Intramedullary fixation with reaming is an excellent operative procedure
that has revolutionized the treatment of fractures of the femoral
shaft. Instead of being confined to bed in traction, patients can
be mobilized on the first postoperative day. The expected union
rate is between 95% and 99%, with infrequent malunion
and infection, at least for closed fractures and for grade-1 and
grade-2 open fractures. Stabilization of a femoral fracture within
the first twenty-four hours after the injury has been shown to reduce
morbidity and mortality in multiply injured patients. However, there
are still controversial issues related to intramedullary femoral
fixation. The present report addresses several of these issues,
including the effect of intramedullary reaming on pulmonary complications
and the rate of fracture union, whether a fracture table or a flat radiolucent
table should be used for nail insertion, and whether the presence
of a head injury alters the treatment selection.
Classically, intramedullary nailing is done with use of a fracture table.
The table assists with fracture reduction by applying sustained
longitudinal traction. A perineal post provides a fulcrum against
which traction is applied. The design of most fracture tables allows
circumferential access to the extremity for manipulation, surgical
exposure, and imaging. When surgery is delayed and length has not
been maintained, the mechanical advantage of a fracture table or
a femoral distractor is needed to regain length.
Alternatively, intramedullary nailing can be performed on a radiolucent
table1-4. Traction can be applied
manually or with the use of a femoral distractor, although it takes almost
as long to apply the distractor as it does to perform the entire
nailing procedure and manual traction is usually sufficient to regain
length. Manual traction works best when nailing is done within twenty-four
hours after the injury; otherwise, muscle-shortening cannot be overcome
with manual traction alone. If surgery is to be delayed, the patient
should be placed in skeletal traction to maintain the normal length
or even slight distraction of the fracture fragments. Radiographic documentation
is suggested. The use of a flat radiolucent table keeps setup time
to a minimum, and access to the piriformis fossa is improved by
adduction of the limb. Disadvantages include difficulty in visualizing
the hip and the proximal part of the femur in the lateral projection;
difficulty in reducing and holding fracture alignment; and, if a
distractor is used, risk to the femoral neurovascular structures
and blockage of the operative field.
With either method, the patient can be placed in the lateral
decubitus or supine position. An advantage of the lateral decubitus
position is the improved access to the piriformis fossa, especially
in obese patients or in those with ipsilateral hip disease associated
with a decreased range of motion of the hip. The disadvantages of
the lateral position include respiratory compromise in patients
with pulmonary injuries, valgus angulation of the fracture, difficulty
in determining proper rotation, and greater difficulty in insertion
of distal locking screws.
Although femoral nailing with use of a fracture table has been associated
with excellent results, there are problems with the technique. Obese
patients are difficult to fit on a fracture table, and it can be
extremely difficult to establish the correct starting hole. It is
cumbersome to treat patients with multiple injuries on a fracture
table since access to the chest, abdomen, contralateral limb, and
the distal part of the ipsilateral limb is limited. These patients
require table changes as well as multiple preparation and draping
procedures, all of which add to the complexity of the operation
and increase operative time. Unstable pelvic and spinal injuries
make it difficult to use a fracture table as well. There are also
several unique complications associated with the use of a fracture
table, including compartment syndrome in the contralateral leg,
perineal slough, and pudendal nerve palsy5-7.
More recently, surgeons have begun to utilize flat radiolucent tables
to treat femoral shaft fractures. There are several advantages to
placement of the patient in the supine position, including ease
of setup, less respiratory compromise, better fracture alignment,
and easier insertion of distal screws. Because the injured leg is
draped free and can be adducted, it is easier to find the starting
point, particularly in larger patients. Moreover, because the entire
involved extremity as well as the contralateral lower extremity
can be prepared and draped at the same time and because it is not
necessary to reposition the patient and repeat the preparation and
draping at the conclusion of femoral nailing, it is easier to address multiple
fractures. The intramedullary nailing can be performed on the same
table used for a laparotomy, eliminating the need for a table change.
Two studies have shown that use of a radiolucent table rather than
a fracture table results in a significant reduction (p < 0.05)
in the time needed for preparation and draping; in the operative
and anesthesia times; and, if multiple injuries are present, in
the number of table changes and times that the patient needs to
be prepared and draped in order to address all of the injuries1,4.
When a fracture table is used, a closed reduction is performed with
use of traction applied through the fracture table combined with
external manipulation of the leg by the surgeon. To minimize the
risk of pudendal nerve palsy5,
the traction is decreased during the preparation and draping of the
patient and during proximal exposure. A small-diameter intramedullary
nail can be placed in the proximal fragment and used as a joystick
to manipulate the proximal fragment and reduce the fracture. This
can be particularly useful for fractures of the proximal third of
the femur. Many implant manufacturers include a device in the nailing
sets for this purpose.
When a radiolucent table is used, the fracture is reduced with
use of in-line manual traction combined with sterile bumps placed posteriorly
to correct angulation in the sagittal plane. Percutaneously placed
Schantz pins in the proximal or distal fragments may aid in the
reduction of fracture fragments. A small-diameter nail can be used
to correct angulation of short proximal segments. The most difficult
fractures to reduce with this method are noncomminuted fractures
of the isthmus in young patients with large thigh muscles. A small
incision to allow direct reduction of the fracture with use of a
bone-hook may be necessary.
A proper entry point is critical to ensure proper nail placement
and fracture reduction. A 2-cm longitudinal incision is made one handbreadth
proximal to the greater trochanter in line with the femoral shaft.
The fascia of the gluteus maximus is incised, and the muscle is
split bluntly in line with its fibers down to the piriformis fossa.
A clamp is placed in the piriformis fossa, its position is confirmed
with fluoroscopy, and then it is spread open upon withdrawal. A
guide-pin is then placed into the piriformis fossa and checked on
anteroposterior and lateral fluoroscopic views. Next, the guide-pin
is overreamed. Medial portal placement should be avoided, as it may
cause a femoral neck fracture. Lateral portal placement may lead
to comminution and varus alignment in fractures of the proximal
part of the femur. Alternatively, an awl may be placed in the piriformis
fossa and the proximal part of the femur may be opened by creating
a pilot hole. If this technique is chosen, a larger skin incision
is required.
When a radiolucent table is used, judging the length of the femur can
be problematic. The typical error when such a table is used is to
fail to restore length fully, whereas the typical error when a fracture
table is used is to overlengthen the limb. If the fracture is minimally
comminuted, radiographic landmarks can be used to judge the proper
length of the femur. If the fracture is so comminuted that radiographic
landmarks cannot be used, it is critical to know the proper length before
beginning the operation. Several methods can be used. A radiograph
of the intact femur can be made with a radiopaque ruler placed along
the thigh, and the distance between two reproducible landmarks,
such as the tip of the greater trochanter and the adductor tubercle,
can be used to determine length. In the operating room, the c-arm
can be used to image nails of different lengths held over the intact femur
until the proper length of nail is found. If both femora are fractured
and comminuted, the length should be determined by measuring the
less comminuted fracture and then making both femora the same length.
Radiographs of the contralateral limb also may be used to assess the
diameter of the medullary canal and the degree of curvature of the
intact femur. Patients with an extremely small medullary canal may
require a special-size implant, which should be determined preoperatively
to ensure implant availability.
The proper rotation is also difficult to judge. We find that
it is easier to judge rotation when a radiolucent table is used,
as it allows the use of several methods. External and internal rotation
of the contralateral hip can be assessed prior to preparation and
draping, and hip rotation on the injured side can be checked after
proximal locking and placement of a drill-bit through a distal locking
hole have been performed. Nearly symmetrical hip rotation indicates
that proper rotation has been restored. Confirmation of proper rotation
is performed by first making a perfect lateral fluoroscopic view
of the knee with the image intensifier. Next, the image intensifier
is slid proximally to the hip and the machine is rotated 15 to account
for femoral anteversion. If the rotation at the fracture site is
correct, this maneuver should produce a true lateral fluoroscopic
view of the hip.
In conclusion, reaming and femoral intramedullary nailing can be
performed safely and effectively on a flat radiolucent table. Operative
and anesthesia times have been shown to be reduced, and the care
of a multiply injured patient is facilitated.
Antegrade femoral nailing (passing the intramedullary nail from proximal
to distal) is the gold standard for surgical treatment of diaphyseal
femoral shaft fractures. It has a high rate of union (99%)
and a low rate of infection and malunion (<1%)8,9. However, antegrade nailing is associated
with a number of complications (including heterotopic ossification
around the hip, abductor weakness resulting in a limp, and limited
ability to walk or climb stairs), and its use is limited in certain
situations10. If a fracture table
is used, additional problems arise, including prolonged setup time,
possible pudendal nerve palsy, and the inability to address other
injuries simultaneously11,12.
Recent clinical studies have shown that the results of retrograde
nailing (passing the intramedullary nail from distal to proximal)
are currently comparable with those of antegrade nailing13-15.
Indications for Retrograde Nailing
Retrograde nailing may be the treatment of choice for certain femoral
fractures16. Distal femoral fractures
with or without articular involvement are easier to reduce and stabilize with
use of an implant that is inserted closer to the fracture site.
