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

A Scoring System for Predicting Nonunion After Intramedullary Nailing of Femoral Shaft Fractures

INTRODUCTION

Femoral shaft nonunion negatively affects patient quality of life. Although multiple risk factors have been identified for femoral shaft nonunion after intramedullary nail (IMN) fixation, there is no quantitative model for predicting nonunion.

STUDY DESCRIPTION

The study is a retrospective cohort study of patients with femoral shaft fractures treated at two level one trauma centers who were followed to fracture union or nonunion. Patient, injury, and surgical characteristics were analyzed to create a quantitative model for nonunion risk after intramedullary nailing.

METHODS

Eight hundred one patients aged 18 years and older with femoral shaft fractures treated with reamed, locked IMNs were identified. Risk factors including demographics, comorbidities, surgical variables, and injury-related characteristics were evaluated. Multivariate analysis was conducted, and several variables were included in a scoring system to predict nonunion risk.

RESULTS

The overall nonunion rate was 7.62% (61/801). Multivariate analysis showed significant association among pulmonary injury (odds ratio [OR] = 2.19, P = 0.022), open fracture (OR=2.36, P = 0.02), current smoking (OR=3.05, P < 0.001), postoperative infection (OR=12.1, P = 0.007), AO/OTA fracture pattern type A or B (OR=0.43, P = 0.014), and percent cortical contact obtained intraoperatively ≥25% (OR=0.41, P = 0.021) and nonunion. The scoring system created to quantitatively stratify nonunion risk showed that a score of 3 or more yielded an OR of 6.38 for nonunion (c-statistic = 0.693, P < 0.0001).

CONCLUSIONS

Femoral shaft nonunion risk is quantifiable based on several independent injury, patient, and surgical factors. This scoring system is an additional tool for clinical decision making when caring for patients with femoral shaft fractures treated with IMNs.

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

BACKGROUND

The purpose of this meta-analysis is to compare the merits and drawbacks between reamed intramedullary nailing (RIN) and unreamed intramedullary nailing (URIN) among adults.

METHODS

We comprehensively searched PubMed, MEDLINE database through the PubMed search engine, Google Scholar, Cochrane Library, Embase, VIPI (Database for Chinese Technical Periodicals), and CNKI (China National Knowledge Infrastructure) from inception to March 2020. Outcomes of interest included nonunion rates, implant failure rates, secondary procedure rates, blood loss, acute respiratory distress syndrome (ARDS) rates, and pulmonary complications rates.

RESULTS

Eight randomized controlled trials were included. The result of nonunion rates shows that the nonunion rate is significantly lower in the RIN group (RR = 0.20, 95% CI = 0.09-0.48, Z = 3.63, P = 0.0003). There were no significant differences for the risk of implant failure rates (RR = 0.55, 95% CI = 0.18-1.69, Z = 1.04, P = 0.30). The secondary procedure rates were significantly lower in the RIN group (RR = 0.28, 95% CI = 0.12-0.66, Z = 2.91, P = 0.004). The result shows that the blood loss of URIN group is significantly lower (RR = 145.52, 95% CI = 39.68-251.36, Z = 2.69, P = 0.007). The result shows that there was no significant difference in the ARDS rates (RR = 1.53, 95% CI = 0.37-6.29, Z = 0.59, P = 0.55) and the pulmonary complications rates between RIN group and URIN group (RR = 1.59, 95% CI = 0.61-4.17, Z = 0.94, P = 0.35).

CONCLUSIONS

Reamed intramedullary nailing would lead to lower nonunion rate, secondary procedure rate and more blood loss. Unreamed intramedullary nailing is related to a higher nonunion rate, secondary procedure rate and less blood loss. No significant difference is found in implant failure rate, ARDS rate and pulmonary complication rate between the two groups.

Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study

INTRODUCTION

Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful.

MATERIAL AND METHODS

This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation.

RESULTS

The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%.

CONCLUSIONS

The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.

Reamed Versus Unreamed Intertrochanteric Femur Fractures, Is It Time?

OBJECTIVES

This study compares the intraoperative and postoperative outcomes of the traditional technique of femoral canal reaming to placement of an unreamed 10-mm nail.

DESIGN

Retrospective cohort study.

SETTING

Academic Level I Trauma Center, Southeastern US.

PATIENTS/PARTICIPANTS

Intertrochanteric femur fractures treated with a CMN (January 2016-December 2018) were retrospectively identified. Inclusion criteria were as follows: low-energy mechanism, at least 60 years of age, and long CMN. Exclusion criteria were as follows: short CMN, polytrauma, and subtrochanteric fractures.

OUTCOME MEASUREMENTS

Records were reviewed for demographics, hematologic markers, transfusion rates, operative times, and postoperative complications. Variables were assessed with a χ or Student T-test. Significance was set at 0.05.

