Retrograde reamed femoral nailing.

Closed, reamed, antegrade nailing remains the standard of care for femoral shaft fractures. This technique however, may be less attractive in the management of femoral shaft fractures associated with (a) ipsilateral acetabular, pelvis, or femoral neck fractures; (b) polytrauma requiring multiple simultaneous surgical procedures; and (c) pregnancy. We now report on our experience with the retrograde femoral nailing as a treatment option in these situations. Between 4/88 and 10/90, 29 retrograde femoral nailing in 24 patients were attempted. Average age was 29.3 (16-74) years. Five fractures were open. Fracture location was isthmal in 14 and infraisthmal in 15. The comminution was classified according to Winquist and Hansen: I(10), II(7), III(7), and IV(5). Nailing was possible in 28/29 cases. Insertion was made through an extraarticular medial condylar portal. Nail diameter ranged from 10 to 13 mm. An AO Universal Femoral Nail was used in the first 11 cases; all subsequent fractures were stabilized using an AO Universal Tibial Nail because its design appeared better suited to this technique. Follow-up was possible for 25 fractures in 21 patients and averaged 16.0 (range, 11-27); months 23/25 (92%) fractures healed within 12 weeks. No case was associated with an infection, loss of reduction, or nail failure. Knee flexion averaged 122 degrees; only two knees had an extensor lag of > 5 degrees. Intraoperative complications included three cases of crack propagation at the insertion site, and four infraisthmal malreductions (two valgus, two flexion). Based on these results, we feel that retrograde reamed femoral nailing is a suitable alternative to antegrade nailing and should be considered in situations where proximal access is neither possible nor desirable.

Early use of the Brooker-Wills interlocking intramedullary nail (BWIIN) for femoral shaft fractures in acute trauma patients.

During a 33-month period, 40 multiply injured patients underwent 43 Brooker-Wills interlocking intramedullary nailings (BWIIN) for femur fractures in the setting of a Level I trauma unit. There were 12 open fractures (28%), 66% of the closed fractures underwent BWIIN within the first 24 hours of injury, and 33 fractures (77%) had comminution of Winquist-Hansen Type II or greater, and either static or dynamic locking techniques were used in 38 (88%) of the cases. There were three intraoperative technical problems. The estimated blood loss and operative times were consistent with other reported series for interlocking nailing techniques. The average followup was 65 weeks. Only one fracture went on to nonunion. There were no problems with angulation or rotation. One patient had 1.5 cm of shortening. There were four major (9%) and four minor (9%) complications. Rod removal was successful in 17 of 18 cases. Mechanical failure (deformation and/or fracture) of the proximal end of the rod was found in four (22%) of the extracted nails and caused failure of removal in one. The Brooker-Wills nail is a versatile device which can be used to treat complex fractures of the entire femoral shaft in acutely injured patients.