For patients with fractures of the ipsilateral femoral neck and
shaft, use of a retrograde nail allows the fracture of the shaft
to be fixed with one implant and the fracture of the neck to be fixed
with a separate implant, thus allowing each fracture to be treated
optimally. Retrograde nailing is useful for the treatment of obese
patients because the femoral intercondylar notch is easier to access
than the piriformis fossa, and it is advantageous for pregnant patients
because the radiation exposure to the fetus is reduced. Antegrade
nailing can be problematic in patients who need operative fixation
of an acetabular or pelvic fracture, as the incision for antegrade
nailing is usually inappropriate for the fixation of these injuries.
With use of an incision around the knee, it is possible to avoid
a second approach in patients with an open knee joint, knee disarticulation,
or a fracture of the ipsilateral tibia (a floating knee). Retrograde
nails can also be used to stabilize femoral shaft fractures proximal
to a knee replacement or distal to a total hip replacement. However,
not all femoral components used for total knee replacement allow
the passage of a nail and, if this is the case, a retrograde nail
cannot be used.
Retrograde Nailing Technique
Retrograde nailing is performed with the patient placed in the supine
position on a flat radiolucent table, with a bolster under the knee
to allow approximately 60 of flexion. A medial parapatellar approach,
either open or percutaneous, is used. The starting point is in the
intercondylar notch, just anterior to the posterior cruciate ligament
attachment and in line with the axis of the femoral shaft. Once
the starting point is identified, a starting hole is made with a
threaded guide-wire. This hole is then enlarged with use of a cannulated
drill, followed by passage of the ball-tipped guide-wire. The fracture can
be reduced with use of bolsters and manual traction. The femoral
distractor can be used, if necessary, to achieve and maintain length
and alignment. The ideal nail diameter is 1.5 to 2 mm less than
the largest reamer used. The nail should be driven proximal to the
level of the lesser trochanter and distally should be flush with
or buried 1 to 2 mm deep to the articular cartilage to avoid impingement
on the patella17.
Distal locking of the nail is done with use of the jig, and the
length of the screws is carefully judged to avoid medial prominence, which
can cause subsequent symptoms. In elderly patients with osteoporotic
bones and poor screw purchase, washers are recommended. Proximal
locking is done freehand in the anterior-posterior direction. The
mass of the quadriceps muscle and the curved anterior femoral surface make
this difficult. The proximal screw should be placed at or proximal
to the level of the lesser trochanter to avoid damage to the neurovascular
structures18.
It is essential that the fracture be reduced before the nail
is inserted so that the correct length and rotation can be ascertained. The
determination of appropriate length and rotation can be difficult,
especially when indirect reduction techniques are used. The correct
nail length should be determined preoperatively, particularly when
the fracture is comminuted and radiographic markers cannot be used
to judge length. Scanograms of the intact femur, fluoroscopic imaging
of the actual implants over the intact femur, or an intraoperative modified
scanogram measuring with a sterile electrocautery cord and c-arm
are all methods that can be used to determine the proper length
of the femur. Rotation is more difficult to judge. Comparing the
cortical diameter of the femur proximal and distal to the fracture
on the fluoroscopic image can help. Palpating the greater trochanter
and comparing its position to that of the intact femur can also
assist in obtaining the correct rotation.
Complications
Malunion is more frequent after retrograde nailing than it is
after antegrade nailing. Malunion is a problem after the retrograde
nailing of very proximal fractures because the capacious canal makes
it difficult to judge and control length and rotation. It is important
to reduce the distal femoral fracture prior to insertion of the
nail. The nail holds the reduction but will not reduce the fracture.
Retrograde nails are not the implant of choice for fractures of
the proximal third of the femur. Early series19 demonstrated
a higher prevalence of delayed union and nonunion after retrograde
nailing; however, with improved technique and the use of canal-matched
implants, the rate of union after retrograde nailing is currently
comparable with that after antegrade nailing.
Clinical Studies
The early reports on the use of retrograde nails were retrospective,
and the results were compared with those of historical controls.
Swiontkowski et al. were the first, as far as we know, to report
on the use of retrograde nails20.
They used a cloverleaf femoral nail in seven patients who had an ipsilateral
fracture of the femoral neck and shaft. The nail was inserted by
means of an extra-articular portal through the medial femoral condyle.
Sanders et al. expanded the indications for retrograde nailing to include
ipsilateral acetabular, pelvic, or femoral neck fractures; polytrauma
requiring multiple simultaneous procedures; and pregnancy21. Initial difficulties with insertion of
the femoral nail necessitated a change to a tibial nail. The authors
reported a healing rate of 92% (twenty-three of twenty-five
fractures), with no instances of infection or nail failure. Patterson
et al., in a study of seventeen fractures (eleven of which were
open), were the first to report on the use of the intercondylar
portal as a starting point22.
They attributed the poor results in their study to the severity
of the initial injury and the high proportion of open fractures. Herscovici
and Whiteman also reported on a series in which this approach was
used23.
Ostrum et al. recommended caution when retrograde nailing is used
to treat type-IIIB open fractures19.
They reported a healing rate of 95% (fifty-eight of sixty-one fractures)
but noted that for seven fractures a secondary procedure was needed
to obtain union. They recommended the use of canal-diameter-matched implants
to increase rates of union and to decrease the need for secondary
procedures.
In a follow-up to their earlier study24,
Moed et al. reported that 94% (thirty-three) of thirty-five
fractures united after retrograde nailing, with a shorter time to
union and with excellent knee scores25.
Laboratory Studies
ElMaraghy et al., in a laboratory study, showed that retrograde femoral
nailing after reaming led to a 52% decrease in anterior cruciate
ligament perfusion and a 49% decrease in posterior cruciate
ligament perfusion in adult dogs26.
It is not known whether this decrease in perfusion occurs in humans
or is clinically important for long-term knee function. Stubbs et
al. examined rabbit knees at two, six, and twelve months after insertion
of a stainless-steel implant and found that the insertion site was
completely covered with fibrous tissue27.
No histological difference was seen in the cartilage or synovial tissue
compared with that on the contralateral side, and there was no evidence
of metallosis.
Koval et al. found no significant difference during axial loading when
the two nailing techniques were compared with regard to strength28.
Randomized Trials
The results of a number of randomized trials comparing antegrade
and retrograde nailing have been published during the last several
years. Tornetta and Tiburzi prospectively compared thirty-eight
fractures treated with antegrade nailing and thirty-one fractures
treated with retrograde nailing and found no difference in operative
time, blood loss, or union rate29.
They found that it was more difficult to judge rotation and length
with use of the retrograde technique. In the most recent prospective,
randomized trial of which we are aware, Ostrum et al. found no difference
between antegrade nailing (forty-six fractures) and retrograde nailing (fifty-four
fractures) with respect to the rate of union or the range of motion
of the knee15. Knee motion improved
more quickly and knee effusion resolved earlier in the group that had
antegrade nailing. However, the group that had retrograde nailing
had an increased need for distal hardware removal and conversion
from a static to a dynamic construct as well as a longer time to
union. These findings were attributed to undersizing of the nail
diameter. Antegrade nailing was associated with an increased prevalence
of hip and thigh pain. The prevalence of knee pain was similar in
both groups.
Overview
The results of retrograde nailing of femoral shaft fractures
are comparable with those of antegrade nailing. Retrograde nails are
useful for fractures of the distal part of the femur with intra-articular
involvement. Intra-articular fractures can be managed with compression
lag screws before the nail is inserted. Fractures of the distal
third of the femoral shaft may be better suited for retrograde nailing,
and they have a lower rate of malalignment20.
Retrograde fixation may be better than antegrade fixation for
the treatment of femoral shaft fractures associated with (a) fracture of
the ipsilateral femoral neck, (b) obesity, (c) pregnancy, (d) knee
disarticulation, (e) ipsilateral acetabular or pelvic fracture, (f)
periprosthetic fracture, (g) a floating knee, or (h) an open knee
joint. It is also better for the treatment of a femoral shaft fracture
in a paraplegic patient with decubitus ulcers. The use of intercondylar
portal nails designed for retrograde insertion and of larger-diameter
nails has decreased the prevalence of complications, including malunion, nonunion,
and implant failure. Retrograde nailing requires the creation of
an intra-articular entry hole. There is concern about the long-term
effect of such an entry hole in young patients as well as the potential for
infection of the joint in patients with an open fracture, as the
knee joint then communicates with the open fracture site. The long-term
effects are still unknown, although the prevalence of knee pain
and the limitation of range of motion in the short to medium term
seem to be no higher than those associated with antegrade nailing.
At present, antegrade nailing remains the gold standard for the treatment
of isolated fractures of the proximal third of the femur and the
femoral diaphysis. Studies with larger numbers and long-term follow-up
are needed before the current recommendations for the use of retrograde nails
can be extended.
Early-generation intramedullary nails were open-section devices designed
to achieve a tight intramedullary fit in order to control rotation.