RESULTS

Sixty-five patients were included (37 reamed and 28 unreamed), with a mean age of 76.2 years and mean body mass index of 25.1. Between the reamed and unreamed groups, respectively, mean nail size was 11.0 (SD 1.1) and 10.0 (SD 0.0), P < 0.001; mean blood loss was 209.1 mL (SD 177.5) and 195.7 mL (SD 151.5), P = 0.220; 55% (21/38), and 43% (12/28) were transfused, P = 0.319; operative time was 98.2 (SD 47.3) and 81.5 minutes (SD 40.7); P = 0.035. Changes in hemoglobin/hematocrit were not significant between the study groups. Two patients from the reamed group experienced implant failure due to femoral head screw cut out and returned to the operating room. Two patients from the unreamed group returned to operating room for proximal incision infection, without implant removal. One reamed patient and 2 unreamed patients died before 6-month follow-up.

CONCLUSIONS

Unreamed CMNs for geriatric intertrochanteric femur fractures provide shorter operative times with no difference in perioperative complications. Both reamed and unreamed techniques are safe and effective measures for fixation of these fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nonunion - consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society

Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.Treatment concepts such as 'mechanobiology' or the 'diamond concept' determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction. Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037.

Effect of Nail Size, Insertion, and Δ Canal-Nail on the Development of a Nonunion After Intramedullary Nailing of Femoral Shaft Fractures

OBJECTIVE

To determine whether intramedullary nail (IMN) diameter, antegrade versus retrograde insertion, or the difference between the canal and IMN diameter affect femoral shaft fracture healing.

DESIGN

Retrospective analysis of a prospective database.

SETTING

Level One Regional Trauma Center.

PATIENTS/PARTICIPANTS

Seven hundred thirty-three femoral shaft fractures (OTA/AO 32) treated with an IMN between 1999 and 2017. After exclusion criteria, 484 fractures remained in the final analysis.

INTERVENTION

Closed section, cannulated, interlocked, titanium alloy IMN using a reamed insertion technique.

MAIN OUTCOME MEASUREMENTS

Nonunion, IMN size (10, 11.5, and 13 mm), antegrade versus retrograde insertion, Δ canal-nail diameter (ΔD) after reaming (<1, 1-2, or >2 mm).

RESULTS

IMN diameters used were as follows: 314/10 mm (64%), 137/11.5 mm (28%), and 33/13 mm (8%). Forty-five percent were placed in antegrade versus 55% retrograde. Four hundred fifty-six fractures (94.2%) healed uneventfully. There were no IMN failures. 10/484 IMNs (2%) had broken interlocking screws; only 4 were associated with a NU. Average time to union was 23 weeks (12-119). Twenty-eight (5.8%) developed NU. There was no statistical correlation between (1) the NU rate and IMN diameter: 10 mm, 6.3%; 11.5 mm, 5.1%; 13 mm, 3% (P = 0.8, power = 0.85), (2) the NU rate and ΔD: 7.1% <1 mm, 5.6% 1-2 mm, 20% >2 mm (P = 0.36), (3) the NU rate and fracture location: Prox = 11%, Mid = 5%, Dist = 3% (P = 0.13), or (4) the NU rate and antegrade (7.2%) versus retrograde (4.2%) insertion (P = 0.24).

CONCLUSION

Similar healing rates occurred regardless of IMN diameter, Δ canal-nail diameter after reaming, or insertion site. This indicates that a closed section, cannulated, interlocked, titanium alloy IMN with a diameter of 10 mm can be considered the standard diameter for the treatment of acute femoral shaft fractures, regardless of entry point. This should be associated with less reaming and therefore shorter operative times, and possibly less hospital implant inventories as well. Larger diameter IMN should be reserved for revision surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Femoral shaft fractures]

Femoral shaft fractures after completion of growth predominantly affect young people with healthy bones. The causes are mostly high-velocity traffic accidents, crushing or running over mechanisms and falls from a great height. Gunshot wounds are relatively rare in Germany but have a certain importance internationally and in military medicine. Accompanying injuries in local or other regions are frequent. The predominant fracture types are transverse, wedge, segment and comminuted fractures. Spiral fractures are a sign of indirect force and are therefore frequently found in older patients with osteoporosis. Atypical fractures under or following bisphosphonate treatment are a new entity, which are typically subtrochanteric and begin on the lateral side of the bone. The characteristics of pathological fractures, femoral shaft fractures in childhood and adolescence as well as periprosthetic fractures are not dealt with in this article.

Comparison of free-hand fluoroscopic guidance and electromagnetic navigation in distal locking of tibia intramedullary nails

BACKGROUND

It is challenges for surgeon to position the distal locking screw of a tibia intramedullary nail. The traditional free-hand (FH) technique is related to the proficiency of surgeons and has a long learning curve. Furthermore, the radiation dose and the accuracy of screw placement should be taken into account. The new technology, the electromagnetic navigation system (ET), which is a radiation-free way to locate the position of the drill bit. The purpose of our study is to evaluate the results of the ET for distal locking screw of a tibia intramedullary nail and to compare the effects with the FH technique.

METHODS

Eighty-nine cases of tibia diaphyseal fracture who needed to treat by intramedullary nails were analyzed retrospectively, and were divided into 2 groups. Patients in navigation group (n = 54) were treated with intramedullary nail using the ET for distal locking, while other 35 patients using FH technique. Intraoperative fluoroscopy exposure times, screw insertion times, and healing times were recorded. The parameter was used for comparison in 2 groups.

