Session IX - Femur Fractures

*Unreamed Retrograde Intramedullary Nailing of Fractures of the Femoral Shaft

Berton R. Moed, MD, J. Tracy Watson, MD, Kathryn E. Cramer, MD, David E. Karges, DO

Henry Ford Hospital, Detroit, Michigan, USA

Purpose: To evaluate the efficacy of retrograde intramedullary(IM) nailing of fractures of the femoral shaft in a second series of patients using modifications suggested from our initial study.

Methods: Based on the findings of a previous study (JBJS 77A pp. 1520-1527, 1995) we began a clinical series incorporating changes consisting of 1) inclusion of any patient with a femoral shaft fracture amenable to IM nailing (ie., closed physes), 2) primary use of a split patellar tendon intracondylar distal femoral entry portal, and 3) the use of a full length femoral implant having variable size availability and dynamization capability. Over a 12 month period 34 patients with 35 femoral shaft fractures were treated. Patients ranged in age from 15 to 88 years. Twenty patients had sustained multiple injuries and 14 had isolated skeletal trauma. Twelve fractures were stable (Winquist I & II) and 23 were unstable (Winquist III & IV). Initial static locking was performed in 29 and dynamic locking in 6. Nails were inserted with minimal or no reaming. The protocol called for planned dynamization in statically locked stable fractures and unstable fractures showing minimal healing at 6-12 weeks.

Results: The split patellar tendon approach resulted in easy access to the femur through a small (<5 cm.) and essentially bloodless incision. Overall, blood loss attributable to the IM nailing procedure was minimal, averaging less than 75cc. The nailing system facilitated the retrograde procedure, allowing sizing of the femoral canal and a simplified implant insertion technique. Operative times were relatively short, averaging approximately 95 minutes. The implant itself satisfied the perceived need for a dynamic locking capability while still providing rotational stability. Incorporating the concepts of canal fill and early dynamization, there were only two nonunions (6%) in this series as compared to 14% in the previously reported series with an overall shorter time to union (12.6 vs. 15 weeks). There were no infections or malunions. Postoperative complaints of knee pain were minimal.

Discussion and Conclusion: Controversy continues regarding the relative merits of antegrade nailing versus retrograde nailing and reamed versus unreamed nailing for the treatment of fractures of the femoral shaft. Our results indicate that unreamed retrograde IM nailing of fractures of the femoral shaft using a split patellar tendon, intercondylar distal femoral entry portal can provide results comparable to reamed antegrade nailing.

The operative technique is quick and simple and blood loss is minimal. Early nail dynamization appears to be important in minimizing the risk of nonunion. Not advocated as a replacement for other techniques, unreamed retrograde nailing is presented as a safe and beneficial fracture fixation method that should be added to the orthopaedic surgeon's treatment armamentarium. Further study is warranted both to evaluate its applicability for patients with isolated injury and the long term effect on knee function.