Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures

OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).     

Compartment syndrome after closed intramedullary nailing of the tibia: a canine model and report of two cases

Two patients developed an anterior tibial compartment syndrome after closed reamed intramedullary nailing of their fractured tibial shaft. Subsequently, a study was undertaken using a canine model to evaluate the risk of compartment syndrome after this operative procedure. A closed tibial fracture was created in 20 mongrel canines by applying a torsional load localized to the tibial shaft through a stress riser made with an intramedullary drill. Compartment pressures were measured in the canine anterolateral and deep posterior leg compartments. In 10 dogs, closed intramedullary nailing with reaming was performed while compartment pressures were measured. The remaining 10 dogs served as controls. Compartment pressures were monitored for 4 hours. In the experimental group, one dog attained and maintained a pressure greater than 50 mm Hg; a second dog maintained a pressure of 20 mm Hg during the postoperative monitoring period. In both of these cases, fasciotomy reduced the pressures to zero. The high tissue pressure readings were localized to the anterolateral muscle compartment. In the control group, no pressures higher than 8 mm Hg were recorded. Compartment syndrome is a potential complication of closed intramedullary nailing of the tibia, and the anterior muscle compartment appears to be the one most at risk. Therefore, perioperative tissue pressure monitoring is recommended.     

Effect of unreamed, limited reamed, and standard reamed intramedullary nailing on cortical bone porosity and new bone formation

OBJECTIVE: To compare the effects of unreamed nail insertion and reamed nail insertion with limited and standard canal reaming on cortical bone porosity and new bone formation. DESIGN: A canine segmental tibial fracture was created in fifteen adult dogs. The tibiae were stabilized with a statically locked 6.5-millimeter intramedullary nail without prior canal reaming (n = 5), after limited reaming to 7.0 millimeters (n = 5), or after standard canal reaming to 9.0 millimeters (n = 5). Porosity, new bone formation, and the mineral apposition rate of cortical bone were directly compared between the three nailing techniques. RESULTS: A significant increase in cortical bone porosity and new bone formation was seen in all three groups of experimental animals compared with the control tibiae. The overall lowest porosity levels were measured in the limited reamed group, with similar porosity levels measured in the unreamed and standard reamed groups. Porosity was lower in the limited reamed group in the entire cortex of the segmental and distal cross sections, as well as the endosteal, anterior, and posterior cortices along the length of the tibia. Overall, there was no difference in the amount of new bone formation or the mineral apposition rate between the three groups of animals at eleven weeks after surgery. DISCUSSION: The results of this study suggest that limited intramedullary reaming is a biologically sound alternative for the treatment of tibial diaphyseal fractures in which the circulation is already compromised.     

Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up

OBJECTIVE: To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures. DESIGN: Prospective, randomized. SETTING: Level 1 trauma center. PATIENTS: Forty-five patients with displaced closed and open Gustilo type I-IIIA fractures of the central two thirds of the tibia. INTERVENTION: Stabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail. MAIN OUTCOME MEASUREMENTS: Nonunions, time to fracture healing, and rate of malunions. RESULTS: The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements. CONCLUSION: Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails.     

髓内钉治疗股骨干骨折扩髓与不扩髓的比较研究

目的探讨非扩髓钉是否比扩髓钉操作简单、迅速、安全。方法用前瞻性随机研究方法将100例单纯股骨干骨折随机分为扩髓组与非扩髓组,比较二组的手术时间、失血量、手术中意外情况的发生。结果扩髓组37例手术时间138min,失血量278ml,6例术中发生意外情况。非扩髓组63例,手术时间108min(P=0．012),失血量186ml(P=0．034)。17例术中发生意外情况,2例需二次手术。结论非扩髓钉操作步骤少,手术时间及失血量少于扩髓组,但非扩髓组手术中意外情况发生较多,虽然统计学差异不显著。     

股骨干骨折髓内针固定术后出现全身炎性反应综合征的回顾研究

目的回顾股骨干骨折髓内针固定扩髓与非扩髓患者术后发生全身炎性反应综合征（SIRS）情况,探讨髓内针固定与发生SIRS的关系。方法1997年4月至2005年4月股骨干骨折患者324例,按伤情分为轻度创伤组（n=179）和中度创伤组（n=145）。治疗采取闭合复位带锁髓内针固定,其中轻度创伤组64例、中度创伤组51例予以扩髓。分别记录每名患者入院后每日的体温、心率、呼吸频率,术后每6h记录相关数据,任何一项出现异常的患者即行血细胞分类计数,记录SIRS发生的情况。检测数据按不同伤情、扩髓与否进行分组,计算SIRS在各组中的发生率,并对之进行组内分组资料的卡方检验。结果术后早期出现SIRS者124例（发生率38．3％）,其中轻度创伤组61例（24例扩髓,37例未扩髓）,中度创伤组63例（27例扩髓,36例未扩髓）。124例中的119例经严密观测及常规术后治疗顺利恢复,5例则出现并发症。统计结果显示SIRS的发生率各组间差异无显著性。结论股骨干髓内针固定术本身会对创伤后的机体产生一定影响,导致发生SIRS;扩髓或非扩髓并不会对患者术后SIRS的发生与否产生明显的影响。     

