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A consecutive, prospective series of ninety-seven patients who had 100 fractures of the femoral shaft that were treated with static interlocking nailing was analyzed to determine the incidence of union of the fracture without planned conversion from static to dynamic intramedullary fixation as a technique to stimulate healing of the fracture. Eighty-four patients (eighty-seven fractures) were studied through union of the fracture (average follow-up, fourteen months). Eighty-five (98 per cent) of the eighty-seven fractures healed with static interlocking fixation. Two patients needed conversion from static to dynamic interlocking fixation because of inadequate fracture-healing; both progressed to uneventful union. The time to full weight-bearing (average, eleven weeks) was individualized for each patient and depended on the cortical contact of the major fragments, the presence of bridging callus as seen on radiographs, and the extent of other injuries of the ipsilateral lower extremity. No deformation or failure of the static interlocking device developed after early walking with weight-bearing, but fatigue failure of one nail occurred in a non-ambulatory patient who had an intracranial injury. Pain related to soft-tissue irritation by the prominent heads of the interlocking screws, clinically presenting as bursitis or snapping of the iliotibial band, was severe enough in six patients to necessitate removal of either the proximal or the distal screw after union of the fracture. We concluded that static interlocking of intramedullary nails in femoral shaft fractures does not appreciably inhibit the process of healing of the fracture, and that routine conversion to dynamic intramedullary fixation, although occasionally necessary, need not be performed.
Dynamic intramedullary fixation depends on the configuration of the fracture for postoperative stability. Unanticipated loss of reduction of the fracture after dynamic intramedullary nailing of the femur may result from errors in surgical decision-making, specifically the failure to insert both proximal and distal interlocking screws. Of 133 dynamic femoral intramedullary nailings that were performed after interlocking techniques became routinely available, fourteen (10.5 per cent) were complicated by loss of postoperative fixation and reduction. Thirteen of the fourteen femora shortened an average of 2.0 centimeters; the remaining femur shortened slightly, with clinical loss of rotational stability. Eight of fourteen patients elected some form of surgical revision, most commonly closed osteoclasis with restoration of femoral length, followed by the insertion of a statically locked nail. Errors in surgical judgment were attributed to inadequate preoperative analysis of the pattern of the fracture; undetected intraoperative comminution during reaming or insertion of the nail, or both; or postoperative failure to recognize an increase in comminution and instability of the fracture. We suggest using high-quality preoperative radiographs to detect non-displaced comminution of the major fracture fragments. Any increase in comminution of the fracture that occurs with reaming of the canal or insertion of the nail is an indication for static interlocking fixation. Radiographs that are made immediately postoperatively should be analyzed while the patient is under anesthesia, and any previously undetected instability of the fracture should be treated by static interlocking fixation. Dynamic intramedullary stabilization of the femur should be reserved for transverse or short oblique fractures at the femoral isthmus that have type-I or type-II comminution.
A clinical study was initiated at the University of Pennsylvania in 1970 to evaluate the use of constant direct current in treating acquired non-union. In 1977 the study was expanded to include twelve participating investigators throughout the United States. The results indicate that, given proper electrical parameters and proper cast immobilization, a rate of bone union comparable to that seen with bone-graft surgery was achieved. Experience dictated that four cathodes, each delivering twenty microamperes of constant direct current for twelve weeks, were required to heal a non-union of a long bone. Of 178 non-union in 175 patients treated with adequate electricity in the University of Pennsylvania series, 149 (83.7 per cent) achieved solid bone union. Patients with a history of osteomyelitis had a healing rate of 74.4 per cent. The presence of previously inserted metallic fixation devices did not affect the end-result healing rate. Of eighty non-unions in seventy-nine patients treated with electricity in the participating investigators' series, fifty-eight (72.5 per cent) achieved solid bone union. Review of the non-unions treated unsuccessfully with constant direct current suggested that inadequate electricity, the presence of synovial pseudarthrosis or infection, and dislodgment of the electrodes are causes for failure with the procedure. Complications of the electrical treatment were minor and there was no deep infection resulting from this procedure in patients without previous osteomyelitis. We concluded that the practicing orthopaedic surgeon utilizing constant direct current to treat non-union should, by adhering to proper fracture management and by following the biophysical principles described herein, be able to achieve a rate of union comparable to that of bone-graft surgery, with a lower associated risk.
To determine the effect of reamed versus nonreamed intramedullary (IM) nailing of lower extremity long bone fractures on the rates of nonunion, implant failure, malunion, compartment syndrome, pulmonary embolus, and infection. Quantitative systematic review of prospective, randomized controlled trials. MEDLINE and SCISEARCH computer searches provided lists of published randomized clinical trials from 1969 to 1998. Extensive hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files identified additional studies. Of 676 citations initially identified, sixty proved potentially eligible, of which four published and five unpublished randomized trials met all eligibility criteria. Each of three investigators assessed study quality and abstracted relevant data. The pooled relative risk of reamed versus nonreamed nails (nine trials, n = 646 patients) was 0.33 [95% confidence interval (CI), 0.16 to 0.68; p = 0.004]. The absolute risk difference in nonunion rates with reamed IM nailing was 7.0 percent (95% CI, 1 to 11 percent). Thus, one nonunion could be prevented for every fourteen patients treated with reamed IM nailing [number needed to treat (NNT) = 14.28]. The risk ratios for secondary outcome measures were: implant failure, 0.30 (95% CI, 0.16 to 0.58; p < 0.001); malunion, 1.06 (95% CI, 0.32 to 3.57); pulmonary embolus, 1.10 (95% CI, 0.26 to 4.76); compartment syndrome, 0.45 (95% CI, 0.13 to 1.56); and infection, 0.98 (95% CI, 0.21 to 4.76). Sensitivity analyses suggested that reported rates of nonunion and implant failure were higher in studies of lower quality. The type of long bone fractured (tibia or femur), the degree of soft tissue injury (open or closed), study quality, and whether a study was published or unpublished did not significantly alter the relative risk of nonunion between reamed and nonreamed IM nailing. There is evidence from a pooled analysis of randomized trials that reamed IM nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing.
Bone healing and Grafting. Orthopaedic Knowledge Update
  • J Aronson
  • Cn Cornell
Aronson J, Cornell CN: Bone healing and Grafting. Orthopaedic Knowledge Update. American Academy of Orthopaedic Surgeons, edition 6, 1999, 25-36.