for significantly higher numbers of patients submitted to I degrees EF in the INT (13.6%, = 0.03) and DCO (17.3%, = 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of multiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I degrees IMN (15.1%) and I degrees EF (9.1%) in the DCO subgroup were compared.

CONCLUSION

A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an increased awareness toward thoracic and abdominal injuries may have played a role. Even during the DCO era, IMN was associated with a higher rate of ARDS than I degrees EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of developing posttraumatic systemic complications such as ARDS and multiple organ failure.

Complicated femoral shaft fractures

The treatment of femoral shaft fractures has become safe and reproducible since the advent of popularization of intramedullary nailing, however, many femoral shaft fractures are complicated by associated fractures, extensive comminution, extensive contamination, and arterial injury compartmental syndrome. Other conditions associated with the use of femoral nailing include femora nonunions, broken hardware, acute fractures with prior implants, and infections. The management of these complex femoral shaft fractures demands special techniques for successful outcome.

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.

Reaming debris in osteotomized sheep tibiae

BACKGROUND

Reamed nailing gives better fracture healing than unreamed nailing in operative treatment of fractures and nonunions. This study investigates the effect of isolated reaming debris on fracture healing in an animal model.

METHODS

Thirty sheep were treated with an osteotomy of the tibia with 5-mm distraction. In one group, the osteotomy gap was left empty; in the second group, the gap was packed with reaming debris from the ipsilateral femur; and in the third group, the gap was packed with cancellous bone from the iliac crest. At follow-up, callus volume was measured on standard radiographs.

RESULTS

After 3 weeks, callus volume from the reaming debris group as well as the iliac crest group had increased significantly compared with the empty group.

CONCLUSION

This study shows that isolated reaming debris supports callus building as much as conventional bone grafting, which might explain why fractures heal with more callus formation when treated with reamed nailing compared with unreamed nailing.

Healing of closed femoral shaft fractures treated with the AO unreamed femoral nail. A comparative study with the AO reamed femoral nail

Out of a hundred and seven closed femoral fractures, fifty-three were treated with the unreamed femoral nail and fifty-four with the reamed femoral nail. There were four delayed unions in the Unreamed Femoral Nail group (UFN) and three in the Reamed Femoral Nail group (RFN). There were no cases of infection or malunion. Implant failure was the cause of implant conversion in one patient of the UFN group. Healing time of the femoral fractures was 19.2 weeks in the UFN group and 19.6 weeks in the RFN group. Due to the significant decrease in operating time with the UFN (70 min) in comparison with the RFN (125 min) and the possible risk of posttraumatic pulmonary oedema (ARDS) with reaming techniques, the authors recommend the UFN for the treatment of acute closed femoral shaft fractures.

Development of small diameter intramedullary nails made from ISO 5832-9 stainless steel

BACKGROUND

In order to improve strength in small diameter intramedullary nails, a system was designed in which the implants were manufactured from 30% coldworked ISO 5832-9 stainless steel.

METHODS

Nail diameters were 9 and 10 mm for the femur, and 8 and 9 mm for the tibia. The nails were solid rods and the screws were partially threaded. Pre-clinical bending yield tests established that the 8-, 9- and 10-mm diameter rods had strengths comparable, respectively, with 10-, 12- and 14-mm diameter Grosse-Kempf nails. Forty-eight femoral and 98 tibial shaft acute fractures were treated with this system. Postoperatively, patients were allowed to gently bear weight as tolerated.

RESULTS

There was one broken nail, occurring 10 months after femoral nailing. There were six broken screws, occurring between 3 and 6 months postoperatively in two patients and after more than 6 months in four patients. The broken screws had no adverse clinical effect. Five patients required late bone grafting or exchange nailing, and 15 patients required dynamization.

CONCLUSION

This design of small diameter locked intramedullary nails was strong enough to allow early weightbearing.

A new era in orthopedic trauma care

The previous 20 years have truly opened a new era of orthopedic trauma care. Rapid advances in the development of systems for internal and external fixation have been made. Improvements in technology and surgical technique have allowed fracture reduction and fixation to be achieved with less-invasive surgical approaches. This has reduced postoperative morbidity, decreased hospitalization, and expedited the recovery of function. A new understanding of processes at the cellular and molecular levels offers the possibility, for the first time, of directly influencing the biology of fracture union and soft-tissue healing. Transitional research has introduced new therapies that are moving rapidly from the laboratory to biotech industry and the clinical arena. Given the present state of scientific acceleration, orthopedic trauma care in the new millennium will be shaped by important developments that physicians can now only imagine.

Exchange nailing for femoral shaft aseptic non-union

Although rare, non-union of femoral shaft fractures is a cause of significant morbidity. In aseptic non-union, excellent union rates have historically been reported following reamed exchange femoral nailing. However, recently, a high incidence of failure requiring additional procedures has been reported. In light of these concerns and a recent change in our practice to the use of thin solid nails we undertook a retrospective study to determine the efficacy of exchange nailing with these modern nails in our hands. We reviewed records and radiographs of 25 patients who had a reamed exchange femoral nailing for established aseptic non-union. 24 patients (96%) united after exchange without the need for an additional procedure. The mean time to union was 29.75 weeks. Patients who had open bone grafting performed at the same procedure tended to unite quicker, but this did not achieve statistical significance (p = 0.14). Union times were not affected by smoking habits or nail type. This study demonstrates that reamed exchange nailing for aseptic femoral non-union remains an effective treatment. We believe that the nail type is less important than the biological effects of reaming, bone grafting and dynamization.