Reamed vs'' Unreamed Femoral Intramedullary Nail Stabilization

1
Reamed vs.. Unreamed Femoral Intramedullary Nail
Stabilization

• Christopher M. Stewart, MD
• PGY III
• LSU-Health Sciences Ctr

2
Smith Nephew Trigen Reamer
Designed to offer a convenient method for
preparing the bone to accommodate the diameter of
the driving end of the implant Flexible Reamer
System includes a single-wound shaft with a broad
selection of reamer head sizes and sounds
3
Stryker BixCut Reamer

• Designed specifically to decrease reaming
  pressure.
• Larger clearance rate for more effective relief
  of pressure
• Forward and side cutting face combination help to
  produce efficient material removal and rapid
  clearance.
• Smaller 6 and 8mm shaft diameters designed to
  reduce IM pressure
• Double-wound shaft designed to transmit torque
  effectively and with high reliability

4
Synthes Reamers/IMNs

• Reamer/Irrigator/Aspirator (RIA)
• Standard reamer

5
Zimmer Pressure Sentinel Reamer

• Designed to maximize the efficiency of the
  cutting head, and facilitate the flow and
  dispersion of the medullary contents.
• The Pressure Sentinel Reamer features a short
  cutting head with deep flutes and sharp edges to
  cut quickly through the medullary canal. In
  addition, the shape of the flutes is optimal for
  channeling the medullary contents past the reamer
  head and into the wide annulus made possible by
  the narrow shaft of the reamer.

6
Winquist, Hansen, Clawson. JBJS
198466,4529-539.

• IMN on 520 femur shaft fxs (500 pts)
• 86 open, 261 comminuted fxs
• 497 closed femoral IMNs, 23 open IMNs w/ cerclage
  wiring
• 99.1 union rate, avg. knee ROM130
• 4 infections (0.9), shortening of gt2.0cm in 10
  (2.0), malrotation gt20 degrees in 12 (2.3)
• IMN fixation became the standard tx in femoral
  shaft fxs

7
AO/OTA Femoral Shaft fx Classification

8
(No Transcript)
9
Winquist Femoral Shaft fx Classification
10
Bone, Johnson, Weigelt, Scheinberg. JBJS 1989
71 3 336-340.

• Prospective randomized study comparing early with
  delayed reduction and stabilization of acute
  femoral fractures in adults over 2 yrs in 178 pts
• ABGs, ISS, pulmonary function, hospital stay, ICU
  stay, and hospital costs were assessed
• When stabilization of the fx was delayed in pts
  who had multiple injuries (gt24 hrs), the
  incidence of pulmonary complications was higher
• Increased ICU stay of 5 days, and increased
  hospital stay of 10 days, 32K vs. 19K cost
  difference
• Pulmonary complications included pneumonia,
  fat-embolism, ARDS
• Authors stated there is overwhelming evidence to
  support early stabilization of long bone fxs in
  multiply injured pts

11
Neudeck, Wozasek, Obertacke, Thurnher,
Schlag.JTrauma 1996 406 980-984.

• An experimental study was performed on 21 sheep
  w/ created blunt thoracic trauma
• Femoral IM pressure, fat embolization, and
  pulmonary arterial response were measured in 3
  groups reamed IMN, unreamed IMN, or plated femur
  
• Group I (reamed group) IM peak pressures were
  highest during reaming, 425 mm Hg (mean 205)
• Group II (unreamed group) IM peak pressures were
  highest during nail insertion, 330 mm Hg (mean
  203)
• Group III (plated group) never led to a pressure
  rise over 67 mm Hg (mean 37)
• The pulmonary arterial pressure did not vary
  significantly postop between the three groups (p
  lt 0.08)
• Authors concluded that IMN fracture fixation
  causes a higher increase of IM pressure and more
  fat and bone marrow embolization than
  extramedullary fixation
• Nevertheless, only minimal differences in the
  pulmonary hemodynamic response (pulmonary
  arterial pressure) were noted even in the
  presence of thoracic trauma