RESULTS

The mean time of distal locking in the ET technique was significant less than that in the FH group (5.89 ± 2.02 minutes vs 12.26 ± 4.40 minutes) and the exposure time was reduced in ET group significantly (2.13 ± 0.73 seconds vs 19.09 ± 10.41 seconds). The healing time was proved to be coincident in FH group and ET group (15.34 ± 2.98w vs 16.06 ± 3.74w). The one-time success rate of distal locking nail operation was 100% in the navigation group, which was significantly higher than that in FH group (P < .05).

CONCLUSION

Compared with the FH technique, the ET for distal locking of tibia intramedullary nail has the advantages of high efficiency and short locking time without radiation.

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.

How much is too much? A guide to appropriately bending ball tip guide wires when using intramedullary nails for the treatment of lower extremity long bone fractures

INTRODUCTION

This study was to determine the angle of bend that can be placed in a ball-tip guide wire while still allowing passage of reamers and nails of several commonly utilized nailing systems.

METHODS

Ball-tip guide wires, opening reamer tips, femoral nails, and tibial nails were collected from several manufacturers. Guide wires were incrementally bent 3 cm from the tip and passed through the reamer tip, tibial nail, and femoral nail until unable to pass.

RESULTS

All systems tested demonstrated that the reamer, with its relative smaller diameter cannula as compared to the nails themselves, determined the smallest tolerable bend to be able to pass the bent guide wire. The bend angle tolerated by reamer tips was on average 7° (4-9°). The bend angle tolerated by femoral nails was more consistent between the tested systems and was on average 15.5° (12-18°). The bend angle tolerated by tibial nails had the most variability between manufacturers and was on average 16° (13-21°).

DISCUSSION

Knowing the degree of guide wire bend which is tolerated can save time in equipment preparation as well as allow one to pre-bend the guide wire and know the intramedullary nail and/or reamers will likely pass. We hope the information provided in this work increases awareness of the potential technical issues with guide wire over-bending and that surgeons may err on the side of minimizing the bend in order to save time in the OR, decrease frustration and eliminate intraoperative complications that can occur.

In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006

BACKGROUND

Optimal surgical timing for definitive treatment of femur fractures in severely injured patients remains controversial. This study was performed to examine in-hospital mortality for patients with femur fractures with regard to surgical timing, Injury Severity Score (ISS), and age.

METHODS

The National Trauma Data Bank version 7.0 was used to evaluate in-hospital mortality for patients presenting with unilateral femur fractures. Patients were stratified into four groups by surgical timing (ST) and four groups by ISS. χ tests were used to evaluate baseline interrelationships. Binary regression was used to examine the association between time to surgery, ISS score, age, and mortality after adjusting for patient medical comorbidities, and personal demographics.

RESULTS

A total of 7,540 patients met inclusion criteria, with a 1.4% overall in-hospital mortality rate. For patients with an isolated femur fracture, surgical delay beyond 48 hours was associated with nearly five times greater mortality risk compared with surgery within 12 hours (adjusted relative risk, 4.8; 95% confidence interval, 1.6-14.1). Only severely injured patients (ISS, 26+) had higher associated mortality with no delay in surgical fixation (ST1 < 12 hours) relative to ST2 of 13 hours to 24 hours with an adjusted relative risk of 4.2 (95% confidence interval, 1.0-16.7). The association between higher mortality rates and surgical delay beyond 48 hours was even stronger in the elderly patients.

CONCLUSION

This study supports the work of previous authors who reported that early definitive fixation of femur fractures is not only beneficial, particularly in the elderly, but also consistent with more recent studies recommending at least 12-hour to 24-hour delay in fixation in severely injured patients to promote better resuscitation.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Fracture near press-on interlocking enhances callus mineralisation in a sheep midshaft tibia osteotomy model

INTRODUCTION

Factors which impair fracture healing after intramedullary (IM) nailing of long bone fractures range from surgical and biological factors to mechanical parameters. Mechanical parameters known to prolong bony consolidation are share forces at the site of the fracture. Fracture near press-on interlocking reduces share forces directly at the fracture site and is hypothesised to enhance callus mineralisation. A sheep model of midshaft tibia osteotomies evaluates the technique.

MATERIALS AND METHODS

Fracture near interlocking was achieved by surfacing a custom made nail with special hutches that enable firm screw seating on top of the nail ("golf ball" structure). Virtual (fine element analysis (FEA)) and biomechanical pilot tests were completed before in vivo application in 12 adult female German black sheep. Midshaft tibia osteotomy was performed creating a subcritical 7 mm gap for delay in union. One group (n=6) was treated with reamed IM nailing employing the custom made nail and in addition to proximal and distal standard interlocking a fracture near press on interlocking was employed. A second group of six sheep without additional press on interlocking served as control. 10 weeks after operation the quality of fracture healing was determined by micro-CT.

RESULTS

The FEA showed that axial loading up to 4000N did not lead to implant fatigue. Fracture near press on interlocking led to significantly more callus mineralisation compared to the conventional interlocking procedure (0.567 g/cm(3) ± 0.106 g/cm(3) versus 0.434 g/cm(3) ± 0.0836 g/cm(3), p=0.043).

