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embolism:
reaming
controversy
Basic
concepts the
relevant
to the
design and
development
of the Point Contact Fixator (PC-Fix)
Peter V Giannoudis1, Christopher Tzioupis2, Hans-Christoph Pape3
Stephan
M.Trauma
Perren
and
Department
& Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK
2
Joy
S. Buchanan
Department
of Trauma & Orthopaedics, St Jamess University Hospital, Leeds, UK
1
3
Summary1 Intramedullary nailing is the preferred treatment method for stabilizing femoral diaphyseal fractures. Despite its superior biomechanical advanSummary
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Although transient, this effect appears to be more prominent with reamed than
unreamed techniques. Additional studies are required to determine whether a
subgroup of trauma patients is adversely affected by intramedullary reaming,
thus necessitating other fixation techniques.
Introduction
Intramedullary (IM) nailing, introduced by Kntscher
[1] in 1940, is currently the treatment of choice
for acute stabilization of femoral shaft fractures in
adults [27].
By successfully controlling both length and rotation, the interlocked intramedullary nail has
expanded the indications for IM nailing to include
virtually all fracture patterns of the femoral shaft,
regardless of the extent of comminution [3, 812].
Numerous authors have documented high success
rates treating femoral shaft fractures with reamed
intramedullary nails [4, 7, 1328].
Over the years, although it is considered as a safe
procedure, pulmonary complications have been reported in some groups of patients [29, 30]. Concerns
1
S51
65 mm Hg in man [61]. Experimentally, pressure
increases as high as 300 mm Hg have been reported
in animals [62]. In patients with fractured femurs,
elevations of intramedullary pressure between 140
and 830 mm Hg have been observed [63]. Other authors found evidence of a shunt mechanism between
the arterial and venous systems in bone and suggested that a rise in intramedullary pressure could
affect the precarious balance between the arterial
and venous systems resulting in embolization of fat
particles [64].
Fat embolization caused by the liberation of intramedullary contents from unstabilized fractures
and their surrounding tissues has given rise to various
explanatory theories, including the release of humoral mediators (thromboxane), the theory of toxic
effects, the theory of coagulation disturbances, and
the colloidal theory [31, 6567]. Indeed, bone marrow embolization in the lung may cause mechanical
obstruction and occlusion of pulmonary vessels. In
an animal study, pressures of 300400 mm Hg were
applied to the intact intramedullary femoral cavity
and blood collected from the vena cava showed
large emboli of bone marrow fat and thrombocytes
as long as 3 cm [68].
Several pathogenetic pathways have been suggested, such as a high thromboplastin content of bone
marrow causing coagulation of thrombocytes and fat
[69], changes of pulmonary artery pressure [35], and
stimulation of the alternative pathway of coagulation
by disrupted fat cells and the intramedullary debris
[70]. However, these mechanisms do not seem strong
enough to cause all the changes observed.
Some authors favor the idea that the toxic effects
of fat can lead to pulmonary endothelial damage
[71]. Others think that the hypoxic-induced endothelial damage can liberate humoral mediators
leading to acute changes in the pulmonary vascular
response [72].
The microvascular obstruction effect caused
by the intravasation of fat and the inflammatory
reactions is thought to modify neutrophil kinetics,
creating favorable conditions for neutrophil-mediated injury [73].
Some authors found evidence of an influence of
neutrophils in trauma-induced lung injury and in response to fat embolization. The pulmonary damage
induced by fat infusion was preventable by induction
of neutropenia [73, 74].
Willis et al [75] measured lung myeloperoxidase
activity to examine the contribution of leukocytes to
lung injury induced by femoral fracture and IMN.
In several studies [58, 76, 77], researchers analyzed lipid-laden cell counts or neutrophil counts
of bronchoalveolar lavage fluid obtained from patients who underwent reamed femoral nailing and
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P V Giannoudis et al
S53
Weresh et al [103], in a prospective study of 50
patients with a femoral fracture, calculated alveolar
dead space (Vo/Vt) and alveolar arterial gradient (Aa D02) during IM nailing. The authors concluded that
intramedullary fixation of femoral shaft fractures
did not routinely generate a large enough burden of
pulmonary embolization to produce a noteworthy alteration in either parameter during reamed nailing,
even when comparing the number of reamer passes
or the presence of pulmonary injury.
