The incidence of diaphyseal femur fractures in adults varies, with recent epidemiologic studies reporting 10 to 21 such fractures per 100,000 person-years.1,2 As techniques associated with intramedullary fixation have advanced, femoral shaft fractures are often treated with intramedullary nailing, with predictably good outcomes expected.3 Closed reduction as well as percutaneous reduction techniques have been well described in association with intramedullary nailing of the femur.4 When closed techniques alone prove inadequate to facilitate reduction, open reduction methods can be used prior to intramedullary nail fixation.4 There are theoretical concerns regarding the opening of a closed fracture; these include increased risk of deep infection and wound complications as well as nonunion secondary to disruption of fracture hematoma.5
Although both closed and open reduction techniques have been previously described, there are limited data analyzing the outcome of closed femoral shaft fractures in adults treated with open reduction and intramedullary nailing.4 Both open and closed reduction techniques have been used to treat closed femoral shaft fractures of adult patients at the authors' academic level I trauma center during the past several years. The purpose of this study was to compare rates of radiographic union, time to union, and incidence of significant complications between those patients treated with closed or percutaneous reduction and those patients treated with open reduction and intramedullary nailing for closed femoral shaft fractures. The authors hypothesized that no statistically significant difference in union rate, time to union, or complication rate would exist between the two groups.
Materials and Methods
This study represents a retrospective review of patients treated at a single level I trauma center. After institutional review board exempt status was obtained, the medical records and radiographs of all patients with closed femoral shaft fractures between January 2012 and June 2017 were reviewed. Included in the study were patients 17 years or older having acute, traumatic fractures of the femoral shaft that were subsequently treated with intramedullary nail fixation. Minimum follow-up of 6 months was required; this was based on prior literature discussing time to union for femoral shaft fractures treated in this manner.6 Pediatric patients younger than 17 years, patients with open fractures, patients with pathologic fractures, and patients with less than 6 months of radiographic follow-up were excluded from the study.
Patient demographic data collected included age and sex (Table 1). Injury and treatment data included type of reduction method used and overall operative time. Postoperative data analyzed included presence of radiographic union as determined by the treating surgeon. Patients underwent routine radiographic follow-up at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. After 6 months of follow-up, patients were evaluated at either 8 months or 9 months postoperatively, depending on surgeon preference, and also at 12 months postoperatively. After 12 months, patients were evaluated at either 18 months or 24 months postoperatively. After 24 months, patients were followed on an as-needed basis. Radiographic union was confirmed with retrospective review of radiographs to evaluate for bridging callus on 3 of 4 cortices on the anteroposterior and lateral radiographs obtained at the time of determination of union. No patients used external bone stimulators to augment fracture healing. Time to radiographic union, length of hospital stay, length of follow-up, deep infection requiring return to the operating room, revision of fixation requiring return to the operating room, and nonunion or delayed union requiring return to the operating room were also analyzed.
Demographic Data of Included Patients
Patients were classified according to reduction method used prior to intramedullary nailing. Those undergoing closed or percutaneous reduction were defined as the closed reduction group. Percutaneous reduction was defined as reduction performed through incisions less than 1 cm long, with instruments such as bone hooks or ball-spike pushers inserted through percutaneous incisions to allow for indirect reduction of fracture fragments. Those undergoing open reduction, defined as a formal incision greater than 1 cm long to facilitate direct manipulation of fracture fragments and provisional stabilization with clamps, plates, or cables, were defined as the open reduction group.
A total of 139 patients underwent intramedullary nailing of closed femoral shaft fractures during the study period. A total of 107 patients with 107 fractures were ultimately included for analysis. Thirty-seven patients underwent open reduction prior to intramedullary nailing, and 70 patients underwent closed reduction. Demographics, surgical time, return to the operating room, union, time to union, postoperative complications, and length of follow-up were analyzed between the categorized groups. Analysis of variance was used for continuous variables. Chi-square test was used for categorical variables. Statistical analysis was performed using SPSS statistics software (IBM Corp, Armonk, New York).
In this study, 61.7% of the patients were male. Males comprised 64% of the closed reduction group and 57% of the open reduction group. The overall mean age of the patients included was 35.3 years (range, 17–87 years). The mean age in the closed reduction group was 36 years, and the mean age in the open reduction group was 35.1 years. Mean follow-up was 14 months in both the closed and open reduction groups.
