1. Mohit Bhandari, MSc, MD, FRCSC Associate Professor, McMaster University, Hamilton, Ontario Femoral Nailing: Reamed vs. Unreamed

2. Objectives, To review the best available evidence regarding the use of reamed vs. unreamed femoral nails in the management of femoral shaft fractures

3. The big questions, Does reaming of the femoral shaft increase the risk of ARDS? Does non-reaming increase the risk of non or delayed union?

4. Objectives, P I C O

5. Objectives, Patient population Intervention Comparison Outcomes

6. Rephrased, P – In those skeletally mature patients with femoral shaft fractures treated with a statically locked intramedullary nail, does… I – reaming the femoral shaft… C – as compared to no reaming… O – affect the rates of delayed/nonunion or pulmonary complications.

7. What is in the Literature Many experimental and observational studies Arguments can be made for either side with these studies

8. What is in the Literature In general, –Some European trauma units have suggested an increased incidence of ARDS in multiply injured patients –Especially those with thoracic trauma The suggestion is to not ream the femur when nailing Pape, et al Injury; 24 suppl 3:82-103

9. What is in the Literature In contrast, large observational studies from the states suggest no difference in ARDS rates between reamed femoral nail and plating of femur fractures –In those with or without a thoracic injury Bosse et al., JBJS Am; 79(6):799-809

10. What is in the Literature Conflicting experimental and observational clinical data suggests, –The very act of nail insertion causes increased fat emboli –Both reaming and non-reaming shower lungs and brain with fat –No significant support for fat emboli as the primary etiology of ARDS Schemitsch, et al., (1997) JBJS Am, 79(7):984-996 Carlson, (1998) JOT, 12(3):164-8 Coles, et al., (2000) J South Orthop Assoc, 9(2):98-104

11. Hierarchy of Evidence Randomized Trials Prospective Cohort Studies Retrospective Case Series Case Control Studies Opinion Evidence- based Practice uses the Best “available” evidence

12. Grades of Recommendation A: consistent level 1 studies B: consistent level 2 or 3 studies –Extrapolations from level 1 studies C: level 4 studies –Extrapolation from level 2 or 3 studies D: level 5 evidence –Troubling inconsistent or inconclusive studies of any level OCEBM grades

13. What’s the Evidence? Previous meta-analysis of RCT’s done by Bhandari et al., in 2000 A number of further RCT’s have been done since then Time for an update…

14. What’s the Evidence? Reaming in Femoral Shaft Fractures: a meta-analysis Petrisor, BA, Poolman, RW, Bhandari, M and Schemitsch, E.

15. What’s the Evidence? Defined Search strategy based on our initial question –Pubmed –Cochrane Database –Embase –References from reviewed articles –OTA archives

16. What’s the Evidence? 10 RCT’s identified –8 published studies –2 OTA abstracts All assessing Reaming vs. Unreamed femoral nails 2 done by Canadian Orthopaedic Trauma Society –Most methodologically robust

17. What’s the Evidence? 1 study assessing only time for the nail, blood loss and intraoperative complications –Essentially trends in non-clinically important parameters Blood loss Units transfused Time for operations

18. What’s the Evidence? Delayed/Nonunion 6 RCT’s assessing delayed or nonunion as an outcome –2 OTA abstracts Total patients Reamed: 336 Unreamed: 313

19. What’s the Evidence? Delayed/Nonunion RR 0.21 RRR 79%

20. What’s the Evidence? Delayed/Nonunion NNT 8 That is, for every 8 patients treated with a reamed intramedullary nail, one delayed or nonunion can be prevented

21. What’s the Evidence? ARDS/Pulmonary Complications 3 RCTs addressing ARDS or pulmonary complications as an outcome

22. What’s the Evidence? ARDS/Pulmonary Complications 3 RCTs addressing ARDS or pulmonary complications as an outcome Total patients Reamed: 271 Unreamed: 291

23. What’s the Evidence? ARDS/Pulmonary Complications RR 1.91

24. What about Complications? Difficult to pool –Lack of reporting –General complications not associated with reaming per se

25. What about Complications? Reamed (n=37) –19% –Iatrogenic comminution –Broken reamer –Broken depth gauge –Rotational malalignment –1 failure to remove exchange tube before nailing Unreamed (n=63) –27% –1 airball distal locking screw –1 femoral derotation –6 iatrogenic comminution –1 broken drill bit –2 missed locking bolts –1 cross threaded cap –1 needed to be opened –1 pulmonary compromise –1 pudendal palsy

26. So how did we do with our question?

27. The Question, P – In those skeletally mature patients with femoral shaft fractures treated with a statically locked intramedullary nail, does… I – reaming the femoral shaft… C – as compared to no reaming… O – affect the rates of delayed/nonunion or pulmonary complications.

28. The Best Available Evidence, Grade B –Level one studies with methodologic limitations Delayed/Nonunion –RR 0.21 (95% CI 0.11 – 0.40) –RRR 79% –NNT 8

29. The Best Available Evidence, Grade B –Level one studies with methodologic limitations ARDS/Pulmonary Complications –RR 1.91 (95% CI 0.74 – 4.93) –Not Significant

30. Thank-you