Bosse et al [99] conducted a retrospective
comparative study of 453 patients with femur
fractures at two trauma centers, one of which
treated femoral fractures primarily with IM nails
and the other mainly with plates. They reported
no significant difference regarding the incidences
of ARDS, pneumonia, pulmonary embolism, multiorgan dysfunction, or death between the reamed
and unreamed groups. The overall incidence of
ARDS was only 2%. Their study suggested that
reamed nailing of femoral fractures did not increase the risk of pulmonary morbidity. Bone et al
[104, 105] and van der Made et al [106] confirmed
these findings and made a similar recommendation
that patients with pulmonary injuries and femoral
fracture should have reamed IM stabilization unless they are hemodynamically unstable, in which
case they still recommended early stabilization,
but with use of an unreamed nail or the plating
technique.
Helttula et al [107] compared pre- and immediate
postoperative central hemodynamic variables in 20
healthy adults with a unilateral simple tibial fracture
undergoing reamed or unreamed IM nailing. They
reported that unchanged cardiac performance but
pathologically altered pulmonary vascular tone were
unrelated to the type of nailing and concluded that
changes in cardiac and pulmonary hemodynamics
were already present after the trauma and before
the IM nailing procedure.
The Canadian Orthopaedic Trauma Society [108],
in a report on the results of a large prospective,
randomized, multicenter study, found no significant
difference between two groups of patients managed
with either reamed or unreamed nailing. They also
reported that the ARDS rate was too low to detect a
significant difference between the groups.
Giannoudis et al [109] reported that reamed
and unreamed femoral nailing provoked similar
increases in PMN elastase release and adhesion
molecule expression (plasma elastase- 1 antitrypsin
complex and CD11b), implying that fracture surgery
constitutes a significant proinflammatory stimulus.
The only patient in the study group who developed
ARDS showed a massive postoperative inflammatory
response shortly after reamed nailing.
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P V Giannoudis et al
of malunion, pulmonary emboli, compartment syndrome, and infection in their metaanalysis from a
pooled analysis of randomized trials.
Conclusion
There is no doubt that intravasation of fat particles
can cause severe lung damage. Animal studies that
show increased pulmonary endothelial permeability
associated with reaming and uncontrolled human
studies support the use of unreamed femoral nails
in patients with chest injuries.
Nevertheless, fat emboli are generated during nail
insertion with the unreamed technique. However,
advocates of the unreamed technique claim that
reaming could cause a cumulative effect (reamer
passages, nail insertion) that could be deleterious
to the patients pulmonary function. Despite the
contradictory results that have been published in
various studies, it seems that the clinical effects
of the embolization associated with intramedullary
manipulations and reaming are no longer as severe,
which can be attributed to the advances made
in pre-hospital care and transport, resuscitation,
critical care medicine, ventilation strategies, and
the increased awareness over the clinical entity.
In addition, careful surgical technique can limit
the medullary canal pressurization associated with
reaming.
The systemic effects of femoral nailing after polytrauma and particularly in selected patients at high
risk of complications is still a topic of animated discussion. It seems that the systemic response to femoral nailing includes the effects of fat and inflammatory reactions. As with any surgical procedure, the
decision to ream or not to ream the intramedullary
canal has to be based on several considerations, including the fracture pattern, concomitant injuries,
and the patients overall physiological status.
The new era that has begun as the result of the
coupling of basic science and applied orthopedics
has led to the alteration of the inherent characteristics of the known fixation methods. The efforts made
travel in two directions: altering the characteristics
of the technique itself and reevaluating the general
concepts of its application.
Our knowledge of the physiological changes between reamed and unreamed intramedullary nailing has increased over the years. The introduction
of damage control orthopedics is likely to have a
positive impact on treating femoral shaft fractures
in polytrauma patients without the risk of side effects. In this context, it appears to be an adequate
alternative for patients at high risk of posttraumatic
complications.
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Correspondence address:
Peter V Giannoudis
Professor Department of Trauma & Orthopaedics
St Jamess University Hospital
Beckett Street
Leeds, LS9 7TF, United Kingdom
Phone: +44 113 243 3144
Fax: +44 113 206 5156
e-mail: pgiannoudi@aol.com