Reaming was necessary to enlarge the canal sufficiently to maximize
implant contact with the endosteum. Since the advent of locked intramedullary
devices, a tight endosteal fit is less necessary because rotational
control, as well as axial control, is achieved by means of proximal
and distal locking bolts. These intramedullary devices behave more
as rods than as nails30.
Reaming of the femoral canal prior to intramedullary nailing has
a multitude of local and systemic effects. Some of the systemic
effects are described in subsequent sections. Local effects have
been classified as biological or mechanical31 and
are discussed in this section.
Biological Factors
Rhinelander described the blood supply of the normal femoral diaphysis
as coming from one or more nutrient arteries supplying the inner
two-thirds of the cortex, with the outer third supplied by means
of periosteal vessels derived from the abundant soft tissue surrounding
the femoral shaft32. The cortical
circulation is defined as centrifugal, with the predominant flow
directed from the medullary canal toward the outer cortex. The medullary blood
supply is disrupted by fracture, leading to necrosis of approximately
50% to 70% of the cortical bone near the fracture30. Fracture-healing is dependent on
the reestablishment of blood flow to the disrupted cortical bone.
This revascularization may be periosteal, endosteal, intracortical,
or, additionally, by a transient extraosseous flow derived from
the soft tissue surrounding the fracture. This extraosseous flow
is particularly important in providing nutrients to callus as well
as to detached fracture fragments33.
Trueta suggested that the overall direction of cortical blood
flow after a fracture is reversed from centrifugal to centripetal34. This was confirmed by Strachan
et al., who showed that ligation of the nutrient artery did not
reduce blood flow to callus following diaphyseal osteotomy35. This reversal of flow takes place
over approximately two weeks, demonstrating that the intramedullary
and extramedullary circulations supplement each other through revascularization
across the cortex of the bone36.
Several animal studies have confirmed these findings37,38.
Placement of any intramedullary device, either with or without reaming,
damages the endosteal blood supply. However, reaming of the medullary
canal causes more substantial destruction of the endosteal circulation
and may lead to necrosis of the inner one-half to two-thirds of
the cortical bone39. This was
well demonstrated in a fractured sheep tibia model with use of Doppler
flowmetry40. Cortical perfusion
was significantly decreased in the group that had nailing with reaming
(p < 0.0009). Revascularization was established by six
weeks in the group that had nailing without reaming compared with
twelve weeks in the group that had nailing with reaming. Hupel et
al. studied the effects of limited reaming on cortical blood flow in
a canine model41. They demonstrated
that minimal reaming, to allow easy passage of a small-diameter
nail, had significantly less impact on the immediate postoperative
cortical blood flow than did standard reaming (p = 0.009).
In addition to the destruction of endosteal blood flow, reaming causes
a hyperemic response in the periosteum and the surrounding soft
tissues. Reichert et al. demonstrated, with use of radiolabeled
microspheres, a substantial increase in periosteal blood flow after
reaming in sheep tibiae37. Schemitsch
et al. showed that muscle perfusion is markedly increased following
long-bone reaming42. Despite the
reduced cortical blood flow that has been demonstrated after reaming,
an experimental model demonstrated no difference between long bones treated
with reaming and those treated without reaming with respect to the
perfusion of callus and the early strength of union43.
Intramedullary nailing with reaming clearly disrupts endosteal
blood circulation to a greater degree than nailing without reaming
does. However, given the change in cortical circulation from centrifugal
to centripetal following fracture, periosteal and extraosseous flow seems
to be the dominant method of revascularization and healing after
fracture fixation with intramedullary nails. This circulation is
stimulated by reaming and is dependent on a more-or-less intact
soft-tissue envelope surrounding the fracture. The excellent soft-tissue coverage
of the femur likely provides a means for this revascularization,
which may not be available after fractures of the tibia, particularly
those associated with open injuries. Reaming of the femur in and
of itself does not seem to have a deleterious effect on the revascularization necessary
for the healing of a fracture treated with intramedullary nailing.
In addition to the circulatory effects, reaming is also thought to
improve fracture-healing by means of autogenous bone-grafting through
the deposition of bone from the reaming at the fracture site.
Mechanical Factors
Nails used without reaming of the femoral canal are typically
of smaller diameter than are nails used with reaming. The moment of
inertia of a nail is a component of its overall strength, increasing
with the fourth power of the nail diameter. Reaming permits the
insertion of a larger-diameter, hence, stronger, intramedullary
nail, and a larger nail can accept larger locking bolts. A larger
nail with larger locking bolts also may allow earlier or immediate
weight-bearing44, even in the
presence of a comminuted fracture. Reaming also increases the contact
area between the nail and the endosteal bone, resulting in a stiffer
fracture construct. However, reaming results in the removal of bone,
theoretically decreasing the overall bone strength. Even so, the
outer diameter of the cortex is the primary contributor of strength
of the bone; thus, reaming removes the bone that contributes least
to the overall strength yet allows a substantially stronger nail
to be inserted45. Finite element
analysis has demonstrated that, within clinical limits, it is not
possible to ream a bone enough to substantially reduce its strength46.
Clinical Outcomes
Numerous studies have demonstrated that use of a locked intramedullary
femoral nail after reaming leads to a union rate of 97% to
100%8,9,47,48. Kröpfl
et al. reported a union rate of 100% in a study of eighty-one
femoral fractures treated with an intramedullary device inserted
without reaming49. However, several
studies have demonstrated lower union rates25 and
an increased need for secondary procedures50,51after
nailing without reaming.
Clatworthy et al. performed a prospective, randomized study comparing
femoral nailing with and without reaming52.
They demonstrated that the group treated with reaming had a faster
time to union (28.5 weeks compared with 39.4 weeks) and that the
group treated without reaming required substantially more secondary
procedures (conversion to a dynamic construct or bone-grafting)
to achieve union. Tornetta and Tiburzi also demonstrated faster union
with reaming (eighty days) than without reaming (109 days)53,54. Distal fractures had a more
dramatic difference in time to union with reaming (eighty days)
than without reaming (158 days). No significant difference was found between
the groups with respect to operative time or transfusion requirements.
The group treated with reaming had fewer technical complications.
A meta-analysis of randomized trials has demonstrated similar findings55.
The use of reaming in the treatment of open tibial fractures
is controversial because of concerns about the destruction of the endosteal
blood supply in a bone with already compromised circulation. However,
the femur has a more substantial soft-tissue envelope than the tibia
does, so periosteal and extraosseous blood supply is better. Clinical studies
of open femoral fractures treated with nailing after reaming have
demonstrated excellent rates of union with a low risk of infection56,57.
Overview
Reaming of the medullary canal has been shown to disrupt the endosteal
circulation. However, fracture-healing involves a reversal of the
normal centrifugal blood flow across the cortex to a circulation
dominated by periosteal and extraosseous flow. Reaming stimulates
this flow. Despite the disruption of the nutrient vessel circulation,
reaming seems actually to lead to increased circulation around a femoral
shaft fracture in the presence of an adequate soft-tissue envelope.
Reaming also permits the insertion of a larger, more stable nail,
which is advantageous for fracture-healing. Numerous clinical studies
have demonstrated that intramedullary nailing with reaming provides more
reliable and faster healing with fewer complications than does nailing
without reaming. Fixation with a femoral nail after reaming is the
treatment of choice for most femoral fractures that are managed
operatively.
The fat embolism syndrome is a multisystem disorder that results from
fat embolization. Clinically, it causes dysfunction of the pulmonary
and central nervous systems as well as fever and rash58. Almost all patients who sustain blunt
trauma have some degree of pulmonary fat embolization as a result
of the soft-tissue injury. The clinical severity of fat embolism
syndrome ranges from subclinical symptoms to the adult respiratory
distress syndrome (ARDS)59-64.
No consistent factors other than the number of long-bone fractures
can be used to identify patients who are at risk. Pulmonary fat
embolization apparently alters pulmonary hemodynamics, increases
pulmonary vascular permeability, activates the fibrinolytic and
coagulation systems, and causes pulmonary leukostasis58,59,65-67.
The clinical pulmonary effects are thought to occur as a result
of an increase in pulmonary vascular resistance secondary to widespread
vascular occlusion due to multiple small emboli. Larger fat emboli
may obstruct the pulmonary circulation, causing a ventilation-perfusion
mismatch and hypoxia. Death occurs as a result of right ventricular
failure58,68,69.
Prevention of Pulmonary Complications
The best treatment of fat embolism syndrome and adult respiratory
distress syndrome is prevention. Prior to the work of Riska et al.60,61 and Goris et al.70, fracture fixation was usually performed
on a delayed basis. One reason given for the delay was to allow
the peak dose of fat emboli to pass before fracture fixation was
undertaken71. Riska et al. demonstrated
that early stabilization of long-bone fractures in multiply injured patients
decreased the prevalence of fat embolism syndrome61.
They thought that fat embolization was an ongoing process that began
at the time of injury. Early fracture stabilization stopped this process
and prevented the development of related symptoms60,61.