CONCLUSIONS

Fracture near press on interlocking increases callus mineralisation in a subcritical osteotomy model in sheep. The results indicate that the reduction of share forces at the fracture site after nailing procedures may be effective in reducing the time until bony consolidation.

Uncoiling of reamer during intramedullary nailing for fracture shaft of femur

Intramedullary nailing is considered the standard of care for closed femoral shaft fractures. Several studies have shown that reamed intramedullary nailing is a safe procedure in fracture shaft femur with lower nonunion rates than unreamed nailing. Reamed intramedullary nailing provides better stability because of increased contact between the nail and medullary canal. However, careful attention to reaming techniques as well good instrumentation is necessary while undertaking such a procedure. We report what is, to the best of our knowledge, the first case of uncoiling of reamer while reaming the medullary canal. Possible causes and measures to avoid such a complication are discussed.

Taylor spatial frame fixation in patients with multiple traumatic injuries: study of 57 long-bone fractures

OBJECTIVE

To evaluate the Taylor spatial frame (TSF) for primary and definitive fixation of lower limb long-bone fractures in patients with multiple traumatic injuries.

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Consecutive series of 52 patients, 57 fractures (25 femoral and 32 tibial), treated between 2005 and 2009. Forty-nine fractures (86%) were open. Injury Severity Score ≥16 for all patients.

INTERVENTION

Fifty-four fractures (95%) underwent definitive fixation with the TSF and 3 were treated primarily within 48 hours of injury. In 22 cases (39%), fractures were acutely reduced with the TSF, fixed to bone and the struts in sliding mode without further adjustment, and in 35 cases (61%), the total residual deformity correction program was undertaken.

MAIN OUTCOME MEASURE

Clinical and radiological.

RESULTS

Complete union was obtained in 52 fractures (91%) without additional surgery at an average of 29 weeks. Four nonunions and 1 delayed union occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 74% excellent, 16% good, 4% fair, and 7% poor for bone outcomes and 35% excellent, 47% good, and 18% fair for functional outcomes. Eighty-eight percent of patients returned to preinjury work activities.

CONCLUSIONS

Primary and definitive fixation with the TSF is effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate and range of motion for lower extremity long-bone fractures in patients with multiple traumatic injuries.

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.

Reamed versus minimally reamed nailing: a prospectively randomised study of 100 patients with closed fractures of the tibia

It is generally accepted that in tibial fractures the results of reamed intramedullary nailing are better than those of unreamed. However, it is not known whether the clinical effects of reaming are cumulative or if minimal reaming would induce the same beneficial effects as more extensive reaming. This international multicentre study has investigated the effects of different degrees of reaming. 100 patients with closed diaphyseal tibial fractures were prospectively randomised in two centres. Method of treatment was reamed nailing up to 12 mm inserting an 11 mm tibial nail (n: 50), and minimally reamed nailing up to 10 mm inserting a 9 mm tibial nail (n: 50). All patients included in the study had follow-up studies at 4,8,12,16,26 and 52 weeks after trauma. Sixty-six male and thirty-four female patients with an average age of 37.5 years were included in the study. Gender, age, and injury side were identical in both groups. There was no significant difference of complications in the two methods. The rate of deep wound infections was higher in the reamed group (n: 3) versus the minimally reamed group (n: 1). Union occurred earlier in the reamed group (17 wks) compared to patients with minimally reamed nailing (19 wks), and there were more patients with reamed nails in whom the fracture had healed by 16 weeks (57%) versus the minimally reamed group (43%), however, this was not statistically significant. Pain scales were similar for both groups from week 4 to week 52. A considerable number of outcome parameters including knee and ankle function, as well as the comparison of time intervals to restart certain activities, and return to work showed no significant statistical difference between the two groups. However, patients of the extensive reamed group returned earlier to running, training, and normal sports activities. This study found no significant evidence that more extensive reaming gave better results, however there seemed to be a tendency of more aggressive reaming to induce earlier fracture healing with a tendency of faster recovery times.

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.

[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.

A critical appraisal of the SPRINT trial

The Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) was a randomized controlled trial to evaluate rates of reoperation and complications resulting from reamed versus unreamed intramedullary nailing for the treatment of tibial shaft fractures. The trial found a possible benefit for reamed intramedullary nailing in patients with closed tibial fractures, but no difference was found between the 2 approaches in patients with open fractures. This article is a review and critique of the methodology used in the SPRINT trial. Numerous aspects of the trial's design served to greatly reduce the potential bias, producing sound and reliable results. Overall, the SPRINT trial should provide recommendations for change in clinical practice and also set a benchmark for the conduct of randomized controlled trials in orthopedic surgery.

