Session I - Femur Fractures

A Prospective Randomized Study of Reamed vs. Unreamed Femoral Intramedullary Nailing: An Assessment of Procedures

Lane Shepherd, MD, Chris Shean, MD, Vincent Carter, MD, Pat McGuire, PA, Jackson Lee, MD

LAC/USC Medical Center, Los Angeles, CA

Hypothesis: The procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing.

Conclusion: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. No significant difference was found between the nailing techniques for fluoroscopy time, perioperative complications or iatrogenic comminution. The unreamed femoral nailing techniques may be useful in polytraumatized patients and Jehovah's witnesses in whom speed and minimizing blood loss are important, but should not otherwise replace reamed nailing as the standard technique.

Methods: From May 1994 to the present, patients with isolated unilateral femoral shaft fractures and no associated injuries were prospectively randomized to either reamed (Zimmer ZMS) or unreamed (Synthes URFN) intramedullary stabilization. Inclusion criteria were skeletal maturity and nonpathologic acute femoral shaft fractures. Patients with vascular injuries, associated long bone fractures, infection, and intraarticular fracture extension were excluded. Surgical time, fluoroscopy time, estimated blood loss, iatrogenic comminution and perioperative complications were recorded shortly after surgery.

Results: 100 patients with 100 femoral shaft fractures were prospectively randomized to the study. There were 4 open fractures, 45 fractures due to gunshots, and 51 closed fractures with similar distributions between each treatment group. 37 patients received reamed and 63 patients received unreamed intramedullary nails. All nails in each group were locked proximally and distally. The average surgical time from skin incision through closure for the reamed nail group was 138 minutes and for the unreamed nail group was 108 minutes (p=0.012). The estimated blood loss for the reamed nail group was 278cc and for the unreamed nail group 186cc ( p=0.034). The fluoroscopy time for each group was recorded for the nailing procedure itself. Reamed intramedullary nailing required an average of 4.72 minutes while unreamed nailing required 4.29 minutes of fluoroscopy time. 7 perioperative complications occurred in the reamed nail group and 18 in the unreamed nail group. 2 patients in the unreamed group required a secondary procedure; one for replacement of initially unrecognized "airball" distal locking screws, and the other for correction of malrotation. Iatrogenic comminution of the fracture site occurred during 3 reamed and 6 unreamed intramedullary nailings. Reaming of the canal was required prior to the successful placement of 3 nails in the unreamed group due to canal/nail diameter mismatch.