12
Bosse, MacKenzie, Brumback, McCarthy, Burgess,
Gens, Yasui. JBJS 199779799-809.

• Retrospective analysis of multiply injured
  patients (ISSgt17) admitted to 2 Level-I trauma
  centers between 83-94, w/ a femoral shaft fx w/
  a thoracic injury (AISSgt2) or w/out a thoracic
  injury
• At Center I IMN with reaming was used in 217
  (95) of the 229 pts, at Center II a plate was
  used in 206 (92) of 224 pts
• This difference was used to investigate the
  effect of acute femoral reaming on the occurrence
  of ARDS in multiply injured pts w/ a chest injury
• 3 groups of pts femur fx thoracic injury,
  femur fx thoracic injury, thoracic injury w/out
  a femur or tibia fx
• ISS, AISS, and GCS were evaluated
• Length of intubation, hospital stay, and
  occurrence of adverse outcomes (death, multiple
  organ failure, ARDS, pneumonia, and pulmonary
  embolism) were determined for each patient
• Reamed IMN tx in 118 pts and ORIF w/ a plate in
  114 pts
• Center I and II ARDS in the 453 pts w/ femoral
  fracture was 10 pts (2).
• Center I 129 pts w/ a thoracic injury w/out
  femoral fx ARDS developed 10 pts (6) and at
  Center II 125 pts w/ a thoracic injury w/out
  femoral fx 10 pts developed ARDS (8)
• ARDS developed in pts w/ a thoracic injury w/ no
  femur fx 129 pts (6) at Center I and 8 at
  Center II
• Occurrence of ARDS, pneumonia, pulmonary
  embolism, multiorgan failure, or death was
  similar regardless or tx

13
Tornetta, Tiburzi. JOT 2000.14115-19.

• Prospective randomized study comparing reamed
  vs.. unreamed IMN fixation of femur fxs
• 171 pts w/ 172 femoral shaft fxs tx w/
  anterograde IMN
• Pt demographics, ISS, operative time, blood loss,
  blood and fluid requirements, technical
  complications, time to callus formation, time to
  union, and overall complications were all
  assessed
• No statistical difference in operative time,
  transfusion requirements, or hypoxic episodes
  between the groups
• Higher intraop blood loss in reamed group
• Time to union was 80 /- 35 days in reamed group
  vs.. 158 days in the unreamed group (p0.012)
• More technical complications in the unreamed
  group
• No advantage to the routine use of IMN fixation
  w/out reamed insertion

14
Nowotarski, Turen, Brumback, Scarboro.JBJS
200082791-781

• Retrospective study of 54 multiply injured pts
  with 59 femoral shaft fxs with exfix followed by
  planned conversion to IMN
• Demographic info, injury severity, clinical
  management data, and fx healing was analyzed
• ISS29, GCS11
• 40 closed femur fx, 19 open femur fx (Type II3,
  Type III8, Type IIIC8)
• Avg exfix time was 7 days, 45 had conversion to
  IMN in one stage
• Avg f/u was 12 months, 56/58 available at f/u had
  healed w/in 6 months
• 3 major complications 1 pt died of PE, 1
  infected nonunion, and 1 nonunion tx successfully
  w/ retrograde exchange IMN
• 11 required re-operation, avg knee ROM107
• Authors concluded that immediate exfix followed
  by IMN of femur fxs is a viable option in
  multiply injured pts

