Session I - Femur Fractures

Early Results of Femur Fractures Treated with Reamed vs. Unreamed Intramedullary Nailing: A Prospective Study

T. Toan Le, MD, John H. Wilber, MD, Brendan M. Patterson, MD, John K. Sontich, MD, Bruce H. Ziran, MD

Metrohealth Medical Center, Cleveland, Ohio

Introduction: Much controversy exists over the potential pulmonary complications arising from intramedullary reaming in the treatment of femur fractures. The use of small diameter nails inserted by an unreamed technique has been advocated to avoid these problems. However, recent studies seem to indicate that there is no significant association of reaming with ARDS, PE or pneumonia. Thus, the issue of potential mechanical instability of fracture fixation and fracture healing with unreamed IM nail needs to be investigated. We performed a prospective randomized study to compare results of reamed vs. unreamed IM nailing in the treatment of femoral shaft fractures.

Methods: Consecutive patients age 16 and over with femoral shaft fracture treated with IM nailing were prospectively randomized into two groups: reamed vs. unreamed. Charts were reviewed to analyze the rate of complications, length of ICU stay and hospital stay and time to union. Three groups were identified. Group I & II had reamed and unreamed IM nailing respectively. Group III was those randomized to unreamed but had to be reamed intraoperatively because of small canal diameter which would not allow insertion of the nail without reaming. Results of Group I & III together were compared versus that of Group II.

Results: 54 femur fractures in 53 patients were entered in the study: group I - 37, group II - 13 and group III - 4. However, a total of 15 patients with 16 femur fractures were lost to follow up. As a result, remaining numbers were available for analysis: Group I (N=26), Group II (N=9) and Group III (N=3). There was no statistical significance between the two groups in the length of ICU stay, hospital stay and time to full weight bearing without pain - "clinical union". However, there were 3 nonunions out of 9 treated with unreamed IM nailing versus 0 out of 29 for the reamed groups. (p=.0l8). The three nonunions were femur fractures involving two midshaft / distal thirds with Winquist 1 and two segmental midshafts with Winquist 4 comminution. All three nonunions required exchanged reamed nailing and went onto unevenful union. There was no nail failure in either groups.

Discussion: Results indicate no statistical difference between ream and unreamed IM nailing in regard to ICU and hospital stay and the rate of progression to full weight bearing. This is consistent with previous studies. However, our data shows a statistically significant higher rate of nonunion with unreamed nail. This may suggest a less than optimal fracture fixation of femur fractures treated with unreamed nail especially those with higher grade of comminution or involving the distal third. Unreamed IM nail should be used with caution especially those with higher grade of comminution or involving the distal third. One should anticipate the potential of delayed union and nonunion when unreamed IM nails are used. However, this can be resolved with exchanged reamed nailing. The weakness of our study is that there is a large discrepancy between the number of reamed vs. unreamed nails enrolled.