Compartment syndrome after intramedullary nailing of the tibia

Three patients had compartment syndrome of the leg after tibial intramedullary nailing with reaming. They were all treated successfully with emergency fasciotomy. A prospective study was done of seven additional patients who had continual monitoring of the pressure in the deep posterior compartment during tibial intramedullary nailing with reaming. In five of them, the procedure was performed three weeks or less after injury and in the remaining two, the nailing was performed later for the treatment of non-union. Two pressure peaks in the deep posterior compartment were noted: one after strong longitudinal traction was applied and the fracture was reduced and the other during intramedullary reaming. Intraoperative pressure of thirty millimeters of mercury or more were recorded in three of the seven patients. In the treatment of tibial fractures, operative procedures that involve forceful traction for a long time may predispose the patient to compartment syndrome in the leg. Close clinical observation of such patients is needed. When there is a high risk of compartment syndrome, monitoring of the pressure in the compartment may be prudent.     

非扩髓交锁髓内钉治疗胫骨骨折

目的探讨非扩髓交锁髓内钉治疗胫骨骨折的方法与疗效。方法回顾102例胫骨骨折均采用非扩髓带锁髓内钉治疗的临床资料，对有关适应证、手术时机、扩髓与否、膝前疼痛、腓骨处理问题进行讨论。结果102例胫骨骨折有98例得到随访3～18个月，平均随访7．5个月，结果评定采用Johner—wruh评分标准，优87例，良11例，差0例。以上病人均无继发性骨筋膜综合征、膝前疼痛、感染、钉体或锁钉断裂、骨折不愈合等发生。结论非扩髓胫骨髓内钉适合胫骨骨折治疗。     

Pulmonary fat embolism after reamed and unreamed nailing of femoral fractures

Background

To determine whether reamed or unreamed intramedullary nailing of femoral fractures results in higher incidence of pulmonary fat embolism, three different methods of intramedullary nailing were compared in sheep. To analyze the presence of bone marrow fat embolism in pulmonary arteries, histological evaluation was undertaken using a quantitative computer-assisted measurement system.

Methods

In this experimental model of 27 female Swiss alpine sheep, an osteotomy of the proximal femur was conducted in each animal. Then, the animals were divided into three groups according to the method of treatment: two different reamed intramedullary nailing techniques and an unreamed nailing technique were used.In the first group “ER” (experimental reamer; n = 9), the nail was inserted after reaming with an experimental reamer; in the second group “CR” (conventional reamer; n = 7), the intramedullary nail was inserted after reaming with the conventional AO-reamer. In the third group “UN” (unreamed; n = 8) unreamed nailing was performed. During the operation procedure intramedullary pressure was measured in the distal fragment.After sacrificing the animals, quantitative histological analyses of bone marrow fat embolism in pulmonary arteries were done using osmium tetroxide fixation and staining of the fat.

Results

The measurement of intramedullary pressure showed significantly lower values for reamed nailing than for the unreamed technique. The quantitative histological evaluation of lung vessels concerning bone marrow fat embolism revealed a statistically significant difference between reamed and unreamed insertion of the nail: 7.77% ± 6.93 (ER) and 6.66% ± 5.61 (CR) vs. 16.25% ± 10.05 (UN) (p < 0.05) of the assessed lung vessels were filled with fat emboli. However, no difference was found between the traditional and experimental reamer.

Conclusions

Intramedullary nailing after reaming is a safe procedure with low systemic embolisation when compared to the unreamed insertion of the nail.     