Goris et al. then showed that early fracture stabilization combined
with mechanical ventilation not only decreased the prevalence of
adult respiratory distress syndrome but also decreased the mortality
rate in patients with an Injury Severity Score of >50 points70. Death was most often due to sepsis
and multiple organ failure.
Bone et al., in a prospective, randomized trial, demonstrated
that patients with femoral shaft fractures and an Injury Severity Score
of >18 points benefited from fracture stabilization within twenty-four
hours after injury72. Early stabilization
led to a decrease in the rates of adult respiratory distress syndrome,
fat embolism syndrome, and pneumonia and to a shorter length of stay
in the intensive care unit. The authors hypothesized that the decreased
fat embolization and the reduced need for narcotics associated with
early stabilization, as well as the ability to position the patient
with the torso upright, may explain these findings.
Femoral Intramedullary Nailing After Reaming:
The Present Controversy
The results of these and other studies have led to the consensus that
early stabilization of long-bone fractures is beneficial to the multiply
injured patient. The current treatment of choice for fractures of
the femoral shaft in adults is insertion of a statically locked
intramedullary nail after reaming. When the nail is inserted with
use of a closed technique, union rates of 95% to 99%,
with low rates of infection and malunion, can be expected9,73. Several clinical studies have shown
that early fixation with an intramedullary nail after reaming has
a beneficial effect in this group of patients, leading to a decrease
in pulmonary complications without an increase in other complications72,74,75. On the basis of the studies reported
to date, it appears that trauma patients without thoracic injuries
benefit from early nailing of a femoral shaft fracture, with a reduction
in the prevalence of pulmonary complications. The potential downside
of using a nail after reaming is the possibility that fat emboli
generated during nail insertion are harmful. This issue was first raised,
to our knowledge, by Pape et al., who analyzed a group of patients
with thoracic injuries and femoral shaft fractures76. Those authors noted a trend toward
an increase in pulmonary complications among patients in whom the
fracture was stabilized with intramedullary nailing with reaming
within twenty-four hours after the injury compared with those in
whom the fracture was stabilized more than twenty-four hours after
the injury. Although this finding was not significant, the authors
concluded that nailing after reaming in the presence of thoracic trauma
led to additional pulmonary damage.
There is no doubt that intramedullary nailing after reaming causes
fat embolization. Numerous clinical and animal studies have demonstrated
that pressurizing the medullary canal results in fat embolization
that can be visualized with use of echocardiography58,77. The questions are whether this fat
embolization has a clinically important effect and whether particular
subgroups of patients are at risk. The study by Pape et al. suggested
that patients with thoracic injuries are at an increased risk for
postoperative complications when early intramedullary nailing with reaming
is done76.
Since the cause of pulmonary dysfunction is multifactorial, it
is hypothesized that an otherwise trivial pulmonary insult such
as fat embolization may potentiate another noxious stimulus, leading
to respiratory impairment. Evidence for this "second hit" phenomenon
has been presented in animal studies66.
In addition to the study by Pape et al.76,
two other clinical studies have been performed to examine this issue.
Charash et al. performed a study quite similar to that of Pape et
al. and came to different conclusions78.
They found that delayed femoral shaft stabilization in patients with
thoracic trauma led to an increase in pulmonary complications. In
fact, the more severely injured the patient, the more pronounced
the difference. Bosse et al., in a report on femoral shaft fractures
that were treated at two institutions, divided patients into groups
on the basis of whether a thoracic injury was also present79. The fractures at one institution were
stabilized with a plate, and those at the other institution were stabilized
with an intramedullary nail after reaming. Presumably, the patients
treated with a plate would have had no pulmonary fat embolization
as a result of the femoral stabilization procedure, whereas those
treated with intramedullary nailing after reaming would have had
fat embolization. If fat embolization were harmful, the group treated
with intramedullary nailing after reaming would have a higher prevalence
of pulmonary complications. However, Bosse et al. found no difference between
the two groups with respect to the prevalence of pulmonary complications.
In a study of sheep, Pape et al.80 subjected
the animals to a lung crush injury and systemic hypotension on day
1. On day 3, the animals underwent nailing either with or without
reaming. Pulmonary permeability increased in both groups, but only
the group that had reaming had an increase in pulmonary arterial
pressures. The authors concluded that nails inserted after reaming
cause more pulmonary damage than do nails inserted without reaming.
In contrast, Wozasek et al. found that intramedullary nailing after reaming
alone did not cause an increase in pulmonary permeability, whereas
nailing combined with systemic hypotension caused a transient increase81. This raises the question of whether
it was the nailing with reaming or the hypotension that altered
the pulmonary permeability in the study by Pape et al.80.
Since it is unclear what pulmonary permeability means clinically,
one of us (P.W.) and colleagues used a sheep model to investigate
the effects of intramedullary nailing after reaming on clinically
applicable hemodynamic and oxymetric parameters82,83.
Two groups of animals were used. The first had a lung crush injury,
and the second had a chemically induced "ARDS-like" state.
No alteration in pulmonary function was noted in either group after
nailing with reaming was performed.
Current investigations are centered on the role of the inflammatory
response in the development of adult respiratory distress syndrome.
Trauma can cause the systemic inflammatory response syndrome (SIRS) early
after injury. Hemorrhagic shock and the reperfusion injury can overstimulate
the immune system and lead to complications, such as acute lung
injury, adult respiratory distress syndrome, systemic inflammatory response
syndrome, and multiple organ dysfunction syndromes. Oxygen free
radicals released by activated neutrophils are thought to play a
key role in this process by damaging endothelial tissues63,84-86. The SIRS score has been developed,
and studies have shown that patients with blunt trauma and higher
SIRS scores have an increased mortality rate and length of stay87. Presumably, these findings are related
to the extent of the inflammatory reaction87.
The association between shock and the development of adult respiratory
distress syndrome is well known. In fact, the likelihood of development
of adult respiratory distress syndrome and the mortality rate have
been found to be related to the initial base deficit, presumably
reflecting the depth of the initial hypoxic event88,89.
In a recent study, no relationship was found between the injury
pattern (that is, chest injury, abdominal injury, fracture, and
so on), patient age, Injury Severity Score on admission, Glasgow
Coma Scale score, hypotension on admission, or time spent in the
operating room and the development of adult respiratory distress
syndrome88. However, the transfusion requirements
in the initial twenty-four hours were substantially higher in the
patients in whom adult respiratory distress syndrome developed.
Those patients also had a lower base deficit in the initial twenty-four hours
after the injury, and the deficit normalized more slowly than did
the base deficit in those in whom adult respiratory distress syndrome
did not develop. In addition, the magnitude of the lowest base deficit
was found to correlate with the increase in cytokines on days 1
through 4, presumably reflecting an increased stimulation of the inflammatory
cascade. It appears that the depth of the initial hypoperfusion
correlates with the development of an early inflammatory response.
The findings in that study suggest that the most effective prevention of
adult respiratory distress syndrome is the early aggressive treatment
of shock88.
It is hypothesized that the initial shock and resuscitation serve
to prime the immune system so that a second, trivial stimulus can lead
to an exaggerated inflammatory response. There are experimental
and clinical data to support this hypothesis81,86,90,91.
Wozasek et al., in a sheep model, demonstrated that only nailing
with reaming and hypotension led to an increase in pulmonary permeability81. Other studies have shown that animals
in shock can tolerate less of a fat load85,92.
The neutrophils of trauma patients have been found to be more
responsive to stimuli to the release of superoxides than are the
neutrophils of healthy donors90.
Since neutrophils are thought to play a central role in the development
of lung injury, this finding suggests that trauma patients who have
had an initial stimulus of the inflammatory cascade as a result
of hypoperfusion may be extremely sensitive to the stimulus of fat
embolization that results from intramedullary nailing after reaming.
Without the initial stimulus, this fat embolization may have had
no significant detectable effect90.
In a recent clinical study, Crowl et al. investigated the effect
of occult hypoperfusion on complications following intramedullary
fixation of the femoral shaft within twenty-four hours after admission
in patients with an Injury Severity Score of >18 points91. Patients were retrospectively divided
into two groups on the basis of lactate levels. No patient had overt
clinical signs of shock. The group with occult hypoperfusion had
a higher complication rate and higher hospital costs. The authors
hypothesized that all trauma patients have activation of the inflammatory
process and that patients who have persistent occult end-organ hypoperfusion may
be more susceptible to a second-hit injury. This suggests that the
patients who may be harmed by early intramedullary nailing after
reaming are those with inadequate resuscitation.
Overview
There is controversy with regard to whether intramedullary nailing
after reaming can cause clinically important additional pulmonary
damage in trauma patients. The studies to date have indicated that
this is not an issue in trauma patients without chest injuries who
have been well resuscitated. The bulk of the literature has indicated
that intramedullary nailing after reaming does not seem to have
a detrimental effect on patients with only a thoracic injury. The current
controversy centers on the systemic inflammatory response syndrome
in underresuscitated patients. It appears that the depth of initial
hypoperfusion is an indicator of the extent of stimulation of the inflammatory
cascade. This factor is thought to play a role in the development
of endothelial injury, one aspect of which is the development of
pulmonary dysfunction including adult respiratory distress syndrome.
