Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery.

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

OBJECTIVE

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

DESIGN

Prospective and randomized.

METHODS

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

RESULTS

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

CONCLUSION

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

Antegrade or retrograde reamed femoral nailing

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery.

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.

Anterograde interlocked nailing of distal femoral fractures after gunshot wounds

Standard treatment for distal femoral fractures has been with blade plate or condylar screw plate devices. Excellent fixation is obtained, but bone grafting is required and the procedure exposes the fracture site. More recently, indirect methods of reduction have been initiated to limit the devascularization of the fracture site. Anterograde interlocked nailing has the advantage of using an incision far from the fracture site, and the technique is familiar to most surgeons. It can be performed regardless of the degree or length of comminution. Thirty-eight patients 16-50 years of age who underwent anterograde interlocked nailing for fractures of the distal femur were retrospectively studied. Follow-up averaged 24 months. All patients sustained their injury from a gunshot wound (GSW). Thirty-one had angiograms. The distance from the fracture to the distal screws was < 5 cm in all cases. There were five Winquist 2, eight Winquist 3, and 25 Winquist 4 type fractures. In five patients the rod tip was cut off to place the screw holes more distally, and in four patients only three corticies were obtained by the distal locking screws. Early motion was obtained in all patients. Fractures healed at an average of 8.6 weeks. No primary or secondary bone grafts were performed. Three of the six patients positioned laterally had 5 degrees or more of valgus angulation, and five of the 34 patients positioned supine had > or = 5 degrees of posterior angulation. A method of using smooth Steinman pins as joysticks to control the distal fragment is presented. Anterograde interlocked intramedullary (IM) nailing is an effective means of fixation for distal femur fractures.

Tension wire position for hybrid external fixation of the proximal tibia

OBJECTIVE

To compare a new configuration of proximal wires for hybrid external fixation with the standard configuration.

DESIGN

Biomechanical testing of five matched pairs of fresh cadaveric tibia.

INTERVENTION

The authors compared the standard tension wire configuration of the three proximal wires with a more sagittal orientation of the oblique wires. A second study compared the new configuration with two wires and an offset half-pin. A two-centimeter segmental defect was created just distal to the tibial tubercle and the tibias fixed in a Montecelli Spinelli (Howmedica, NJ, U.S.A.) hybrid frame. The constructs were biomechanically tested using an Instron servohydraulic biaxial testing machine.

RESULTS

There was a significant 67 percent decrease in displacement during anterior posterior bending and a significant 40 percent decrease in displacement in posterior bending with the new configuration compared with the standard configuration (p < 0.05). The differences in stability in all other testing modes were not significant. There was no significant difference between the new configuration and the two wire and off-set half-pin configuration.

CONCLUSION

We recommend anterior placement of the oblique tension wires in the proximal tibia to more effectively resist bending in the sagittal plane, which is the most common deforming force on proximal metaphyseal fractures.