Success of Exchange Reamed Intramedullary Nailing for Femoral Shaft Nonunion or Delayed Union :

Intramedullary nailing was performed on 520 femoral fractures in 500 patients. The series included eighty-six open fractures and 261 comminuted fractures. Closed intramedullary nailing was used in 497 femora and open intramedullary nailing with cerclage wiring, in twenty-three. The union rate was 99.1 per cent. The range of motion of the knee at follow-up averaged 130 degrees. Complications included four infections (0.9 per cent). Shortening of more than two centimeters occurred in ten patients (2.0 per cent) and malrotation of more than 20 degrees was observed in twelve patients (2.3 per cent). After prompt emergency measures had been taken, routine treatment included strong preoperative traction followed by accurate positioning of the patient on the operating table; selection of the correct insertion point for a properly sized, prebent, flexible, bullet-tipped nail; and accurate reduction of the fracture. Careful rehabilitation of the patient also contributed to the excellence of the results.

For many fractures of the femoral shaft, closed intramedullary nailing will not control rotation or telescoping of the fragments. Locked intramedullary nailing combines closed nailing with the percutaneous insertion of screws that interlock the bone and nail. This method permits static locking that controls rotation and telescoping and subsequently conversion to dynamic locking when weight-bearing is started after approximately twelve weeks. By providing greater stability, this method extends the indications for intramedullary nailing to severely comminuted, oblique, and spiral fractures as well as to fractures complicated by loss of bone and fractures in the proximal and distal ends of the femoral shaft. Of fifty-two patients with forty-nine severely comminuted fractures of the femoral shaft and three fractures that were complicated by loss of bone, forty-seven patients had uneventful consolidation of the fracture, with a mean time of 4.5 months for the severely comminuted fractures and seven months for the fractures that had a loss of bone. At follow-up, all forty-seven patients had normal motion of the hip, and forty-five had normal motion of the knee. Of the remaining five patients, four had a non-union that eventually healed (three after a second locked nailing and one after a third) and one had a septic non-union that eventually healed after removal of the nail and screws, débridement, and immobilization with an external fixator. Based on this experience, we concluded that this form of treatment has many advantages. The risk of infection and non-union is low, the incidence and severity of malunion are reduced, the hospital stay is short, and early mobilization of the patient is possible.

To investigate the relationship of smoking with the rate of pseudarthrosis (surgical nonunion), 50 patients, who were smokers, and 50 patients, who were not, and who had had a two-level laminectomy and fusion during 1977 and 1978 were randomly selected for this study. Most of those participating had sustained job-related injuries whereas the others had no common etiology for their back dysfunction. Most of the patients were from the southeastern United States. Ages ranged from 23 to 62 years, with a mean age of 42.4 years for smokers and 42.7 years for nonsmokers. There was an equal representation of males and females, with minorities represented according to their general percentage in the population. Examination 1 to 2 years after surgery revealed that 40% (20) of the smokers had developed a pseudarthrosis, whereas among nonsmokers, the rate was 8% (4). This finding appears to be independent of age, sex, or race and was statistically significant (chi 2 = 14.035, P = .001). It was hypothesized that the higher incidence of surgical nonunion among smokers may be related to blood gas levels. Nonsmokers showed no significant deficiencies, whereas smokers showed a mean PO2 level of 78.5% (normal = 95-97) and a mean O2 saturation level of 92.9% (normal = 95 or above). Implications and suggestions for further research are also discussed.