Alternative fixation method for open femoral fractures from a damage control orthopaedics perspective

A decision for immediate versus delayed fixation in a polytrauma patient mainly in cases of open femoral fracture depends upon time elapsed since injury, duration of stay in intensive care, soft tissue status, probable intra-operative difficulties and presence of systemic complication. We studied the outcome of the Taylor Spatial Frame (TSF) as a solution in the role of primary and definitive fixator for patients in whom definitive osteosynthesis with intramedullary nailing (IMN) can be associated with higher rate of complications. In view of damage control orthopaedics (DCO), we found that TSF is an effective technique compared to internal nails and earlier external fixator devices, attributable to its advantages such as continuity of frame till union, preventing any second-hit phenomenon, early mobilisation and restoration of primary defect due to bone loss by differential distraction osteogenesis without additional surgery. According to the Paley and Maar's evaluation criteria, 11 patients had an excellent result with clinical and radiological union; the functional result was excellent in three patients, good in five, fair in two and poor in one.

Reaming does not add significant time to intramedullary nailing of diaphyseal fractures of the tibia and femur

BACKGROUND

Reamed intramedullary nailing is the current gold standard for the treatment of diaphyseal fractures of the femur and tibia. Current concepts of orthopedic damage control surgery for patients with multiple injuries have placed an emphasis on appropriate surgical timing, limiting blood loss, and the duration of the initial operative procedure(s). Proponents of unreamed nailing have stated that reaming places polytraumatized patients "at risk," in part because it adds to the length of the surgical procedure and may exacerbate the severity of a patient's pulmonary injury. The purpose of this study was to determine how many minutes reaming actually takes and what percentage of operative time reaming comprises during intramedullary nailing of femoral and tibial shaft fractures.

METHODS

Intraoperative timing data were collected prospectively on a total of 52 patients with 54 fractures (21 femoral and 33 tibial) who underwent reamed intramedullary nailing of acute closed or open femoral or tibial shaft fractures over a 10-month period. Total operating room, surgical, and reaming times were collected.

RESULTS

The average reaming time for femur and tibia fractures was 6.9 minutes and 7 minutes, respectively. On average, reaming accounted for 4.9% of the surgical time and 3.2% of the total operating room time for femur fractures and 4.9% of the surgical time and 3.4% of the total operating room for tibia fractures.

CONCLUSION

Our results show that reaming comprises a small percentage of the operative time and the total time a patient spends in the operating room.

The Early Effects of Intramedullary Reaming of the Femur on Bone Mineral Density; an Experimental Study in Pigs

Background and Aims:

Both fracture and fracture treatment affect bone mineral density (BMD). BMD after standard intramedullary reaming of the femoral cavity and after reaming with a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would lead to lower BMD levels.

Material and Methods:

Dual-energy X-ray absorptiometry (DXA) was performed on the third day after operation with standard intramedullary nailing technique (n = 6)or RIA technique (n = 7) in intact femora of young Norwegian landrace pigs.

Results and conclusion:

Significantly lower BMD were found in the mid-shaft and total femur after reaming with the RIA technique compared to the non-operated femur. Traditional reaming technique resulted in significantly higher BMD in the distal femur.

Interpretation:

The results of this study indicate that standard reaming increased BMD in the distal femur, suggesting compressive effects on trabecular bone. The RIA technique decreased BMD in the femoral diaphysis and total femur, suggesting removal of trabecular bone. A possible clinical impact of the findings remains to be investigated.

The SPRINT Investigators. Study to prospectively evaluate reamed intramedually nails in patients with tibial fractures (S.P.R.I.N.T.): study rationale and design

BACKGROUND

Surgeons agree on the benefits of operative treatment of tibial fractures - the most common of long bone fractures - with an intramedullary rod or nail. Rates of re-operation remain high - between 23% and 60% in prior trials - and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better.

METHODS/DESIGN

The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0-3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes.

DISCUSSION

The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following re-operations: bone grafts, implant exchanges, and dynamizations, in patients with fracture gaps less than 1 cm post intramedullary nail insertion. Infections and fasciotomies were considered events irrespective of the fracture gap. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. S.P.R.I.N.T is the largest collaborative trial evaluating alternative orthopaedic surgical interventions in patients with tibial shaft fractures. The methodological rigor will set new benchmarks for future trials in the field and its results will have important impact on patient care. The S.P.R.I.N.T trial was registered [ID NCT00038129] and received research ethics approval (REB#99-077).

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.

The influence of a one-step reamer-irrigator-aspirator technique on the intramedullary pressure in the pig femur

BACKGROUND

Increased intramedullary pressure in the femoral cavity causes intravasation of bone marrow content to the circulation which may lead to occlusion of pulmonary vessels and cardiorespiratory dysfunction. A one-step reamer-irrigator-aspirator (RIA) technique has been developed to reduce the intramedullary pressure (IMP) during the reaming procedure. This study was design to compare IMP with a standard reaming technique with IMP during reaming with the RIA system with a hypothesis that the RIA system would involve lower pressures.

MATERIAL AND METHOD

In a randomised study in 19 Norwegian landrace pigs reamed intramedullary nailing was performed with two different reamer devices. Nine animals were operated with a traditional reamer and 10 animals with RIA. One animal in the RIA group was excluded due to a perioperative femoral fracture, and three animals in the traditional group were excluded due to a perforation of the distal medial femoral cortex. The intramedullary pressure was registrated with a transducer-tipped pressure monitoring catheter during reaming.

