Session I - Femur Fractures

Reamed vs. Nonreamed Femoral Nailing: A Preliminary Report

Paul Tornetta, III, MD, Douglas Tiburzi, MD

Kings County Hospital, Brooklyn, NY

Introduction: Nonreamed nailing of the femur has been advocated on the basis of animal studies showing less fat emboli and pulmonary shunting. The purpose of this study was to compare standard reamed nailing with nonreamed nailing in terms of fracture healing and complications.

Methods: 100 consecutive patients with femur fractures were entered into a prospective. randomized study comparing reamed (RN) with nonreamed nailing (NRN). All nails were statically locked. Reamed nails were placed after reaming 1.0 to 1.5 mm of cortical bone. Nonreamed nails were placed with an effort to avoid a tight cortical fit. Winquist class, fracture pattern, fracture location, operative time, blood loss, time to callus formation, bridging callus, PWB, FWB, and union were evaluated and recorded by one observer. Careful examination for signs of fat emboli were done pre- and post- operatively. There were 53 NRN and 47 RN. There were no differences between the groups with respect to age, fracture pattern or location, or Winquist class.

Results: For the overall groups, there was no statistical difference in operative time (NRN = 107, RN = 109 mins), days to bridging callus (NRN = 50, RN = 38), PWB, FWB, or union (NRN = 84, RN= 72). There was a statistical difference in blood loss (NRN = 247 ± 160, RN = 396cc ± 170) [p<.001] and in days to callus formation (NRN = 25, RN = 17) [p<.05]. When distal fractures were evaluated, there was a statistical difference in healing (NRN =130 days; RN =84 days). There were no clinically significant episodes of fat emboli in either group postoperatively, and one episode preoperatively. Complications were slightly more common in the nonreamed group.

Discussion: This study evaluates the results of operative data and healing in a prospective, randomized trial of NRN and RN. Significant postoperative pulmonary complications were not seen in either group. The operative time was the same for both groups, but there was a statistical increase in blood loss for reamed nails (150cc) that did not require a greater transfusion rate. The time to callus formation was statistically shorter for RN. The time to healing was less for the reamed group, but was not statistically different (p=0.3). However, when distal fractures were evaluated separately, there was a statistical difference in time to union with reamed faster than nonreamed.

Conclusion: Nonreamed nailing is comparable to reamed nailing in the proximal 2/3 of the femur. In the distal third, as this study continues, we would caution against the use of NRN unless pulmonary injury is present at the time of nailing.