The Treatment of the Femoral Diaphyseal Fracture with Intramedullary Nailing: A Review of 313 Cases

Abstract

Purpose: The purpose of this study is to present our experience of interlocking intramedullary nailing in the treatment of femoral fractures and to report the results and the complications.
Material and Method: In a period of nine years (1993-2001) were treated 313 diaphyseal fractures 228 with AIM titanium intramedullary nailing and 85 with Gross-Kempf. All femoral fractures were reamed except the pathological fractures.
The 313 fractures according to AO classification were divided as follows:
Type A 81 (25.9 %), Type B 132 (42.8 %) and Type C 100 (31.3 %). The 89 % of fractures were caused by high energy injuries (traffic accidents). The mean age was 26 yrs (17-78 yrs). From all fractures 256 were closed and 57 were open (grade I: 27, grade II 19, grade III a 11). For type A fractures dynamic intramedullary nailing was the treatment of choice, while in type B, C fractures static intramedullary nailing was performed. In all patients we used prophylactic antibiotics for 48 hours and low weight molecular heparin for a month. The median time of radiation exposure was 16 sec (range 5-42). From the second postoperative day we encourage our patients to walk with partial weight bearing, except those with type C fractures who started their weight bearing after 3 weeks.
EM EMTYPE="BOLD">Results: All type A fractures were united in an average time of 16 weeks, type B in 20 weeks and type C in 23 weeks. In regard to complications, we had: 5 aseptic pseudarthrosis (1.6 %), 12 delayed unions (3.8 %), torsional malunion (5°) in 3 patients (0.96 %). The majority of them were treated with intramedullary nailing revision. In 4 patients (1.28 %) we had limb shortening of 15 mm. (In one case we made dynamic nailing instead of the correct static intramedullary nailing and in 3 cases we failed to centralize the proximal screw. All of them were reoperated.)
Neurological complications were observed postoperatively in 29 patients, 22 with paresis of the pudendal nerve, due to traction (all recovered in a month), and 7 with paresis of peroneal nerve which were recovered in 3 months. There was found 23 broken screws but no broken nail. In one case of pathological fracture (lower 1/3) the guide wire was penetrate in the knee join.
We had two pulmonary and one fat embolism (in patients without chest injury), but none of them was fatal. Also we noticed no superficial or deep infections and we didn't have a case of compartment syndrome. In two patients was observed clinically thrombosis below knee.
Patients returned to their previous activities in a mean time of 12 weeks.
Conclusion: Locking intramedullary nailing offers excellent results in treatment of femoral diaphyseal fractures. We choose AIM titanium nail because the modulus of elasticity is more closer with bone elasticity. Also the fatigue strength, yield strength and ultimate tensile strength, are higher than any other implant. For this reasons we can use smaller diameter nails, with less reaming, and less disturbance of endosteal blood supply.

Femoral diaphysis - fracture - intramedullary nailing - reaming - complications

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