RESULTS

There was a significantly higher intramedullary pressure (P<0.05) during reaming in the traditional reamer group (mean 188+/-38 mmHg) than in the RIA group (mean 33+/-8 mmHg). Intramedullary pressures recorded before surgery, at the opening of the femoral cavity with an awl, by insertion of a guide wire, at insertion of the intramedullary nail, and 10 min after nail insertion showed no significant differences between the groups.

CONCLUSION

The use of a one-step reamer-irrigator-aspirator technique in the pig femur induced less intramedullary pressure increase than the use of a traditional reamer.

Common errors in the design of orthopaedic studies

There are several issues that one has to take into consideration in order to avoid potential pitfalls in the design of orthopaedic studies. This article highlights how to avoid common errors and how to continue the drive towards the unattainable, but laudable, goal of perfection.

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.

The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature

The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6 degrees . The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6 degrees . The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union.

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.

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.

Retrograde fixation of distal femoral fractures: results using a new nail system

OBJECTIVES

To investigate the management and outcome of distal femur fractures treated with retrograde nailing.

DESIGN

Prospective.

SETTING

Unfallkrankenhaus Berlin, level I trauma center.

PATIENTS

A consecutive series of 47 patients with 48 fractures of the distal femur (37 fractures AO type A and 11 fractures type C) operated on between May 1999 and June 2000.

OUTCOME MEASURES

Outcome was assessed by using standard radiographic criteria of time to union, incidence of infection, malunion, and knee function (Leung score).

RESULTS

After an average time of 33 months (range 12-37 months), 44 patients were reexamined. Three patients were lost to follow-up. The average age was 44 years (range 17-92 years). Of patients, 19 sustained polytrauma, and 10 had associated soft tissue damage. A total of 34 patients underwent primary definitive osteosynthesis within 12 hours after trauma. All fractures healed after an average of 12.6 weeks (range 9-17 weeks). Seven complications were noted-three related to severity of injury (one deep venous thrombosis, two leg length shortenings of 1.5 cm and 2.5 cm) and four related to the operation (insufficient counterboring of the nail in two patients, one malreduction, one iatrogenic fracture of femur shaft). There was no relevant difference between type A and type C fractures in functional, clinical, or radiographic outcomes.

CONCLUSIONS

Retrograde nailing is recommended as an alternative method to plate osteosynthesis in stabilizing distal femoral fractures, particularly in type C fractures.

Predictors of reoperation following operative management of fractures of the tibial shaft

BACKGROUND

Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors.

OBJECTIVE

We conducted an observational study to determine which prognostic factors were associated with an increased risk of reoperation following operative treatment in a heterogeneous population of patients with tibial shaft fractures.

DESIGN

Retrospective observational study.

SETTING

Level 1 trauma center.

METHODS

We identified 200 patients with tibial shaft fractures from two university-affiliated centers. Two reviewers independently abstracted data regarding 20 possible prognostic variables, reviewed preoperative and postoperative radiographs, and documented reoperations (defined as any surgical procedure </=1 year after the initial surgery that was aimed specifically at achieving bony union of the fracture, including bone grafts, implant exchanges, or débridement for infections). We chose a Cox proportion hazards model to conduct a survival analysis for time to reoperation and constructed a multivariable model to estimate the relative risk of reoperation and associated 95%confidence interval (CI) for each predictor variable.

MAIN OUTCOME MEASURES

Time to reoperation following the initial surgery.

RESULTS

Complete follow-up information was available for 192 of 200 (96%) patients. Three variables predicted reoperation: the presence of an open fracture wound (relative risk 4.32, 95% CI 1.76 to 11.26), lack of cortical continuity between the fracture ends following fixation (relative risk 8.33, 95% CI 3.03 to 25.0), and the presence of a transverse fracture (relative risk 20.0, 95% CI 4.34 to 142.86).

CONCLUSIONS

We identified a set of three simple prognostic variables (open fracture, transverse fracture, and postoperative fracture gap) that can assist surgeons in predicting reoperation following operative treatment of tibial shaft fractures.

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

OBJECTIVE

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

DESIGN

Experimental study.

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASUREMENTS

The number of bone nodules was quantified by light microscopy.

RESULTS

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

CONCLUSIONS

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

Current practice in the intramedullary nailing of tibial shaft fractures: an international survey

BACKGROUND

Tibial fractures are the most common of all long bone fractures. Although many tibial fractures may be managed conservatively, a certain subset, including unstable fractures and open fractures, require operative stabilization. Intramedullary nails have become the popular choice of implant in the treatment of tibial shaft fractures. The variability in outcomes with tibial shaft fractures may reflect technical aspects of the surgical procedure and perioperative care regimens among surgeons. Identifying the distribution of surgeons' preferences in nailing technique, and the rationale for their choices, will aid in focusing educational activities for the orthopedic community and planning future clinical trials. Our objectives were to clarify surgeons' opinions regarding technical aspects of surgery and perioperative care after intramedullary nailing of closed and open tibial shaft fractures, and to identify predictors of surgeons' preferences in technique and perioperative care.

