Fractures of the femur Leeds 2005 AO Principles Course David L Shaw Module : Principles of operative management of common fractures

Fractures of the Femoral Shaft (AO 3.2) Why should I fix the #? How should I fix it ? What complications can I expect ?

Paediatric fractures J Am Acad Orth Surg 1995 no3 See article Gallows Hip Spica Traction J Am Acad Orth Surg 1995 no3 J Am Acad Orth Surg 1995 no3

Why fix the # Save life Save limb Preserve function Poly trauma Stabilisation with immediate rehabilitation

Choose a method ? Plating Ext fixn IM Nail Rigid fixation Abs stability LISS LCP Ext fixn IM Nail Consider absolute vs relative stability Consider soft tissues and scars Consider facilities and equipment J Am Acad Orth Surg 1995 no3

Choose a method 2 Patient factors Facilities, time and polytrauma Damage control orthopaedics J Am Acad Orth Surg 1995 no3

“Get me a nail!”

Rods & Nails The truth is out there! When is a nail not a nail Hollow – Slotted – Solid Why nails fail Effects of Reaming

Bones & Nails Hollow structures Hollow bones for strength Early nails were hollow & needed 3 point fixation

Kuntcher - Clover leaf nail 3 point fixation Inserted open so no guide wire required

GK & AO – Slotted hollow nail Allowed guide wire insertion Flat sheet manufacture

Reaming to increase the contact area

Lets talk about stiffness

Bending Stiffness Second Moment of Inertia (I) Tube I=(Ro4 – Ri4) * ¶/4  Radius cubed

Hollow structures are relatively strong for the volume of material For a given increase in radius torsional and bending stiffness go up to the fourth power Torsional stiffness roughly 2x inc vs bending as radius At physiological loads torsional deformation more clinically evident

Slotted nails especially are weak in torsion

The advantage of “Unreamed” The advantage of Solid Solid Ti nails are strong enough at diameters small enough to be inserted without reaming Not possible with SS nails Expensive

“You be the Judge”

For unreamed Healing 170 # Equivalent healing time (19/52) 55mins quicker = delayed unions Reynders Injury 2000

For unreamed General Results 164# retrospective series 93% union rate with UFN AO type C healed at 6.2mo (ave) UFN “healing rates comparable with historical standards” Herscovici JOT 2000

For unreamed Intramedullary pressure Clinical trial 38 pts 5x increased pressure in reamed group Pressure correlated with fat extravasation Berger JOT 1997

For unreamed Poly Trauma Femur # in polytrauma pts managed by; Early Total Care Intermediate Stabilisation “Damage Control Surgery” “A significant reduction in the incidence of complications was found ..regardless of the type of fixation” Garapati & Krettek J of T 2002

Against unreamed method Healing 147# 6 weeks longer to heal Giannoudis Injury 1997 172# 4 weeks longer to heal More “technical complications” Tornetta JOT 2000

Against unreamed method Stimulation of the inflammatory system IL6, CD11b, s-ICAM-1, E-selectin & elastase Reamed vs Unreamed Evidence of a “second hit” to the immune system No difference reamed vs unreamed Giannoudis JBJS(B) 1999 If you don’t ream you still get a second hit to the immune system

Against unreamed method Complications 100 randomised pts 2x iatrogenic comminution in unreamed Reaming was “required” in the unreamed group in 3 Shepherd J Orthop Trauma 2001

For unreamed Quicker Simpler Less equipment Equivalent healing rate Less fat embolus Less H-O Lower immune “hit”

For reamed Faster union Fewer implant related complications Lung injury not directly & only caused by reaming “Second hit” not specifically caused by reaming

It’s all about technique

Solid nails are implants Reaming is a technique Solid nails are implants

Solid nail ? Who would put a 9mm nail in this pt!

Summary & “Verdict” Reaming is a technique Solid vs Slotted vs Cannulated is a design / manufacturing process

“I always do reamed nails”

Solid Hollow Reamed Unreamed

Solid Reamed Hollow Unreamed

Solid Reamed Hollow Unreamed

Solid Reamed Hollow Unreamed

Solid Reamed Hollow Unreamed

Summary Chose the smallest nail which is strong enough for the patient and his/her injury Ream if necessary to put the appropriate size of nail in for the patient & injury Don’t confuse implants with technique

Other peoples’ complications General complications Specific # related comlpications Malunion

Cambell’s Operative Orthopaedics “Malunions after closed treatment are the rule”

Malrotation > 10 degrees in 8-19% of fractures JBJS 75 (B) 799-803 JBJS 66 (A) 529-39

Cambell’s Operative Orthopaedics “..become significant only if they result in shortening of more than 2.5 cm angulated more than 10 degrees internally or externally rotated to the point that the knee cannot be aligned with forward motion during gait.”

? How much rotation ? External rotation less well compensated than internal 15 degree limit Based on functional assessments and FPA Nijmegen group: Injury 35 1270-1278 2004

Malunion > 2.5 cm shortening > 10° angular deformity >15° rotation deformity

Malunion > 2.5 cm shortening > 10° angular deformity Rotation that the pt can see !

Fractures of the Femoral Shaft (AO 3.2) Why should I fix the #? Damage control Restore function How should I fix it ? For the fracture / for the patient What complications can I expect Length , Rotation the pt can see