The already stimulated inflammatory reaction may exhibit inappropriate
exuberance if stimulated again by factors such as the fat embolization
generated during intramedullary nailing after reaming. Therefore,
prior to intramedullary nailing with reaming, the patient must be fully
resuscitated according to laboratory data (such as base deficit
or lactate) to make sure that occult hypoperfusion is not present.
If a patient is hemodynamically unstable or is not fully resuscitated,
femoral fixation should be delayed or an alternative, less invasive
procedure for stabilization, such as external fixation, should be
used93. It seems that the extent
of resuscitation rather than the presence or absence of a thoracic
injury is the critical risk factor for further pulmonary damage
as a result of intramedullary nailing after reaming.
The management of patients with a femoral fracture associated
with a severe head injury is controversial94-101.
A head injury is usually considered severe if the patient presents with
a Glasgow Coma Scale score of £8 points or an Abbreviated
Injury Scale score of 3 points102.
It is postulated that patients undergoing early stabilization of a
long-bone fracture in the presence of a severe head injury may be
at risk for a secondary brain injury as a result of reduced cerebral
perfusion pressure, hypoxemia, hypotension, and fat embolization59,95,99,103. This raises the question
of whether the risk of secondary brain injury outweighs the benefits
of early stabilization of a long-bone fracture in a patient with
a severe head injury and a femoral fracture. If so, can traumatologists
decide who should and who should not undergo early stabilization
of a femoral fracture in the presence of a severe head injury?
After a severe head injury, numerous factors can lead to secondary
ischemic brain injury, and ischemic brain injury has been shown
to be the major determinant of long-term neurologic disability104. Hypotension on or before admission
substantially increases the rate of poor neurologic outcomes104-106. Immediately after a severe
head injury, the normal autoregulation that maintains a stable cerebral
perfusion pressure (and thus cerebral blood flow and oxygen) is
altered. This effect is most pronounced in the first twenty-four
to forty-eight hours after injury107,108.
During this time, cerebral perfusion pressure is directly proportional
to mean arterial pressure. Thus, any hypotension during this period
can lead to cerebral hypoperfusion and hypoxemia—that is,
the so-called secondary brain injury104.
The complicating issues are that the duration of altered autoregulation
varies and that there can be regional cerebral ischemia up to forty-eight
hours following the injury109.
Cerebral perfusion pressure reflects cerebral blood flow, and the
current method of assessment is to monitor the intracranial pressure.
In this way, once the mean arterial pressure is determined (by means
of arterial line monitoring), the cerebral perfusion pressure is
determined by subtracting the intracranial pressure from the mean
arterial pressure. The generally accepted normal values are <20-25
mm Hg for intracranial pressure and >70 mm Hg for cerebral
perfusion pressure110. This means
that the mean arterial pressure should stay in the range of 90 mm
Hg to avoid cerebral hypoperfusion and thus cerebral hypoxemia.
Additional information concerning cerebral oxygenation can be obtained
by sampling the central venous oxygen tension through a central venous
catheter111. Thus, during the
initial period following a severe head injury, protection against
secondary brain injury requires aggressive resuscitation with crystalloid, blood
products, and, if necessary, inotropic support as well as invasive
monitoring of arterial, central venous, and intracerebral pressures
to avoid systemic hypotension and cerebral hypoperfusion and ischemia.
Despite the known benefit of early stabilization of long-bone fractures
and increased knowledge with regard to the treatment of patients
with head injuries, there is no consensus on how best to manage
a patient with both injuries. There are no large, prospective, randomized
studies comparing early and delayed stabilization of long-bone fractures in
the setting of a severe head injury. The advocates of each approach
base their decision on small retrospective studies.
The advocates for delaying long-bone stabilization in patients with
a head injury cite published reports indicating that hypotension
leads to worse neurologic outcomes in patients undergoing an early
operation (within the first twenty-four hours after injury)95,99,103. Jaicks et al. reported on
a cohort of thirty-three patients who had blunt trauma associated with
severe head injury (an Abbreviated Injury Scale score of >2
points) and femoral fracture95.
Nineteen patients underwent early fracture fixation (within twenty-four
hours after injury), and fourteen patients underwent late fixation
(more than twenty-four hours after injury). The two groups were
matched for age, Glasgow Coma Scale score, Injury Severity Score,
and neurologic and orthopaedic Abbreviated Injury Scale scores.
The early fixation group required significantly more fluids (p < 0.05) in
the first forty-eight hours and tended toward a higher rate of intraoperative
hypotension (observed in three patients who had early fixation and
one who had late fixation) and intraoperative hypoxia (observed
in two patients who had early fixation and one who had late fixation). Despite
these findings, the neurologic complication rate was similar in
the two groups. Although the mean Glasgow Coma Scale score on discharge was
lower in the early-fixation group (13.5 3.7 points) than in the
late-fixation group (15 0.0 points), the mean hospital stay was
five days longer in the late-fixation group (27 13 days) than in
the early-fixation group (22 20 days). No confidence intervals
were given for these data. The authors concluded that early fracture
fixation leads to greater fluid administration in patients with
head injuries. They thought that prospective studies were required
to evaluate the impact of the timing of fracture fixation on head
injury.
The advocates of early stabilization cite an equal (if not greater) number
of reports indicating that the severity of the initial head injury—not
the timing of long-bone stabilization—determines the ultimate
neurologic function96-98,100,101.
McKee et al. reported on a group of forty-six patients with a femoral
fracture and a severe head injury (mean Glasgow Coma Scale score, <8
points) who had early fracture stabilization (85% had stabilization within
twenty-four hours after injury) and compared them with a cohort
of ninety-nine patients with a severe head injury alone (mean Glasgow
Coma Scale Score, 8 points; range, 3 to 13 points)98. There were no differences between
the two groups with respect to demographic data or other injury
patterns. No significant differences between the two groups were
found in terms of early mortality, length of hospitalization, length
of stay in the intensive-care unit, level of neurologic disability,
or results of cognitive testing. The authors concluded that (1)
femoral fractures in patients with head injuries should be aggressively managed
with early fixation; (2) adequate oxygenation and cerebral perfusion
pressure must be maintained during operative procedures, including
femoral nailing after reaming; and (3) early femoral nailing after
reaming did not negatively affect neurologic outcome in this subset
of trauma patients98. Thus, each
side of the argument is supported in the literature—albeit
by small retrospective cohort studies—and the only solution
may be to perform a large, multicenter, prospective, randomized
study.
When faced with a patient with a severe head injury and a femoral fracture,
it is imperative to adopt a multidisciplinary approach that includes
the trauma service, the orthopaedic surgeon, the neurosurgeon, and
the anesthesiologist. This approach will allow optimal resuscitation
of the patient, establishment of the diagnosis and prognosis of
the head injury, and placement of invasive monitors prior to orthopaedic
intervention. The aggressive correction of hypothermia and coagulopathy,
as well as timely use of inotropes to maintain optimal mean arterial
pressure (and thus cerebral perfusion pressure), must be undertaken. The
exact timing of long-bone stabilization is determined on the basis
of the status of the patient, the results of the computerized tomography
scan of the head, and the parameters made available by invasive
monitoring. Prolonged orthopaedic interventions should be avoided,
with timely fracture stabilization being the goal. A mass lesion,
such as a subdural or epidural hematoma, seen on the computerized
tomography scan of the head requires urgent neurosurgical intervention.
A constellation of bad prognostic signs on the computerized tomography
scan, such as extensive amounts of subarachnoid blood, a ventricular
shift, and/or cerebellar herniation, may preclude any surgical
intervention. Certainly, if the intracranial pressure or the cerebral
perfusion pressure remains abnormal or labile, a delay in definitive
stabilization of long-bone fractures is recommended. In these patients, external
fixation for temporary fracture stabilization may be of benefit.
This would be especially important in the presence of an open femoral
fracture, in which case there is an urgency to get to the operating
room. External fixation would then be followed by definitive stabilization
with an intramedullary nail. The external fixator is usually applied
as an anterior half-frame, with two pins in each fracture segment.
In one series, this approach, called "damage control orthopedics," was
required for 13% of 327 patients with a femoral fracture and
multiple injuries who were treated at a level-I trauma center. This
approach mirrors the experience with devastating abdominal injuries112 and is appropriate for patients who
cannot tolerate additional blood loss, including those with head
injuries and those who are not yet fully resuscitated. External
fixation has been associated with a shorter operating-room time
and less blood loss than has intramedullary nailing after reaming93. In rare cases, when the patient is in
extremis, temporary skeletal traction may be required.
The timing of definitive stabilization with an intramedullary nail
is determined by the status of the patient, but because of the risk
of contamination of the external fixator pin site it is desirable
to perform the procedure within five to seven days. In some cases,
when the patient’s general or neurologic parameters do
not stabilize, the external fixator can be used for definitive fixation93.
In summary, there is no evidence in the literature that early
fixation of femoral fractures is deleterious in the presence of
a severe head injury. However, aggressive resuscitation and invasive
monitoring are required to achieve and maintain stable intracranial
and systemic parameters. If these parameters remain unstable, temporization
with external fixation or, rarely, skeletal traction may be required.