METHODS

This study was a cross-sectional survey using focus groups, key informants, and sampling to redundancy strategies to develop a survey to examine surgeons' preferences in the treatment of tibial shaft fractures. The survey was pilot tested for clarity and content validity. We mailed this survey in July 2000 to 577 orthopedic surgeons who have an interest in trauma care. These were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, or European AO International affiliated trauma centers. We used several strategies to improve response rates including personalized cover letters, stamped return envelopes, follow-up telephone calls, and repeat mailing of questionnaires. Main outcome measures included technical issues such as reduction, exposure, intramedullary reaming, and interlocking screws; and factors associated with surgeons' preferences such as age, fellowship, academic practice, and geographic location.

RESULTS

Four hundred forty-four surgeons (77%) responded. Sixty percent of respondents had an academic practice, 84% supervised residents, and 65.1% had fellowship training in trauma. Approximately half (51.5%) of surgeons used a tourniquet. The odds that a surgeon in Asia or Africa used tourniquets was 10 times that of a North American surgeon (p = 0.004 and p = 0.002, respectively). Patellar tendon retraction and an inferior-based entry portal was the popular choice among surgeons (70.1% and 70.8%, respectively). Surgeons from Australia (odds ratio [OR] = 50, p < 0.001), South America (OR = 9.0, p < 0.001), Europe (OR = 3.7, p = 0.001), and Asia (OR = 3.8, p = 0.006) were significantly more likely to use a patellar splitting approach compared with North American surgeons. In the perioperative care of open tibial shaft fractures, there was consensus in the use of intravenous antibiotics and wound irrigation (96.5% and 95.6%, respectively). However, we found considerable variability in surgeons' preference in wound irrigation pressures (high, 38.7%; low, 45.4%). Surgeons in South America were 10 times more likely to use low-pressure irrigation than North American surgeons (p = 0.0005). In grade IIIB open tibial shaft fractures, 94% of surgeons believed wound closure should be obtained within the first 7 days after the injury. A surgeon's geographic location was a significant predictor of the timing of soft tissue coverage (p = 0.001).

CONCLUSION

Consensus in the use of irrigation and intravenous antibiotics in open fractures was achieved among surgeons. However, there remains considerable variability in the surgical technique of intramedullary nailing, the duration of antibiotic use, and the timing of wound closure in open tibial fracture care. Continued education and large multicenter trials are needed to establish best practice in the operative treatment of tibial shaft fracture.

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.

Ipsilateral femoral neck and shaft fractures: complications and their treatment

An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. Despite this relatively common presentation, decision-making often is difficult. Furthermore, the risk for complications is greater in the treatment of this combination injury pattern than for single-level fractures. A retrospective review of the authors' large trauma database revealed 13 patients who had healing complications develop after their index surgical procedure. Six of the eight (75%) femoral neck nonunions occurring in these 13 patients developed after the use of a second generation, reconstruction-type intramedullary nail. Factors contributing to nonunion of the femoral shaft were the presence of an open fracture, use of an unreamed, small diameter intramedullary nail, and prolonged delay to weightbearing. The femoral neck nonunions healed after either valgus intertrochanteric osteotomy (seven patients) or compression hip screw fixation (one patient). The femoral shaft nonunion proved more difficult than expected to treat with some patients with femoral shaft nonunions requiring more than one operative procedure to achieve union. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications. Therefore, this approach is recommended as the treatment of choice.

Associated injuries complicating the management of acetabular fractures: review and case studies

The treatment of acetabular fractures has evolved considerably in the past three decades. Associated injuries to the femoral head, proximal femur, or femoral shaft can complicate the initial management of the acetabular fracture, and mandate a careful treatment strategy for optimal treatment of both the acetabular fracture and associated injury. These injuries may have a large impact on the clinical outcome. The surgeon must consider surgical approaches, timing, and alternative modes of fixation. A discussion with case illustrations is provided.

Retrograde versus antegrade nailing of femoral shaft fractures

OBJECTIVES

To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing.

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05).

INTERVENTION

Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques.

MAIN OUTCOME MEASURES

Union, delayed union, nonunion, malunion, and complication rates.

RESULTS

After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05).

CONCLUSIONS

Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.

Angular malalignment after intramedullary nailing of femoral shaft fractures

OBJECTIVES

To determine factors associated with angular malalignment of femoral shaft fractures treated with intramedullary nails and to determine differences in the incidence of angular malalignment based on fracture location, fracture comminution, and method of treatment (i.e., antegrade or retrograde).

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Three hundred sixty patients with 374 femoral shaft fractures were identified from a prospectively obtained orthopaedic trauma database. Complete sets of immediate postoperative anteroposterior and lateral radiographs were available for 355 (95 percent) of the 374 fractures.

INTERVENTION

Patients were treated with antegrade (183 cases) or retrograde (174 cases) intramedullary femoral nailing.

MAIN OUTCOME MEASURE

Goniometric measurements were made on all immediate postoperative radiographs to determine the coronal plane and sagittal plane angular alignments. A multiple linear regression statistical analysis was used to determine factors associated with increasing angular malalignment. The incidence of malalignment was determined using more than 5 degrees of deformity in any plane as the definition of malalignment.

