The Journal of Bone and Joint Surgery 82:781 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply Injured Patients*
Peter J. Nowotarski, M.D. ,
Clifford H. Turen, M.D. ,
Robert J. Brumback, M.D. and
J. Mark Scarboro, B.A.
Investigation performed at the Section of Orthopaedic Traumatology,
The R Adams Cowley Shock Trauma Center, The University of Maryland
Medical System, Baltimore, Maryland
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
Department of Orthopaedic Surgery, University of Tennessee, 923
East Third Street, Suite 1203, Chatanooga, Tennessee 37421.
Shock Trauma Orthopaedics, The R Adams Cowley Shock Trauma Center,
22 South Greene Street, Room T3R64, Baltimore, Maryland 21201-1595.
Please address requests for reprints to C. H. Turen, c/o Elaine
P. Bulson, Editor. E-mail address for Elaine P. Bulson: ebulson{at}smail.umaryland.edu
Background: From 1989 to 1997, 1507 fractures
of the shaft of the femur were treated with intramedullary nailing at
The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of
those fractures were treated with early external fixation followed
by planned conversion to intramedullary nail fixation. This two-stage
stabilization protocol was selected for patients who were critically
ill and poor candidates for an immediate intramedullary procedure
or who required expedient femoral fixation followed by repair of
an ipsilateral vascular injury. The purpose of the current investigation
was to determine whether this protocol is an appropriate alternative
for the management of fractures of the femur in patients who are
poor candidates for immediate intramedullary nailing.
Methods: Fifty-four multiply injured patients
with a total of fifty-nine fractures of the shaft of the femur treated with
external fixation followed by planned conversion to intramedullary
nail fixation were evaluated in a retrospective review to gather
demographic, injury, management, and fracture-healing data for analysis.
Results: The average Injury Severity Score for
the fifty-four patients was 29 (range, 13 to 43); the average Glasgow
Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four)
had additional orthopaedic injuries (average, three; range, zero
to eight), and associated injuries such as severe brain injury,
solid-organ rupture, chest trauma, and aortic tears were common.
Forty fractures were closed, and nineteen fractures were open. According
to the system of Gustilo and Anderson, three of the open fractures
were type II, eight were type IIIA, and eight were type IIIC. Intramedullary
nailing was delayed secondary to medical instability in forty-six
patients and secondary to vascular injury in eight. All fractures
of the shaft of the femur were stabilized with a unilateral external
fixator within the first twenty-four hours after the injury; the
average duration of the procedure was thirty minutes. The duration
of external fixation averaged seven days (range, one to forty-nine
days) before the fixation with the static interlocked intramedullary
nail. Forty-nine of the nailing procedures were antegrade, and ten
were retrograde. For fifty-five of the fifty-nine fractures, the
external fixation was converted to intramedullary nail fixation
in a one-stage procedure. The other four fractures were associated
with draining pin sites, and skeletal traction to allow pin-site
healing was used for an average of ten days (range, eight to fifteen
days) after fixator removal and before intramedullary nailing. Follow-up
averaged twelve months (range, six to eighty-seven months). Of the fifty-eight
fractures available for follow-up until union, fifty-six (97 percent)
healed within six months. There were three major complications: one
patient died from a pulmonary embolism before union, one patient
had a refractory infected nonunion, and one patient had a nonunion
with nail failure, which was successfully treated with retrograde
exchange nailing. The infection rate was 1.7 percent. Four other
patients required a minor reoperation: two were managed with manipulation
under anesthesia because of knee stiffness, and two underwent derotation
and relocking of the nail because of rotational malalignment. The
rate of unplanned reoperations was 11 percent. The average range
of motion of the knee was 107 degrees (range, 60 to 140 degrees).
Conclusions: We concluded that immediate external
fixation followed by early closed intramedullary nailing is a safe
treatment method for fractures of the shaft of the femur in selected
multiply injured patients.
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