Scientific Article   |    
Femoral Intramedullary Nailing: Comparison of Fracture-Table and Manual Traction A Prospective, Randomized Study
David J.G. Stephen, MD, BSc, FRCS(C); Hans J. Kreder, MD, MPH(C), FRCS(C); Emil H. Schemitsch, MD, FRCS(C); Lisa B. Conlan; Lisa Wild, RN; Michael D. McKee, MD, FRCS(C)
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Investigation performed at the University of Toronto Orthopaedic Trauma Research Group, Toronto, Ontario, Canada

David J.G. Stephen, MD, BSc, FRCS(C)
Hans J. Kreder, MD, MPH, FRCS(C)
Lisa B. Conlan
Division of Orthopaedic Surgery (D.J.G.S., H.J.K., and L.B.C.) and Department of Health Policy Management and Evaluation (H.J.K.), University of Toronto, Sunnybrook and Women's College Health Sciences Centre, MG 365, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for H.J. Kreder: kreder@rogers.com

Emil H. Schemitsch, MD, FRCS(C)
Michael D. McKee, MD, FRCS(C)
Lisa Wild, RN
Department of Orthopaedic Surgery, St. Michael's Hospital, 30 Bond Street Toronto, ON M5B 1W8, Canada

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Canadian Orthopaedic Foundation and Smith and Nephew Richards. 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.

J Bone Joint Surg Am, 2002 Sep 01;84(9):1514-1521
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Background: The purpose of this study was to compare manual traction and fracture-table traction for the reduction and nailing of femoral shaft fractures. We evaluated the quality of the reduction, operative time, complications, and functional status of the patient.

Methods: Eighty-seven consecutive adult patients with a unilateral fracture of the femoral diaphysis that did not extend into the knee joint or proximal to the lesser trochanter were enrolled in the study. Patients who were transferred to our institution more than forty-eight hours after injury; those with multiple-system injuries, injury to the ipsilateral lower extremity, or pathological fracture; and those who were unable or unwilling to provide consent or to return for follow-up were excluded. Forty-five patients were randomized to manual traction and forty-two, to fracture-table traction; all were treated in the supine position. The number of surgical assistants, operative and fluoroscopy time, complications, functional scores, and other outcomes were recorded.

Results: There were no significant differences between the groups with respect to age, gender, Glasgow Coma Score, Injury Severity Score, side or mechanism of injury, fracture type, or time from injury to treatment. Internal malrotation was significantly more common when the fracture table had been used: twelve (29%) of the forty-two femora were internally rotated by >10° compared with three (7%) of the forty-five treated with manual traction (p = 0.007). Total operative time, from the beginning of the patient positioning to the completion of the skin closure, was decreased from a mean of 139 minutes (range, 100 to 212 minutes) when the fracture table was used to a mean of 119 minutes (range, sixty-five to 180 minutes) when manual traction was used (p = 0.033). There was no significant difference between the two treatment groups with regard to the number of assistants per case (mean two; range, zero to three), fluoroscopy time, other complications including femoral shortening or lengthening, or functional status of the patient at one year.

Conclusions: Compared with fracture-table traction with the patient in a supine position, manual traction for intramedullary nailing of isolated fractures of the femoral shaft is an effective technique that decreases operative time and improves the quality of the reduction.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    gunasekaran kumar
    Posted on November 19, 2002
    Letter to editor
    Royal Albert Edward Infirmary, wigan, UK, WN1 2NN

    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 10º’. 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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