Malalignment of the tibia--comparative investigation of three stabilization procedures by clinical analysis and radiological measuring techniques

INTRODUCTION: Malalignment after osteosynthetic stabilization of lower leg fractures is still a common problem for trauma surgeons. The aim of the present study was to evaluate the incidence of torsional and varus- or valgus-malalignment of the lower leg subsequent to osteosynthetic stabilization techniques such as reamed nailing, unreamed nailing and tibial plating. METHODS: 70 patients with 73 fractures of the lower leg were included in the study. The fractures were treated consecutively in 37 cases with an unreamed nail (UTN), in 21 cases with a reamed nail and 15 cases were stabilized with a plate. During clinical follow-up after 5.7 years each patient was analyzed for malalignment of the lower leg with a CT-Scan and a dual-energy X-ray absorptiometry (DXA) analysis. RESULTS: Multi-level CT-scans revealed a significant rotational malalignment in 16.4 % of patients. Interestingly, all misaligned cases were treated with a nail (9.6 % UTN, 6.8 % reamed nail). Varus- or valgus-malalignment was detected in 5.4 % of cases all of whom had been treated with an intramedullary nail. CONCLUSIONS: Malalignment is still a common problem after osteosynthetic stabilization of lower leg fractures, whereby the majority of these cases can be expected after intramedullary nailing. Rotational malalignment can be detected by CT-Scans, whereas DXA analysis is a reliable procedure to diagnose varus- or valgus-malalignment after osteosynthetic stabilization of lower leg fractures.     

Fat embolism and related effects during reamed and unreamed intramedullary nailing in a pig model

OBJECTIVES: To determine whether reamed or unreamed femoral intramedullary nailing is more adverse to pulmonary function, the authors compared three populations of healthy pigs, analyzing the biochemical and hemodynamic effects related to fat embolism. Likewise, the authors histologically evaluated the presence of bone marrow fat embolism in lungs, heart, kidney, brain, and retina. DESIGN: Randomized, experimental model. SETTING: Laboratory. PARTICIPANTS: Twenty-five male Duroc Jersey adult healthy pigs divided in three groups. INTERVENTION: Reamed and unreamed intramedullary nailing. OUTCOME MEASUREMENTS: Biochemical, hemodinamical, and histologic analysis. METHODS: In the first group of ten pigs, a reamed nail was inserted; in the second group of ten specimens, the authors placed an unreamed nail; and in the third group of five animals (control), only the surgical approach was made without opening the medullary cavity. RESULTS: The authors did not find statistically significant differences in pulmonary function between the reamed and unreamed group in the hemodynamic, biochemical, and histopathologic parameters evaluated. The histologic analysis of the lung tissue revealed a statistically significant difference between the nailed groups and the control (P < 0.04). CONCLUSIONS: In this animal model, the results indicate that pulmonary changes and fat embolization during intramedullary nailing occur to the same degree in reamed and in unreamed femurs.     

股骨干骨折扩髓与不扩髓固定对肺气体交换功能的影响

目的 :探讨股骨干骨折髓内钉固定过程中扩髓与不扩髓对肺气体交换功能的影响。方法 :38例股骨干骨折分别采用扩髓和不扩髓交锁钉内固定 ,术中不同时间段进行动脉血气分析 ,计算肺泡死腔分数 (Vd/Vt)、氧合指数(PaO2 /FiO2 )。结果 :扩髓组 ,髓腔扩大后Vd/Vt增加 (p <0 .0 5 ) ;PaO2 /FiO2 降低 (p <0 .0 1) ;不扩髓组 ,插入髓钉后30minVd/Vt增加 ( p <0 .0 5 ) ,PaO2 /FiO2 降低 ( p <0 .0 1) ,髓内钉插入后 6 0min时二者在 2组间均恢复正常 ;扩髓后 2组间Vd/Vt、PaO2 /FiO2 差异具有显著性 ,其它时间段 2组间无差异 ;动脉血气分析 ,各时间段和组间差异无显著性。结论 :扩大髓腔的髓内钉固定 ,并不影响肺气体交换功能 ,股骨干骨折患者血流动力学稳定时 ,能耐受扩髓髓内钉固定手术。     

Safe surgical technique: intramedullary nail fixation of tibial shaft fractures

Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.     

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.     

Transesophageal echocardiography in quantification of emboli during femoral nailing: reamed versus unreamed techniques

We quantified the embolic load to the lungs created with two different techniques of femoral nailing. Eleven patients with 12 traumatic femur fractures were randomized to reamed (7 fractures) and unreamed (5 fractures) groups. Intramedullary nailing was with the AO/ASIF* universal reamed or unreamed nail. Transesophageal echocardiography (TEE) was used to evaluate the quantity and quality of emboli generated by nailing. Data were analyzed using software that digitized the TEE images and quantified the area of embolic particles in each frame. The duration of each level of embolic phenomena (zero, moderate, severe) was used to determine total embolic load with various steps (fracture manipulation, proximal portal opening, reaming, and nail passage). Manual grading of emboli correlated highly with software quantification. Our data confirm the presence and similarity of emboli generation with both methods of intramedullary nailing. Unreamed nails do not protect the patient from pulmonary embolization of marrow contents.     