RESULTS

Proximal fracture location, distal fracture location, and unstable fracture pattern were associated with increasing fracture angulation (p < 0.001). Fracture location in the middle third, stable fracture pattern, method of treatment (i.e., antegrade or retrograde), and nail diameter were not associated with increasing fracture angulation (p > 0.05). The incidence of malalignment was 9 percent for the entire group of patients, 30 percent when the fracture was of the proximal third of the femoral shaft, 2 percent when the fracture was of the middle third, and 10 percent when the fracture was of the distal third. The incidence of malreduction was 7 percent for patients with stable fracture patterns and 12 percent for those with unstable fracture patterns.

CONCLUSIONS

Patients with fractures of the proximal third of the femoral shaft treated with intramedullary nails are at highest risk for malalignment. Proximal fracture location, distal fracture location, and unstable fracture pattern are associated with increasing fracture angulation.

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.

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.

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.

Femoral nailing for metastatic disease of the femur: a comparison of reamed and unreamed femoral nailing

A total of 73 consecutive intramedullary femoral nails were inserted for metastatic disease of the femur; 43 were reamed and 30 were solid nails. The two groups were similar with regards to age, type of primary tumour, anatomical site, acute or 'impending' fracture and postoperative survival. The 'solid' nail offers a satisfactory alternative form of stabilisation for metastatic disease of the femur with rates of implant failure which are comparable with the reamed nail. In this series bilateral nailing was not associated with any increase in mortality. Contrary to other reports, imposing a delay in patients with pain and a short life expectancy seems unjustified. The use of the 'solid' femoral nail does not prevent sudden death due to massive fat embolism.

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.

Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis

OBJECTIVE

To determine the effect of reamed versus nonreamed intramedullary (IM) nailing of lower extremity long bone fractures on the rates of nonunion, implant failure, malunion, compartment syndrome, pulmonary embolus, and infection.

DESIGN

Quantitative systematic review of prospective, randomized controlled trials.

DATA IDENTIFICATION

MEDLINE and SCISEARCH computer searches provided lists of published randomized clinical trials from 1969 to 1998. Extensive hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files identified additional studies.

STUDY SELECTION AND DATA EXTRACTION

Of 676 citations initially identified, sixty proved potentially eligible, of which four published and five unpublished randomized trials met all eligibility criteria. Each of three investigators assessed study quality and abstracted relevant data.

RESULTS

The pooled relative risk of reamed versus nonreamed nails (nine trials, n = 646 patients) was 0.33 [95% confidence interval (CI), 0.16 to 0.68; p = 0.004]. The absolute risk difference in nonunion rates with reamed IM nailing was 7.0 percent (95% CI, 1 to 11 percent). Thus, one nonunion could be prevented for every fourteen patients treated with reamed IM nailing [number needed to treat (NNT) = 14.28]. The risk ratios for secondary outcome measures were: implant failure, 0.30 (95% CI, 0.16 to 0.58; p < 0.001); malunion, 1.06 (95% CI, 0.32 to 3.57); pulmonary embolus, 1.10 (95% CI, 0.26 to 4.76); compartment syndrome, 0.45 (95% CI, 0.13 to 1.56); and infection, 0.98 (95% CI, 0.21 to 4.76). Sensitivity analyses suggested that reported rates of nonunion and implant failure were higher in studies of lower quality. The type of long bone fractured (tibia or femur), the degree of soft tissue injury (open or closed), study quality, and whether a study was published or unpublished did not significantly alter the relative risk of nonunion between reamed and nonreamed IM nailing.

CONCLUSIONS

There is evidence from a pooled analysis of randomized trials that reamed IM nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing.

Treatment of femoral shaft fracture using unreamed interlocked nails

OBJECTIVE

To evaluate healing rates of femoral shaft fractures treated with interlocked nails inserted without reaming.

STUDY DESIGN

Review of prospectively collected data.

SETTING

Level I trauma center.

METHODS

From the trauma registry, 159 patients with 164 femoral shaft fractures were identified who had been treated from March 1993 through December 1995 with femoral nails inserted without reaming in either an antergrade or retrograde manner. Fractures were classified according to the AO/OTA method. Patients were followed for a minimum of one year with clinical and radiographic examinations.

RESULTS

One hundred twenty-one patients with 125 fractures were available for review. Average follow-up was 18.3 months (range 12 to 59 months). One hundred sixteen of the 125 fractures (93 percent) healed after the index procedure. Type A fractures healed at an average of 3.8 months (range 2 to 8 months), Type B fractures at 4.8 months (range 2 to 16 months), and Type C fractures at 6.2 months (range 3 to 12 months). There were no increases in complication rates or differences in ranges of knee and hip motion as compared with other published series. Overall, there was no difference in the length of time to union between antegrade or retrograde nailings, and the healing rates for the two methods showed only a small statistical difference.

CONCLUSIONS

The use of femoral nails inserted in an unreamed manner in this series produced healing rates comparable with historic standards using reamed insertion. Smaller diameter nails inserted without reaming did not compromise fracture management and produced no increase in complication rates. The causes for delayed union or nonunion appear to be multifactorial, and secondary procedures should be considered if fractures have demonstrated little or no healing by three months.

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.