A multidisciplinary approach must be adopted to allow an optimal outcome
in this subset of trauma patients.
Wolinsky PR, McCarty EC, Shyr Y,Johnson KD. Length of operative procedures: reamed femoral intramedullary nailing
performed with and without a fracture table. J Orthop Trauma,1998;12: 485-95. 12485
1998
[PubMed][CrossRef]
Karpos PA, McFerran MA,Johnson KD. Intramedullary nailing of acute femoral shaft fractures
using manual traction without a fracture table. J Orthop Trauma,1995;9: 57-62. 957
1995
[PubMed][CrossRef]
Sirkin MS, Behrens F, McCracken K, Aurori K, Aurori B,Schenk R. Femoral nailing without a fracture table. Clin Orthop,1996;332: 119-25. 332119
1996
[PubMed][CrossRef]
Stephan DJG, Kreder HJ, Schemitsch
EJ, McKee MD, Wilde L, Conlan
L. A prospective randomized clinical trial comparing femoral
nailing using a fracture table versus manual traction. Read at the Annual
Meeting of the Orthopaedic Trauma Association; 2000 Oct 12-14; San
Antonio, TX.
Brumback RJ, Ellison TS, Molligan H, Molligan DJ, Mahaffey S,Schmidhauser C. Pudendal nerve palsy complicating intramedullary nailing
of the femur.. J Bone Joint Surg Am,1992;74: 1450-5. 741450
1992
[PubMed]
Callanan I, Choudhry V, ,Smith H. Perineal sloughing as a result of pressure necrosis from
the traction post during prolonged bilateral femoral nailing. Injury,1994;25: 472. 25472
1994
[PubMed][CrossRef]
Anglen J,Banovetz J. Compartment syndrome in the well leg resulting from fracture-table
positioning. Clin Orthop,1994;301: 239-42. 301239
1994
[PubMed]
Wolinsky PR, McCarty E, Shyr Y,Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma,1999;46: 392-9. 46392
1999
[PubMed][CrossRef]
Winquist RA, Hansen ST Jr,Clawson DK. Closed intramedullary nailing of femoral fractures. A
report of five hundred and twenty cases. J Bone Joint Surg Am,1984;66: 529-39. 66529
1984
[PubMed]
Bain GI, Zacest AC, Paterson DC, Middleton J,Pohl AP. Abduction strength following intramedullary nailing of
the femur. J Orthop Trauma,1997;11: 93-7. 1193
1997
[PubMed][CrossRef]
Benirschke SK, Melder I, Henley MB, Routt ML, Smith DG, Chapman JR,Swiontkowski MF. Closed interlocking nailing of femoral shaft fractures:
assessment of technical complications and functional outcomes by comparison
of a prospective database with retrospective review. J Orthop Trauma,1993;7: 118-22. 7118
1993
[PubMed][CrossRef]
Johnson EE, Marroquin CE,Kossovsky N. Synovial metallosis resulting from intraarticular intramedullary
nailing of a distal femoral nonunion. J Orthop Trauma,1993;7: 320-4. 7320
1993
[PubMed][CrossRef]
Tornetta P 3rd, Tiburzi
D. Anterograde vs. retrograde reamed femoral nailing: a prospective
randomized trial. Read at the Annual Meeting of the Orthopaedic
Trauma Association; 1998 Oct 8-10; Vancouver, BC, Canada.
Ricci WM, Bellabarba
C, O’Boyle M, Lewis RG, Herscovici
D, DiPasquale T, Sanders RW. Retrograde
vs. antegrade nailing of femoral shaft fractures. Read at the Annual
Meeting of the Orthopaedic Trauma Association; 1998 Oct 8-10; Vancouver, BC,
Canada.
Ostrum RF, Agarwal A, Lakatos R,Poka A. Prospective comparison of retrograde and antegrade femoral intramedullary
nailing. J Orthop Trauma,2000;14: 496-501. 14496
2000
[PubMed][CrossRef]
Gellman RE, Paiement GD, Green HD,Coughlin RR. Treatment of supracondylar femoral fractures with a retrograde intramedullary
nail. Clin Orthop,1996;332: 90-7. 33290
1996
[PubMed][CrossRef]
Morgan E, Ostrum RF, DiCicco J, McElroy J,Poka A. Effects of retrograde femoral intramedullary nailing on
the patellofemoral articulation. J Orthop Trauma,1999;13: 13-6. 1313
1999
[PubMed][CrossRef]
Riina J, Tornetta P 3rd, Ritter C,Geller J. Neurologic and vascular structures at risk during anterior-posterior
locking of retrograde femoral nails. J Orthop Trauma,1998;12: 379-81. 12379
1998
[PubMed][CrossRef]
Ostrum RF, DiCicco J, Lakatos R,Poka A. Retrograde intramedullary nailing of femoral diaphyseal
fractures. J Orthop Trauma,1998;12: 464-8.. 12464
1998
[PubMed][CrossRef]
Swiontkowski MF, Hansen ST Jr,Kellam J. Ipsilateral fractures of the femoral neck and shaft. A
treatment protocol. J Bone Joint Surg Am,1984;66: 260-8. 66260
1984
[PubMed]
Sanders R, Koval KJ, DiPasquale T, Helfet DL,Frankle M. Retrograde reamed femoral nailing. J Orthop Trauma,1993;7: 293-302. 7293
1993
[PubMed][CrossRef]
Patterson BM, Routt ML Jr, Benirschke SK,Hansen ST Jr. Retrograde nailing of femoral shaft fractures. J Trauma,1995;38: 38-43. 3838
1995
[PubMed][CrossRef]
Herscovici D Jr,Whiteman KW. Retrograde nailing of the femur using an intercondylar
approach. Clin Orthop,1996;332: 98-104. 33298
1996
[PubMed][CrossRef]
Moed BR,Watson JT. Retrograde intramedullary nailing, without reaming, of
fractures of the femoral shaft in multiply injured patients. J Bone Joint Surg Am,1995;77: 1520-7. 771520
1995
[PubMed]
Moed BR, Watson JT, Cramer KE, Karges DE,Teefey JS. Unreamed retrograde intramedullary nailing of fractures
of the femoral shaft. J Orthop Trauma,1998;12: 334-42. 12334
1998
[PubMed][CrossRef]
ElMaraghy AW, Schemitsch EH,Richards RR. Femoral and cruciate blood flow after retrograde femoral
nailing: a canine study using laser Doppler flowmetry. J Orthop Trauma,1998;12: 253-8. 12253
1998
[PubMed][CrossRef]
Stubbs M, Zhang H, Vrahas MS, Baratta RV,Zieske A. Effect of intraarticular stainless steel implants on the
health of the rabbit knee joint: an experimental study. J Orthop Trauma,2000;14: 567-70. 14567
2000
[PubMed][CrossRef]
Koval KJ, Kummer FJ, Bharam S, Chen D,Halder S. Distal femoral fixation: a laboratory comparison of the
95 degrees plate, antegrade and retrograde inserted reamed intramedullary
nails. J Orthop Trauma,1996;10: 378-82. 10378
1996
[PubMed][CrossRef]
Tornetta P 3rd,Tiburzi D. Antegrade or retrograde reamed femoral nailing. A prospective, randomised
trial. J Bone Joint Surg Br,2000;82: 652-4. 82652
2000
[PubMed][CrossRef]
Brumback RJ,Virkus WW. Intramedullary nailing of the femur: reamed versus nonreamed. J Am Acad Orthop Surg,2000;8: 83-90. 883
2000
[PubMed]
Chapman MW. The effect of reamed and nonreamed intramedullary nailing on
fracture healing. Clin Orthop,1998;355 Suppl: 230-8. 355 Suppl230
1998
Rhinelander FW. Effects of medullary nailing on the normal blood supply
of diaphyseal cortex. Instr Course Lect,1973;22: 161-87. 22161
1973
Rhinelander FW. The vascular
response of bone to internal fixation. In: Browner BD, Edwards CC,
editors. The science and practice of intramedullary nailing. Philadelphia:
Lea and Febiger; 1987. p 25-60
Trueta J. Blood supply and the rate of healing of tibial fractures. Clin Orthop,1974;105: 11-26.. 10511
1974
[PubMed]
Strachan RK, McCarthy I, Fleming R,Hughes SP. The role of the tibial nutrient artery. Microsphere estimation
of blood flow in the osteotomised canine tibia. J Bone Joint Surg Br,1990;72: 391-4. 72391
1990
[PubMed]
Whiteside LA,Lesker PA. The effects of extraperiosteal and subperiosteal dissection.
II. On fracture healing. J Bone Joint Surg Am,1978;60: 26-30. 6026
1978
[PubMed]
Reichert IL, McCarthy ID,Hughes SP. The acute vascular response to intramedullary reaming.
Microsphere estimation of blood flow in the intact ovine tibia. J Bone Joint Surg Br,1995;77: 490-3. 77490
1995
[PubMed]
Cole JD. The vascular response
of bone to internal fixation. In: Browner BD, editor. The
science and practice of intramedullary nailing. 2nd ed.
