THE SUCCESS OF EXCHANGE REAMED INTRAMEDULLARY NAILING FOR FEMORAL SHAFT NONUNION OR DELAYED UNION

Participants: D. J. Hak, S.S. Lee, J.A. Goulet

Keywords: exchange reamed nailing, intramedullary nail, femoral shaft nonunion, delayed union

Introduction

Objectives: The purpose of this study was to investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunions following intramedullary nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing.

Materials and Methods

Design: Retrospective consecutive clinical series

Setting: Level one trauma center and tertiary university hospital

Patients: Twenty-three patients were identified whose radiographs failed to show progression of healing for four months following treatment with a reamed intramedullary femoral nail. Nineteen patients had undergone primary intramedullary nailing of an acute femoral shaft fracture, one patient had been converted to an intramedullary nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing.

Intervention: All patients were treated by exchange reamed femoral nailing. The new nail diameter was increased by 1 to 3 mm with the majority being increased by 2 mm. The intramedullary canal was over-reamed by 1 mm larger than the diameter of the nail. Most of the nails were statically locked and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed, or by applying compression with a femoral distractor.

Main outcome measurements: Radiographic evaluation of union was determined by presence of healing on at least three of four cortices. Factors reviewed included the patients age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures.

Results

Exchange reamed femoral nailing was successful in eighteen cases (78%). Three patients achieved union with additional procedures. All eight of the nonsmokers healed following exchange reamed nailing, while only ten of the fifteen smokers (67%) healed following exchange reamed nailing. Intramedullary cultures were positive in five cases and all of these achieved successful union.

Conclusions

Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed intramedullary nailing has a low morbidity, may obviate the need for additional bone grafting, and allows full weight bearing and active rehabilitation. Nicotine use may have an adverse effect on nonunion healing following exchange reamed femoral nailing.