Infection after reamed intramedullary nailing of the tibia: a case series review

OBJECTIVE: We reviewed those patients who developed a postoperative infection after reamed intramedullary nailing of tibial shaft fractures to investigate the possible causes of infection, its effect on union time, and the requirement for reconstructive surgery. DESIGN: Retrospective review of patients who developed deep infection after reamed tibial nailing during a 15-year period. SETTING: University Level II Trauma Center. PATIENTS: Thirty-five with tibial diaphyseal fractures. INTERVENTION: All patients were treated with reamed intramedullary nailing. OUTCOME MEASURES: Union, union time, compartment syndrome, requirement for reconstructive procedures, and development of deep infection. RESULTS: In the closed-fracture group, 43.8% of patients were considered to have developed infection because of inappropriate fasciotomy closure, exchange nailing, and thermal necrosis. In the open-fracture group, 62.5% were considered to have developed infection attributable to late complications of plastic surgery. The most significant problem was marginal necrosis after flap cover. CONCLUSIONS: A number of deep infections after reamed intramedullary tibial nailing are avoidable. Particular attention must be paid to correct reaming, exchange nailing, and fasciotomy closure in closed fractures. In open fractures, marginal flap necrosis should be actively treated and not left to granulate.     

Interleukin-10 release and monocyte human leukocyte antigen-DR expression during femoral nailing

This study determined the effect of femoral nailing on the expression of monocyte Class II antigens and interleukin-10 release and sought to differentiate any differences in the release of these elements of immune reactivity in patients undergoing reamed and unreamed nailing. Thirty-two patients presenting with an acute femoral fracture were studied. In 15 patients, the femoral fracture was stabilized with a reamed technique and in 17 patients with an unreamed technique. Venous blood samples were taken at presentation, at anesthetic induction, immediately after nail insertion, and subsequently at 1, 4, and 24 hours and at 3, 5, and 7 days after surgery. Serum interleukin-10 was measured by an enzyme-linked immunosorbent assay, and monocyte human leukocyte antigen-DR expression was quantified by flow cytometry. Serum interleukin-10 release and human leukocyte antigen-DR expression on monocytes showed a clear response to the nailing procedure. The group of patients undergoing a reamed femoral nailing procedure showed significantly higher interleukin-10 release and a significant depression in the expression of human leukocyte antigen-DR on monocytes compared with those whose nail had been inserted unreamed. One patient in the reamed femoral nailing group died of adult respiratory distress syndrome 3 days after injury. Reamed intramedullary nailing appears to be associated with greater impairment of immune reactivity than is the unreamed nailing technique.     

胫骨髓内钉术后膝关节痛的临床观察

目的通过胫骨髓内钉术后膝关节痛的临床观察,探讨膝关节痛的病因.方法回顾在我院应用闭合复位交锁髓内钉治疗新鲜胫骨干骨折129个(126例病人).结果膝关节痛的共有17例,其中4例是由于钉尾突出胫骨近段,引起局部疼痛.另13例疼痛原因不详;所有病人膝关节活动均>110°,其中7例<110°时有痛(包括4例钉突出的),10例在极度屈膝活动时自觉有膝关节痛;除4例钉尾突出外,13例中在非扩髓组6/55例,扩髓组7/70例,统计学分析无差异;膝关节痛与髓内钉的品牌无统计学差异;经髌韧带入路关节痛发生率(11/44)明显高于髌韧带内侧入路(2/72),统计学上有显著差异.结论建议使用髌韧带周围入路;胫骨交锁髓内钉后出现的膝关节痛虽然比较少,其原因还需进一步观察与研究.     

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

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

Exchange reamed nailing for aseptic nonunion of the tibia

BACKGROUND: Exchange reamed nailing of the tibia is a common procedure in the treatment of an aseptic tibial nonunion. However, reports in the literature supporting this technique are limited. METHODS: Forty patients with a tibial nonunion after initial unreamed intramedullary nailing were retrospectively assessed after an exchange reamed nailing. The main outcome measurements included radiographic and clinical union as well as time from exchange reamed nailing to union. RESULTS: Thirty-eight patients achieved union of their fracture (95%). The average time from exchange nailing to union was 29 +/- 21 weeks. Complications included one deep vein thrombosis (2.5%) and two hardware failures (5%). CONCLUSION: Exchange reamed nailing for nonunions of the tibia results in a high union rate and is associated with a low complication rate. This technique is recommended as a standard procedure for aseptic tibial nonunions after initial unreamed intramedullary nailing.