Introduction

The femoral shaft fractures are very commonly encountered These may result in severe disability unless the treatment is appropriate ^(8).

Reamed nailing for fractures has already got established.

Interlocking nailing widens the surgical indications of nailing, allowing it to be used for comminuted fractures, on fractures too proximal or too distal.^. These are often the result of high energy trauma. Prolonged Anesthesia and Radiation both to the surgeon and the patient is a real hazard

These fractures being already life threatening from an open wound, fat embolism covert or overt ,ARDS and resultant multiple organ failure, can be better off with less invasive surgical procedure and anesthetic time.

30 cases with closed femoral fractures admitted in Bone & joint Hospital were taken up . The purpose was to assess the results of application of this technique to these patients visa-vis its influence on fracture stability and overall union.

Material And Methods

30 patients with closed diaphyseal femoral fractures were included in this study. The age of all these patients was more than 18 years

We excluded:

a -compound fractures

b- multiple trauma

c- >3wk old trauma

d- path fractures

e- patients with unstable knee

f-Heavy patients.

Surgery

Figure 1

Figure 1;Screw infection

Figure 2

Figure 2;Shortening visualised

Figure 3

Figure 3;proximal nail migration

After proper anesthesia the patient was placed supine and traction table was used. The

Figure 4

Figure 4:operative position used

affected limb was adducted and the hip flexed to 25-30ºThe incision was given from just

Figure 5

Figure 5;Draping and insision

distal to the greater trochanter to about 7-8 cms proximal & posterior.

Using a curved awl, pyriform fossa was opened in the midplane of femur in both AP &

Figure 6

Figure 6;Procedure being continued

lateral views. Manipulative reduction of the fracture was done and a 3.2 mm guide rod was introduced. Femur was reamed over the guide wire by means of various sized reamers in 0.5 mm increments. Proximal femur was reamed 1mm more than the predetermined diameter of the nail. The nail was introduced and seated. Proximal locking was done by means of a jig and the distal locking was done by freehand technique.

Figure 7

Figure 7;locking procedure

All patients were assessed thoroughly and investigated.

Postoperative Rehabilitation

On first postop day quadriceps muscle setting exercises and range of motion was begun on the morning after operation. Progressive weight bearing was allowed depending upon clinical & radiological union.

Mponthly review was done until final assessment at 6 months.

Results

The results were assessed as under:

Figure 8

1-AGE

The mean age of the patients was 32 years. This reflects the involvement of the younger population in outdoor activities.

Figure 9

2-SEX

Figure 10

3-SIDE INVOLVED

Figure 11

4-MODE OF INJURY

Figure 12

5-SITE OF FRACTURE

Figure 13

6-WINQUIST CLASSIFICATION

7 -2 8 cases were locked statically & 2 dynamically as the fracture was too proximal in these. One case was dynamised in a delayed manner at 18 wks.

8- 12[n=12]40% ca ses showed a callus appearance at 7wks and 13.3% cases at 12 wks

Figure 14

F igure 8;Progressive union

.However, 25 [n=25]83.3% cases showed a callus formation from 4-8 wks.

9 -87% cases showed full ROM and 13% showed some restriction of motion in the adjacent joints.

Figure 15

Figure 9;Full function achieved

Figure 16

Figure 10;full function achuieved

Figure 17

10-COMPLICATIONS

Figure 18

11-GRADING AS PER PINTORE et al ,1992(5)

Discussion

Diaphyseal fractures of the femur represent a major chunk of the skeletal system injuries and mostly affect active young adults. closed intramedullary locked nailing is standard method for these fractures. The biologically good effects of physiological loading on fracture healing are well known. Early weight bearing improves vascularisation, enhances fracture healing. We didn’t note any disturbances in weight bearing using single screws.

The advantages of intramedullary nailing in the treatment of patients who have displaced disphyseal fractures of femur are well documented and complex fractures that are unstable in length or rotation can be treated with closed intramedullary nailing using two screws with few complications ⁽⁴⁾. However,the fractures stable in length and rotation can be managed using single screws.⁴

Preservation of length ,alignment and rotation have been facilitated by the introduction of the intramedullary nails with locking capabilities, thereby extending the indications of the technique to even highly comminuted femur fractures. The risk of infection and non-union is low, the hospital stay is relatively low and early movement by the patient is possible ^(4).

According to Gross & Kempf Interlocking nailing can be used to any fracture of the femur provided about 3-4cms of bone is intact proximal & distal to the fracture site ^(3).

Reaming nailing for lower limb fractures is a well established technique and several reports have evaluated its results. Interlocking nailing for long bone fractures of the lower limb have greatly increased the scope of the technique of closed intramedullary interlocking nailing ^(2).

The average time between injury & surgery was about 5 days which was due to the huge workload in our hospital. Satisfactory closed reduction was performed in all the cases

The nail diameters used in our study were in the range of 9-11mm.Other studies ^{6, 7} show the use of the nail of 13-14mm.Racial differences in the bony dimensions of are responsible for this variability.

Infection rate of 6.66%,[two patients with infection at distal screw site] was noted by us.

Majority of the cases in this series ended up with a stable fixation with early rehabilitation, mobilization & return to work.This technique of using one one proximal and one distal screw doesn’t in an way compromise the stability of frrature.

Conclusion

Interlocking intramedullary nailing gave satisfactory results in our sudy. About 2 cases (6.66%) delayed unions were noted. No non-unions or malunions were noted.

Based on the present study it could be concluded that:

{ 1} This technique is as efficient as the conventional two screw technique

{2} It doesn’t expose the patient to an undue risk of infection or nonunion .

{ 3} it reduces surgical time, radiation exposure and prolonged anesthesia

{4} it decreases the length of hospital stay further.

{ 5} It is a minimally invasive procedure.

{6}It doesn’t hamper fracture stability