Plating or Intramedullary Nailing

Particularly in the patient with multiple injuries, plating was thought to have advantages in preventing brain damage in the patient with head injury.⁶ Thus, our first question using the PICO format is: In patients with head injury and femoral shaft fracture (P), will plating (I) or intramedullary nailing (C) result in better neurologic outcome (O)? Bhandari and coworkers⁶ evaluated this question in an observational study. The authors identified 21 patients with severe head injuries treated with a reamed femoral nail for a femoral fracture and 29 comparable patients treated by means of a femoral plate. In their series, severity of the head injury was the strongest predictor for outcome. Nailing was considered a safe procedure that did not worsen outcome, although the authors conclude that a large, sufficiently powered, randomized, controlled trial (RCT) is needed to definitively resolve this controversy⁶ (grade C).

Bosse and coworkers’⁷ retrospective study compares data from a trauma center using reamed nailing (I) for acute stabilization of femoral fractures with data from another North American center using plating (C). The rate of adult respiratory distress syndrome (O) in the patients who had a femoral fracture without a thoracic injury did not vary considerably according to whether the fracture had been nailed (118 patients) or plated (114 patients). Equally, the occurrence of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or mortality for the patients who had a femoral fracture and thoracic injury was comparable regardless of whether reamed nailing (117 patients) or plating (104 patients) had been used. The authors conclude that the use of intramedullary reamed nailing for acute fixation of fractures of the femur in patients with multiple injuries who have a thoracic injury without major comorbidity did not seem to increase the likelihood of development of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or mortality⁷ (grade C).

Fracture-Table versus Freehand Reduction

After choosing intramedullary nailing as the treatment option for femoral shaft fractures, surgeons have different fracture reduction techniques in their toolbox. Stephen and coworkers⁸ compared fracture-table (I) with manual traction (C) in femoral intramedullary nailing in a well-designed, sufficiently powered RCT.⁸ The primary outcome was number of patients with 10 degrees or more malrotation. Also, the authors scored severity of rotational malalignment. Operative procedure time was a secondary outcome. Internal malrotation was exceedingly more frequent when the fracture table had been used: 12 (29%) of the 43 femora were internally rotated by more than 10 degrees compared with 3 (7%) of the 45 reduced with manual traction (P = 0.007). Total procedure time, from the beginning of the patient positioning to the finishing point of the skin closure, was reduced from a mean of 139 minutes (range, 100–212 minutes) when the fracture table was used to a mean of 119 minutes (range, 65–180 minutes) when manual traction was used (P = 0.033). No significant difference was found between the two treatment groups with regard to the number of assistants per case (mean, 2; range, 0–3), fluoroscopy time, other adverse events including femoral leg length discrepancy, or functional condition of the patient at 1-year follow-up⁸ (grade A).

Slotted versus Solid Intramedullary Nail

After the fracture is manually well reduced and rotationally aligned options for nailing include using either a slotted or a solid nail. One European and one North American study evaluated this issue.^9,10 Alho and coauthors¹⁰ randomized 22 nonslotted Gross–Kempf nails and 24 slotted AO/ASIF universal femoral nails. Although the nonslotted nails showed higher stiffness than the slotted nails, insertion resulted in splintering of the distal fragment, one resulting in a change of the implant to a condylar plate. Other complications were not implant related. No nonunions were observed in either group.

Cameron and coworkers⁹ randomized patients with femoral shaft fractures into three groups: 32 were treated with a nonslotted Grosse–Kempf nail, 29 with a Russell–Taylor nail (nonslotted), and 27 with a Synthes nail (slotted). The operation took less time in the Grosse–Kempf nail group. Three proximal fractures could not be locked with the Synthes nail. At follow-up examination, the authors did not find important difference in pain, limp, range of motion, or time to union. On the other hand, the investigators removed fewer Synthes nails to resolve patient reports of pain. Three delayed unions were due to fracture distraction and were not implant related. The authors conclude that all three nails are suitable for the treatment of almost all femoral shaft fractures (grade I).

Antegrade versus Retrograde Nailing

Two studies compared antegrade versus retrograde reamed intramedullary nailing in RCTs with methodologic shortcomings. Tornetta and Tiburzi¹¹