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 used hospital chart numbers for patient allocation and randomized 38 fractures in the antegrade group and 31 in the retrograde group. A rotational deformity of greater than 10 degrees was seen on computed tomographic rotation studies in 3 of 18 (17%) of the antegrade and in 5 of 15 (33%) of retrograde nailings performed in cases with unstable patterns. Shortening occurred in five unstable fractures in the retrograde group, but in none of such injuries in the antegrade group. In these five patients, shortening averaged 12 mm (5–30 mm). Return to the operating room for acute lengthening and relocking was necessary for a patient with 3 cm of shortening. At union, four patients with retrograde nailing and five with antegrade nailing reported pain in the knee.

Ostrum and coworkers¹² compared 44 fractures (7 bilateral) treated with a retrograde nail and 46 (1 bilateral) with an antegrade nail. Discussing fracture results and not patients complicates making inferences when patients with bilateral fractures are compared with patients with single-site fractures.^5,13 Knee pain was equal in both groups (4 patients in the antegrade group; 5 patients in the retrograde group), but hip and thigh pain was in the majority in the antegrade-treated group (10 patients in the antegrade group; 2 patients in the retrograde group; P = 0.0108). Finally, three retrospective case series described this issue.^14–17

Table 62-1 provides detailed information on the available data. Despite the potential for complications, most concerns have been unrealized in recent comparisons between antegrade and retrograde intramedullary nails in patients with femoral shaft fractures (see Table 62-1). In brief, retrograde nails achieve equal union rates and function at the expense of an increased need for nail dynamization. Shortening occurs at a greater rate with retrograde nail insertion but is seldom clinically significant (<1.5 cm). Thigh and hip pain, a common occurrence in antegrade nails, is significantly reduced with retrograde nail insertion. In conclusion, surgeons with experience in retrograde nailing techniques can achieve outcomes similar to those of antegrade nailing techniques. Retrograde nailing may be particularly useful in patients with multiple ipsilateral injuries and in obese patients. Based on our review, both antegrade and retrograde procedures can have acceptable results (grade B).

Trochanteric versus Piriformis Entry Point

Based on a prospective cohort study comparing 38 patients in the trochanteric starting point group with 53 in the piriformis fossa entry point, Ricci and coworkers¹⁸ found reduced fluoroscopy time using a trochanteric starting point and similar overall outcome (grade C).

Reamed versus Unreamed Nailing

The controversy surrounding reamed versus unreamed nailing is evaluated in several RCTs. Bhandari and coworkers¹⁹ performed a systematic review published in 2000 comparing reamed versus unreamed nailing of lower extremity long bone fractures. Since this publication, new RCTs and a new systematic review have become available.²⁰

Key outcomes of interest in these studies are delayed or nonunion and post-traumatic acute respiratory distress syndrome (ARDS). Pooling the data of four currently published studies showed a relative risk of 0.29 (95% confidence interval [CI], 0.14–0.57) for delayed or nonunion favoring reamed nails (Fig. 62-1).^21–24 Translated into number needed to treat (NNT) equals 7 (95% CI, 5–12); that is, with every 7 patients treated with a reamed nail, 1 delayed or nonunion result will be prevented.

FIGURE 62-1 Pooled results reamed versus unreamed nailing in preventing nonunion.21–24 CI, confidence interval; RR, relative risk.

Data from Canadian Orthopaedic Trauma Society: Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am 85-A:2093-2096, 2003; Clatworthy MG, Clark DI, Gray DH, and Hardy AE: Reamed versus unreamed femoral nails. A randomised, prospective trial. [see comment]. J Bone Joint Surg Br 80:485-489, 1998; Selvakumar K, Saw KY, and Fathima M: Comparison study between reamed and unreamed nailing of closed femoral fractures. Med J Malaysia 56 Suppl D:24-28, 2001; and Tornetta P, III and Tiburzi D: Reamed versus nonreamed anterograde femoral nailing. J Orthop Trauma 14:15-19, 2000.

The relative risk for ARDS in patients treated with a reamed nail was 1.91 (95% CI, 0.74–4.93) (Fig. 62-2).^{21,24, 25} The CIs crossing 1 indicate a nonsignificant result.

FIGURE 62-2 Pooled results reamed versus undreamed femoral nailing in preventing acute respiratory distress syndrome (ARDS).^{24,25, 29} CI, confidence interval; RR, relative risk.

Data from Anwar IA, Battistella FD, Neiman R, Olson SA, Chapman MW, and Moehring HD: Femur fractures and lung complications: a prospective randomized study of reaming. Clin Orthop 71-76, 2004; and Canadian Orthopaedic Trauma Society: Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am 85-A: 2093-2096, 2003.

Data on reported adverse events as a composite end point showed a widespread range from patient-unimportant outcomes (e.g., a broken drill bit) to patient-important outcomes (such as pudendal nerve palsy), making pooling of these data futile as a single composite outcome measure.

Femoral shaft fractures can be treated safely using reamed intramedullary nails preventing delayed or nonunions without strong evidence for increasing risk for ARDS (grade B).

Static or Dynamic Locking

After the nail is inserted, static or dynamic locking of the nail is possible. One small RCT with methodologic shortcomings did not show a difference in union rates between static and dynamic locking; however, the authors did observe a trend to earlier union in the dynamically locked group.²⁶ Of the 26 femoral fractures in the dynamized group, union occurred between 13 and 28 weeks (average, 19.2 weeks) in 25 of 26 patients. Union rate was 96.2% in the dynamized group. Of the 24 patients with femoral fractures in the static group, union was achieved in 23 between 16 and 30 weeks (average, 23.45 weeks); union rate was 95.8%.

Conflicting information comes from a larger observational study comparing data from two Italian hospitals.²⁷ Time to union was significantly shorter in the 104 patients treated in the static group (103 days) compared with the 75 patients treated in the dynamized group (126 days)²⁷ (grade I conflicting data). Biomechanical data suggest that immediate weight bearing as tolerated is safe after static locking, even in comminuted fractures.²⁸ Dynamic locking of comminuted shaft fractures should be avoided because it would preclude immediate weight bearing without incurring shortening of the fracture.

Cost

In our literature search, we could not identify studies evaluating cost associated with treatment options for femoral shaft fractures. To our knowledge, economic analyses currently are lacking.

Patients with Multiple Injuries

Currently limited data are available to make inferences on the optimal treatment strategy for the patient with multiple injuries with a femoral shaft fracture.