Baltimore: Williams and Wilkins; 1996. p 43-70
Klein MP, Rahn BA, Frigg R, Kessler S,Perren SM. Reaming versus non-reaming in medullary nailing: interference with
cortical circulation of the canine tibia. Arch Orthop Trauma Surg,1990;109: 314-6. 109314
1990
[PubMed][CrossRef]
Schemitsch EH, Kowalski MJ, Swiontkowski MF,Senft D. Cortical bone blood flow in reamed and unreamed locked intramedullary
nailing: a fractured tibia model in sheep. J Orthop Trauma,1994;8: 373-82. 8373
1994
[PubMed][CrossRef]
Hupel TM, Aksenov SA,Schemitsch EH. Effect of limited and standard reaming on cortical bone
blood flow and early strength of union following segmental fracture. J Orthop Trauma,1998;12: 400-6. 12400
1998
[PubMed][CrossRef]
Schemitsch EH, Kowalski MJ,Swiontkowski MF. Soft-tissue blood flow following reamed versus unreamed
locked intramedullary nailing: a fractured sheep tibia model. Ann Plast Surg,1996;36: 70-5. 3670
1996
[PubMed][CrossRef]
Schemitsch EH, Kowalski MJ, Swiontkowski MF,Harrington RM. Comparison of the effect of reamed and unreamed locked intramedullary
nailing on blood flow in the callus and strength of union following
fracture of the sheep tibia. J Orthop Res,1995;13: 382-9. 13382
1995
[PubMed][CrossRef]
Brumback RJ, Toal TR Jr, Murphy-Zane MS, Novak VP,Belkoff SM. Immediate weight-bearing after treatment of a comminuted
fracture of the femoral shaft with a statically locked intramedullary nail. J Bone Joint Surg Am,1999;81: 1538-44. 811538
1999
[PubMed]
Bechtold JE, Kyle RF, Perren SM. Biomechanics
of intramedullary nailing. In: Browner BD, editor. The science
and practice of intramedullary nailing. 2nd ed. Baltimore:
Williams and Wilkins; 1996. p 89-101.
Sandvig S. Effect of reaming
on the torsional strength of femora. Masters’ thesis, University
of Minnesota, 1995, cited in: Bechtold JE, Kyle RF, Perren SM. Biomechanics
of intramedullary nailing. In: Browner BD, editor. The science
and practice of intramedullary nailing. 2nd ed. Baltimore:
Williams and Wilkins; 1996.
Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH,Burgess AR. Intramedullary nailing of femoral shaft fractures. Part
II: Fracture-healing with static interlocking fixation. J Bone Joint Surg Am,1988;70: 1453-62. 701453
1988
[PubMed]
Wiss DA, Fleming CH, Matta JM,Clark D. Comminuted and rotationally unstable fractures of the
femur treated with an interlocking nail. Clin Orthop,1986;212: 35-47. 21235
1986
[PubMed]
Kröpfl A, Naglik H, Primavesi C,Hertz H. Unreamed intramedullary nailing of femoral fractures. J Trauma,1995;38: 717-26.. 38717
1995
[PubMed][CrossRef]
Bone L, Kowalski J, Rohrbacher B,Stegemann P. Reamed versus unreamed femoral nailing: a prospective
randomized study. Orthop Trans,1997;21: 603.. 21603
1997
Le TT, Wilber JH, Patterson BM, Sontich JK,Ziran BH. Early results of femur fractures treated with reamed vs
unreamed intramedullary nailing: a prospective study. Orthop Trans,1997;21: 604. 21604
1997
Clatworthy MG, Clark DI, Gray DH,Hardy AE. Reamed versus unreamed femoral nails. A randomized, prospective
trial. J Bone Joint Surg Br,1998;80: 485-9. 80485
1998
[PubMed][CrossRef]
Tornetta P 3rd,Tiburzi D. The treatment of femoral shaft fractures using intramedullary interlocked
nails with and without intramedullary reaming: a preliminary report. J Orthop Trauma,1997;11: 89-92. 1189
1997
[PubMed][CrossRef]
Tornetta P 3rd,Tiburzi D. Reamed versus nonreamed anterograde femoral nailing. J Orthop Trauma,2000;14: 15-9. 1415
2000
[PubMed][CrossRef]
Bhandari M, Guyatt GH, Tong D, Adili A,Shaughnessy SG. Reamed versus nonreamed intramedullary nailing of lower extremity
long bone fractures: a systematic overview and meta-analysis. J Orthop Trauma,2000;14: 2-9. 142
2000
[PubMed][CrossRef]
Brumback RJ, Ellison PS Jr, Poka A, Lakatos R, Bathon GH,Burgess AR. Intramedullary nailing of open fractures of the femoral
shaft. J Bone Joint Surg Am,1989;71: 1324-31. 711324
1989
[PubMed]
Lhowe DW,Hansen ST. Immediate nailing of open fractures of the femoral shaft. J Bone Joint Surg Am,1988;70: 812-20. 70812
1988
[PubMed]
Pell AC, Christie J, Keating JF,Sutherland GR. The detection of fat embolism by transoesophageal echocardiography
during reamed intramedullary nailing. A study of 24 patients with
femoral and tibial fractures. J Bone Joint Surg Br,1993;75: 921-5.. 75921
1993
[PubMed]
Levy D. The fat embolism syndrome. A review. Clin Orthop,1990;261: 281-6. 261281
1990
[PubMed]
Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O,Paavilainen T. Prevention of fat embolism by early internal fixation
of fractures in patients with multiple injuries. Injury,1976;8: 110-6. 8110
1976
[PubMed][CrossRef]
Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kaviluoto O,Paavilainen T. Primary operative fixation of long bone fractures in patients with
multiple injuries. J Trauma,1977;17: 111-21. 17111
1977
[PubMed][CrossRef]
Riska EB,Myllynen P. Fat embolism in patients with multiple injuries. J Trauma,1982;22: 891-4. 22891
1982
[PubMed][CrossRef]
Flick MR. Pulmonary edema
and acute lung injury. In: Murray JF, Nadel JA, editors. Textbook
of respiratory medicine. 2nd ed, vol 2. Philadelphia: WB Saunders;
1994. p 1725-77
Gurd AR. Fat embolism: an aid to diagnosis. J Bone Joint Surg Br,1970;52: 732-7. 52732
1970
[PubMed]
Barie PS, Minnear FL,Malik AB. Increased pulmonary vascular permeability after bone marrow injection
in sheep. Am Rev Respir Dis,1981;123: 648-53. 123648
1981
[PubMed]
Regel G, Nerlich ML, Dwenger A, Siedel J, Schmidt C,Sturm JA.. Induction of pulmonary injury by polymorphonuclear leucocytes
after bone marrow fat injection and endotoxemia: a sheep model. Theoret Surg,1989;4: 22-30. 422
1989
Nakata Y,Dahms TE. Triolein increases microvascular permeability in isolated
perfused rabbit lungs: role of neutrophils. J Trauma,2000;49: 320-6.. 49320
2000
[PubMed][CrossRef]
Peltier LF. Fat embolism. An appraisal of the problem. Clin Orthop,1984;187: 3-17. 1873
1984
[PubMed]
Peltier LF. Fat embolism. A perspective. Clin Orthop,1988;232: 263-70. 232263
1988
[PubMed]
Goris RJ, Gimbrere JS, van Niekerk JL, Schoots FJ,Booy LH. Early osteosynthesis and prophylactic mechanical ventilation
in the multitrauma patient. J Trauma,1982;22: 895-903. 22895
1982
[PubMed][CrossRef]
Wickstrom J,Corban MS. Intramedullary fixation for fractures of the femoral shaft.
A study of complications in 298 operations. J Trauma,1967;7: 551-83. 7551
1967
[PubMed][CrossRef]
Bone LB, Johnson KD, Weigelt J,Scheinberg R. Early versus delayed stabilization of femoral fractures.
