UNREAMED RETROGRADE INTRAMEDULLARY NAILING OF FRACTURES OF THE FEMORAL-SHAFT

Objective: To evaluate the efficacy of unreamed retrograde intramedull ary (IM) nailing of fractures of the femoral shaft in a second series of patients using modifications suggested from our initial study. Desi gn: Prospective. Setting: Level I trauma center. Methods: Based on the findings of a previous study, we began a clinical series incorporatin g changes consisting of (a) inclusion of any patient with a femoral sh aft fracture amenable to IM nailing (i.e., closed physes), (b) primary use of a split patellar tendon intercondylar distal femoral entry por tal, and (c) the use of a full-length femoral implant having variable size availability and dynamization capability. Over a twelve-month per iod, thirty four patients with thirty-five femoral shaft fractures wer e treated. The protocol called for planned dynamization in statically locked stable fractures and unstable fractures showing minimal healing at six to twelve weeks. Functional outcome was assessed by using the Knee Society clinical rating system. Results: Incorporating the concep ts of canal fill and early dynamization, there were only two nonunions (6 percent) in this series as compared with 14 percent in the previou sly reported series with an overall shorter time to union (12.6 versus 15 weeks). There were no infections or malunions. Postoperative compl aints of knee pain were minimal (knee score average: 98 points) and kn ee function was excellent (knee score average: 97 points). Conclusions : Although not advocated as a replacement for other techniques, unream ed retrograde nailing is presented as a safe and beneficial fracture f ixation method that should be added to the orthopaedic surgeon's treat ment armamentarium. The operative technique is quick and simple, and b lood loss is minimal. Early nail dynamization and early weight-bearing are important in minimizing the risk of nonunion.