We read with interest the above mentioned article. Technology like
history seems to have gone a full circle, as far as nailing techniques are
concerned.
There are a few points of contention regarding the described methods
of femoral nailing. “.. an assistant reduced the fracture using
manipulation and longitudinal traction…”, is possible only if one hand is
used for manipulation and one hand for applying traction. Having had first
hand experience, (pun unintended) in the manual traction technique of
femoral fracture nailing, we would like to point out that manual traction
is not as simple as it is described in this article. The paper does not
mention whether the scrubbed assistants, during the procedure, shared
among themselves the unenviable role of the ‘leg boy’. The fracture has to
be reduced and maintained while the nail entry portal is made, guide wire
is passed, reaming is performed, nail is passed and locking screws are
inserted. This exerts a considerable strain on the surgical assistants.
In three femoral nailings performed by the manual traction method
there were no scrubbed surgical assistants. The paper does not explain how
the operating surgeon reduced and maintained the fracture while performing
these nailings.
With no post to provide counter traction in the manual traction
method, there is no mention about the precautions taken to prevent the
patient from being pulled off the operating table.
The authors say that they checked for rotational mal alignment after
insertion of the nail. There is no mention of the number of cases in the
manual traction method where the rotational alignment was unsatisfactory
after the first attempt of femoral nailing. If malrotation is detected at
this stage, to correct the rotational mal alignment the nail would have to
be removed. After rotational alignment is achieved the nail is reinserted.
This would have increased the surgical time.
Fluoroscopy times have been shown to be similiar for both methods.
This implies that the time taken for nailing by the fracture table method
is similar to the time taken for nailing the fracture and checking the
rotational alignment by the manual method.
‘Locking of nail (from the time nail was inserted to the completion
of screw insertion)’ is shown to be faster by manual traction method. As
above, this means the time to lock the nail by the fracture table method
is more than the time to assess the rotational alignment and lock the nail
by manual method. This seems to be unrealistic.
In spite of the presence of significant internal malrotation in
femora where the fracture table method was used, this does not seem to
reflect in the Musculoskeletal Function Assessment Instrument scores at
six months and one year. Actually table traction method has a better
result at one year (well almost, only 0.01 away from being significant).
From Table II it can be seen that, as far as mal rotation is
concerned, the only significant difference is in internal malrotation
>10°. This could be due to, as pointed out by the authors, the practice
of internally rotating the limb to allow access to entry portal for the
nail. But in the table traction method, it is mentioned – ‘The foot of the
affected limb was….externally rotated approximately 10ş’. If this was the
case internal rotation at the fracture site would not have occurred.
Our initial experience in femoral nailing has been in the manual
traction method. However after working in the UK we found femoral nailing
by the fracture table method more considerate towards the surgical team
and if appropriate precautions are taken, the results are satisfactory.
Perhaps it is just a question of preference of method or perhaps the grass
appears greener on the other side.
We look forward to comments by the authors regarding these obsvervations.
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