A prospective randomized study. J Bone Joint Surg Am,1989;71: 336-40. 71336
1989
[PubMed]
Wolinsky PR, McCarty E, Shyr Y,Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma,1999;46: 392-9. 46392
1999
[PubMed][CrossRef]
Behrman SW, Fabian TC, Kudsk KA,Taylor JC. Improved outcome with femur fractures: early vs. delayed
fixation. J Trauma,1990;30: 792-8. 30792
1990
[PubMed][CrossRef]
Talucci RC, Manning J, Lampard S, Bach A,Carrico CJ. Early intramedullary nailing of femoral shaft fractures:
a cause of fat embolism syndrome. Am J Surg,1983;146: 107-11. 146107
1983
[PubMed][CrossRef]
Pape HC, Auf’m’Kolk M, Paffrath T, Regel G, Sturm JA,Tscherne H. Primary intramedullary femur fixation in multiple trauma patients
with associated lung contusion—a cause of posttraumatic
ARDS?. J Trauma,1993;34: 540-8. 34540
1993
[PubMed][CrossRef]
Wenda K, Runkel M, Degreif J,Ritter G. Pathogenesis and clinical relevance of bone marrow embolism in
medullary nailing—demonstrated by intraoperative echocardiography. Injury,1993;24 (3 Suppl): 73-81.. 24 (3 Suppl)73
1993
[CrossRef]
Charash WE, Fabian TC,Croce MA. Delayed surgical fixation of femur fractures is a risk
factor for pulmonary failure independent of thoracic trauma. J Trauma,1994;37: 667-72. 37667
1994
[PubMed][CrossRef]
Bosse MJ, Mackenzie EJ, Riemer BL, Brumback RJ, McCarthy ML,Burgess AR. Adult respiratory distress syndrome, pneumonia, and mortality
following thoracic injury and a femoral fracture treated either with
intramedullary nailing with reaming or with a plate. A comparative
study. J Bone Joint Surg Am,1997;79: 799-809. 79799
1997
[PubMed]
Pape HC, Dwenger A, Regel G, Schweitzer G, Jonas M, Remmers D, Krumm K, Neumann C, Sturm JA,Tscherne H. Pulmonary damage after intramedullary femoral nailing
in traumatized sheep—is there an effect from different
nailing methods. J Trauma,1992;33: 574-81. 33574
1992
[PubMed][CrossRef]
Wozasek GE, Thurnher M, Redl H,Schlag G. Pulmonary reaction during intramedullary fracture management
in traumatic shock: an experimental study. J Trauma,1994;37: 249-54. 37249
1994
[PubMed][CrossRef]
Wolinsky PR, Sciadini MF, Parker RE, Plitman JD, Snapper JR, Rutherford EJ, Schulman M,Johnson KD. Effects on pulmonary physiology of reamed femoral intramedullary
nailing in an open-chest sheep model. J Orthop Trauma,1996;10: 75-80.. 1075
1996
[PubMed][CrossRef]
Wolinsky PR, Banit D, Parker RE, Shyr Y, Snapper JR, Rutherford EJ,Johnson KD. Reamed intramedullary femoral nailing after induction
of an "ARDS-like" state in sheep: effect on clinically
applicable markers of pulmonary function. J Orthop Trauma,1998;12: 169-76. 12169
1998
[PubMed][CrossRef]
Marrhay MA, Matthay RA. Pulmonary
edema: cardiogenic and noncardiogenic chest medicine essentials
of pulmonary and critical care medicine. In: George RB, Light RW
editors. Baltimore: Williams and Wilkins; 1990. p 439.
Bulger EM, Jurkovich GJ, Gentilello LM,Maier RV. Current clinical options for the treatment and management
of acute respiratory distress syndrome. J Trauma,2000;48: 562-72. 48562
2000
[PubMed][CrossRef]
Rhee P, Morris J, Durham R, Hauser C, Cipolle M, Wilson R, Luchette F, McSwain N,Miller R. Recombinant humanized monoclonal antibody against CD18 (rhuMAb
CD18) in traumatic hemorrhagic shock: results of a phase II clinical
trial. Traumatic Shock Group. J Trauma,2000;49: 611-20. 49611
2000
[PubMed][CrossRef]
Napolitano LM, Ferrer T, McCarter RJ Jr,Scalea TM. Systemic inflammatory response syndrome score at admission independently
predicts mortality and length of stay in trauma patients. J Trauma,2000;49: 647-53. 49647
2000
[PubMed][CrossRef]
Rixen D,Siegel JH. Metabolic correlates of oxygen debt predict posttrauma
early acute respiratory distress syndrome and the related cytokine response. J Trauma,2000;49: 392-403. 49392
2000
[PubMed][CrossRef]
Davis JW, Parks SN, Kaups KL, Gladen HE,O’Donnell-Nicol S. Admission base deficit predicts transfusion requirements
and risk of complications. J Trauma,1996;41: 769-74. Comment: 1997;42:571-3.41769
1996
[PubMed][CrossRef]
Rotstein OD. Novel strategies for immunomodulation after trauma: revisiting
hypertonic saline as a resuscitation strategy for hemorrhagic shock. J Trauma,2000;49: 580-3.. 49580
2000
[PubMed][CrossRef]
Crowl AC, Young JS, Kahler DM, Claridge JA, Chrzanowski DS,Pomphrey M. Occult hypoperfusion is associated with increased morbidity
in patients undergoing early femur fracture fixation. J Trauma,2000;48: 260-7. 48260
2000
[PubMed][CrossRef]
Harmon JW,Ragatz FJ. The pathogenesis of experimental fat embolism. Am J Path,1949;25: 809-10. 25809
1949
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME,Pollak AN. External fixation as a bridge to intramedullary nailing
for patients with multiple injuries and with femur fractures: damage
control orthopedics. J Trauma,2000;48: 613-21. 48613
2000
[PubMed][CrossRef]
Garland DE, Rothi B,Waters RL. Femoral fractures in head-injured adults. Clin Orthop,1982;166: 219-25. 166219
1982
[PubMed]
Jaicks RR, Cohn SM,Moller BA. Early fracture fixation may be deleterious after head
injury. J Trauma,1997;42: 1-6. 421
1997
[PubMed][CrossRef]
Poole GV, Miller JD, Agnew SG,Griswold JA. Lower extremity fracture fixation in head-injured patients. J Trauma,1992;32: 654-9. 32654
1992
[PubMed][CrossRef]
Malisano LP, Stevens D,Hunter GA. The management of long bone fractures in the head-injured polytrauma
patient. J Orthop Trauma,1994;8: 1-5. 81
1994
[PubMed][CrossRef]
McKee MD, Schemitsch EH, Vincent LO, Sullivan I,Yoo D.. The effect of a femoral fracture on concomitant closed
head injury in patients with multiple injuries. J Trauma,1997;42: 1041-5. 421041
1997
[PubMed][CrossRef]
Townsend RN, Lheureau T, Protech J, Riemer B,Simon D. Timing fracture repair in patients with severe brain injury
(Glasgow Coma Scale score <9). J Trauma,1998;44: 977-82. 44977
1998
[PubMed][CrossRef]
Starr AJ, Hunt JL, Chason DP, Reinert CM,Walker JTreatment of femur fracture with associated head
injury.J Orthop Trauma,1998;12: 38-45. 1238
1998
[PubMed][CrossRef]
Scalea TM, Scott JD, Brumback RJ, Burgess AR, Mitchell KA, Kufera JA, Turen C,Champion HREarly fracture fixation may be "just
fine" after head injury: no difference in central nervous
system outcomes.J Trauma,1999;46: 839-46. 46839
1999
[PubMed][CrossRef]
Greenspan L, McLellan BA,Greig HAbbreviated Injury Scale and Injury Severity Score:
a scoring chart.J Trauma,1985;25: 60-4. 2560
1985
[PubMed][CrossRef]
Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD,Zhuang JThe deleterious effects of intraoperative hypotension
on outcome in patients with severe head injuries.J Trauma,1992;33: 403-7. 33403
1992
[PubMed][CrossRef]
Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A,Foulkes MAThe role of secondary brain injury in determining
outcome from severe head injury.J Trauma,1993;34: 216-22. 34216
1993
[PubMed][CrossRef]
Shackford SR, Mackersie RC, Davis JW, Wolf PL,Hoyt DBEpidemiology and pathology of traumatic deaths
occurring at a level I trauma center in a regionalized system: the
importance of secondary brain injury.J Trauma,1989;29: 1392-7. 291392
1989
[PubMed][CrossRef]
Wald SL, Shackford SR,Fenwick J. The effect of secondary insults on mortality and long-term
disability after severe head injury in a rural region without a
trauma system. J Trauma,1993;34: 377-82. 34377
1993
[PubMed][CrossRef]
Go KG, editor.Central
pathophysiology. Amsterdam: Elsevier; 1991. The fluid environment
of the central nervous system; p 66-172.
Bouma GJ, Muizelaar JP, Bandoh K,Marmarou ABlood pressure and intracranial pressure—volume
dynamics in severe head injury: relationship with cerebral blood
flow.J Neurosurg,1992;77: 15-9. 7715
1992
[PubMed][CrossRef]
Marion DW, Darby J,Yonas HAcute regional cerebral blood flow changes caused
by severe head injuries.J Neurosurg,1991;74: 407-14. 74407
1991
[PubMed][CrossRef]
Shackford SR, Zhuang J, Schmoker JIntravenous fluid tonicity: effect on intracranial
pressure, cerebral blood flow,cerebral oxygen delivery in focal brain injury.J Neurosurg,1992;76: 91-8. 7691
1992
[PubMed][CrossRef]
Fortune JB, Feustel PJ, Weigle CG,Popp AJContinuous measurement of jugular venous oxygen
saturation in response to transient elevations of blood pressure
in head-injured patients.J Neurosurg,1994;80: 461-8. 80461
1994
[PubMed][CrossRef]
Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kunder DR, Latenser BA,Angood PADamage control: an approach for improved survival
in exsanguinating penetrating abdominal injury.J Trauma,1993;35: 375-82. 35375
1993
[PubMed][CrossRef]