15
Norris, Patton, Rudd, Schmitt, Kline.JBJS
200183 1162-1168.

• Determine whether alveolar dead space increases
  during IMN of femoral shaft fxs and whether
  alveolar dead space predicts postoperative
  pulmonary dysfunction in patients undergoing IMN
  of a femoral shaft fx?
• 74 pts w/ 80 femoral shaft fxs were prospectively
  evaluated
• ABGs were measured at 3 consecutive time-periods
  after induction of GETA, before IMN, and 10 and
  30 minutes post
• ETCO2 volume, minute ventilation, PEEP, and
  percent of inspired and expired inhalation agent
  were recorded w/ ABGs.
• Postop pts were monitored for evidence of
  pulmonary dysfunction need for mechanical
  ventilation or supplemental oxygen (at a
  FiO2gt40) w/ RRgt20 or the use of accessory
  muscles
• Mean alveolar dead-space was 14.5 at canal
  opening and 15.8 at 10 min, and 152 at 30 min
  (p 0.2) in all 74 pts
• Mean alveolar dead-space was 20.5, 22.7, and
  24.2 in the 20 pts with postop pulmonary
  dysfunction (p 0.05)
• According to univariate and multivariate
  analysis, the alveolar dead-space measurement was
  strongly associated with postop pulmonary
  dysfunction
• Authors concluded that IMN fixation of a femur fx
  did not significantly increase alveolar dead
  space, and the amount of alveolar dead space can
  predict which patients will have pulmonary
  dysfunction postop

16
Canadian Orthopaedic Society.JOT 2006 206
384-387.

• Randomized prospective study at 7 Level I Trauma
  Centers to determine ARDS in pts undergoing IMN
  of femoral shaft fxs
• 315 pts w/ 322 femoral shaft fxs were stratified
  to 2 groups according to ISS gt or lt 18, and then
  randomized to reamed or unreamed IMN
• 151 fx w/ unreamed IMN and 171 fx w/ reamed IMN,
  all w/in 24hrs
• 3/63 multiply injured pts w/ reamed IMN developed
  ARDS vs. 2/46 pts in unreamed group (p0.42 w/ a
  5 power, i.e.. needed 39,817 pts)
• 4 deaths, 2 each in reamed and unreamed groups
  w/ no death attributed to ARDS
• Concluded that the overall incidence of ARDS
  between reamed and unreamed groups was not
  different (given the sample size)

17
Weninger, Spitaler, Mauritz, Hertz. JTrauma
2007623692-696.

• Prospective cohort study between 5/98-12/04 at a
  Trauma Hospital in Austria
• 578, age 15-55, severely injured admitted pts w/
  AISSgt3 and ISSgt18
• 45 pts had severe thoracic trauma and femoral fx
  tx w/ unreamed IMN (w/in 24hrs)
• 107 pts were in the cohort with severe thoracic
  trauma and no lower extremity fx
• Pt status (GCS, RTS, ISS, APS II), tx (intubation
  time, thoracic drainage, surgery), and outcomes
  (ICU stay, vent support time, ARDS rate,
  multiorgan failure) were analyzed
• Both cohorts were comparable w/ regard to pt
  data, ISS, AISS in thoracic region, and incidence
  and severity of brain injury
• No difference in rate of ARDS, multiorgan failure
  and mortality
• Concluded that early unreamed IMN fixation of
  femoral fxs in thoracic trauma pts seems to be
  justified

18
JH21 male s/p MVC
19
JH21 male s/p MVC
20
Clinical course

• Admitted 7/15/07 pelvic fx and ligamentous
  injury, scapular/clavicle fx, B/L PTX/HTX w/ lung
  contusions, CHI, rib fxs, nasal fx, spine TP fxs
• B/L CT placed for PTX/HTX upon admission
• Went on to develop ARDS w/in 2 days, with
  inability to ventilate
• Pt placed on ECMO for ARDS, cont for 27 days
• While on ECMO pt developed MRSA bacteremia,
  multiorgan failure (renal, hepatic), Serratia
  pneumonia, DIC
• Pt required CVVH for renal failure
• Pt intubated for nearly 2 months
• Pt required nearly 60 units PRBCs while inpt
• Had R and L ST femur fx IMN, 1 month post
  admission, in two separate procedures 2 days
  apart with no complications
• Pt developed Pseudomonas UTI and Pneumonia post
  IMNs
• Pt D/C on 9/6/07, w/ trach collar on RA, eating
  and drinking normally
• Trach was removed 2 months post D/C
• Developed L hip proximal screw persistent
  drainage at 6 months postop, requiring screw
  removal and PO Abx
• Pt at 6 months postop is WBAT, only using
  crutches for balancing

21
CXR over 3 day period
22
L femur x 6 months
23
R femur x 6 months