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The Journal of Bone and Joint Surgery (American) 85:2093-2096 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Nonunion Following Intramedullary Nailing of the Femur with and without Reaming

Results of a Multicenter Randomized Clinical Trial

The Canadian Orthopaedic Trauma Society

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from AO North America, Alberta Heritage Foundation, Synthes Canada, and Foothills Hospital Foundation, Calgary General Hospital, and the Canadian Orthopaedic Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

This manuscript was prepared by the Canadian Orthopaedic Trauma Society, c/o James N. Powell, MD, FRCS(C), AC144C, 1403-29th Street, N.W., Calgary, AB T2N 2T9, Canada. Principal Investigator: James Powell. Protocol Development: Russell DeGroote, Judy Seidel, Richard Buckley, Robert McCormack, Ross Leighton, Robert Feibel, Emil Schemitsch, Michael McKee, and James Powell. Site Coordinators: Richard Buckley, Robert McCormack, Robert Feibel, Ross Leighton, Emil Schemitsch, David Stephen, and James Powell. Statistical Analysis: Hans Kreder. Manuscript Preparation: Jorge Barla, Russell DeGroote, Richard Buckley, Robert McCormack, Ross Leighton, Robert Feibel, Emil Schemitsch, Michael McKee, David Stephen, Hans Kreder, and James Powell. Contributing Surgeons: R. McCormack, C. Fisher, S. Pirani, G. Pate, B. Perey, M. Spangehl, R. VandeGuchte, H. Kreder, J. Schatzker, R. Hu, D. Stephen, T. Axelrod, J. Finklestein, M. Tile, R. McBroom, E. Schemitsch, J. Waddell, D. Puskas, M. McKee, R. Richards, S. Bowden, D. Alexander, R. Leighton, P. Lammens, D. Petrie, C. Coady, M. Gross, D. Johnston, R. Feibel, G. Moreau, A. Giachino, J. McAuley, G. Dervin, J. Bouchard, D. Barei, J. Powell, R. Buckley, S. Miller, C. Fairbanks, C. Fennell, R. Dewar, J. Donaghy, N. Schachar, J. Splawinsky, and H. Dougall. Research Coordinators: K. Parkhill, L. Gillis, A. Russell, L. Wilde, L. Conlan, J. Grabowski, M. Zomar, and L. Elves.

Background: Intramedullary nailing of the femur without reaming of the medullary canal has been advocated as a method to reduce marrow embolization to the lungs and the rate of infection after open fractures. The use of nailing without reaming, however, has been associated with lower rates of fracture-healing. The purpose of this prospective study was to compare the rate of union of femoral shaft fractures following intramedullary nailing with and without reaming.

Methods: Two hundred and twenty-four patients were enrolled in a multicenter, prospective, randomized clinical trial to compare nailing without reaming and nailing with reaming. One hundred and six patients with 107 femoral shaft fractures were treated with a smaller diameter nail without reaming of the canal, and 118 patients with 121 fractures had reaming of the canal and insertion of a relatively larger diameter nail. Patients were followed at six-week intervals until union occurred or a nonunion was diagnosed.

Results: The two groups were comparable with regard to the measured patient and injury characteristics. Eight (7.5%) of the 107 fractures in the group without reaming had a nonunion compared with two (1.7%) of 121 fractures in the group with reaming (p = 0.049). The relative risk of nonunion was 4.5 times greater (95% confidence interval = 1 to 20) without reaming and with use of a relatively small-diameter nail.

Conclusion: Intramedullary nailing of femoral shaft fractures without reaming results in a significantly higher rate of nonunion compared with intramedullary nailing with reaming.

Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.


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Letters to the Editor:

Read all Letters to the Editor

Nonunion Following Intramedullary Nailing of the Femur
Richard Stern, M.D.
JBJS Online, 1 Dec 2003 [Full text]
Reamed V/S Unreamed nail in Femoral fractures
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