Overall rate of union was 91.6% (98 of 107). Union rate was 92.9% (65 of 70) in the closed reduction group and 89.1% (33 of 37) in the open reduction group (P=.24). Of the 9 patients having nonunion after initial surgical treatment, 2 patients in the closed reduction group and 1 patient in the open reduction group reported tobacco use at the time of injury or during follow-up (P=.64). The mean time to union of all patients was 5.6 months (range, 3–12 months). The mean time to union was 5.4 months (range, 3–11 months) in the closed reduction group and 6.2 months (range, 3–12 months) in the open reduction group (P=.13). The mean hospital stay was 6.41 days in the closed reduction group and 6.57 days in the open reduction group (P=.96).
A total of 12 patients required return to the operating room for deep infection, revision of fixation, or treatment of delayed union or nonunion (11.2%) (Table 2). Six of 70 patients (8.6%) in the closed reduction group required return to the operating room, and 6 of 37 patients (16.2%) in the open reduction group required return to the operating room. This difference was not statistically significant (P=.18).
Complications Associated With Type of Reduction
Two patients required return to the operating room for treatment of deep infection (1.9%): 1 patient (1.4%) in the closed reduction group and 1 patient (2.7%) in the open reduction group (P=.29). Both patients underwent surgical debridement and removal of implants at the time of return to the operating room. One patient in the open reduction group (2.7%) required return to the operating room for revision of fixation; no patients in the closed reduction group required such intervention (P=.35).
Eight patients (8.4%) underwent a total of 9 surgical procedures to address delayed union or nonunion. Four patients (6%) in the closed reduction group underwent 4 subsequent surgical procedures to address their nonunion, with 1 patient forgoing further surgical treatment of documented nonunion. Four patients (13.5%) in the open reduction group underwent a total of 5 surgical procedures to address delayed union or nonunion. This difference was not statistically significant (P=.15).
One patient (1.4%) in the closed reduction group had a postoperative superficial surgical site infection treated with oral antibiotics, whereas no patients in the open reduction group had superficial infection (P=.64).
Mean operative time was 1.3 hours in the closed reduction group vs 1.8 hours in the open reduction group (P=.007).
Several prior studies have evaluated the outcomes of open vs closed reduction prior to intramedullary nailing for the treatment of femoral shaft fractures. In 1969, Rokkanen et al7 compared non-operative management with both open nailing and closed intramedullary nailing. Their analysis focused exclusively on functional outcomes. Leighton et al8 evaluated 130 patients treated with open vs closed intramedullary nailing, noting no significant difference between treatment groups. They noted that 92% of the patients undergoing closed intramedullary nailing had satisfactory outcomes vs 97% of the patients undergoing open reduction and intramedullary nailing. These authors determined that open reduction should be considered if closed reduction is not readily feasible intraoperatively. In the series reported by Harper6 in 1985, closed vs open reduction and intramedullary nailing resulted in similar times to union. A higher rate of rotational malunion was seen in those patients treated with closed intramedullary nailing.
The current retrospective study indicated no significant difference in union rates, time to union, or rates of return to the operating room for significant complication between closed femoral shaft fractures treated with open reduction prior to intramedullary nailing compared with closed reduction prior to intramedullary nailing. It has previously been theorized that closed reduction prior to intramedullary nailing would allow for biologic preservation of the hematoma formed at the fracture site, and that extensive periosteal stripping and disruption of this biologic environment could contribute to lower rates of union or prolonged time to union.9–11 Gourishankar11 noted longer time to radiographic union and higher infection rates in patients with femoral shaft fractures treated with open reduction when compared with those treated with closed reduction and Kuntsher nailing. Malik et al12 noted a higher rate of non-union in patients with long bone fractures treated with open reduction at the time of intramedullary nailing; however, their study included open fractures, pathologic fractures, and fractures of the tibia and humerus.
The current study differs in that it sought to analyze only closed, nonpathologic fractures of the femoral shaft and to note that open reduction did not result in significantly different rates of union or time to union. Although biologic preservation and avoidance of periosteal stripping are important principles of operative fracture care, the authors theorize that due to the robust soft tissue envelope surrounding the femoral shaft, open reduction may offer an advantageous technique for certain patients and for certain fracture patterns. Prior case series have demonstrated the clinical utility of open reduction prior to intramedullary nailing.13,14 These studies have advocated for the use of open reduction for polytraumatized patients and for those with fractures not reducible using closed means.
The authors believe that open reduction may represent a useful technique for types of fractures not easily reduced using closed methods and for patients in whom positioning may prove challenging. These patients include those with multiple associated traumatic injuries and obese patients in whom external manipulation may not be sufficient to achieve closed reduction. The benefits of improved fracture exposure through an open approach may outweigh potential concerns regarding disruption of the fracture site. This is supported by prior studies evaluating the factors contributing to nonunion in fractures of the femoral shaft.15,16 Ma et al16 noted that unsatisfactory reduction was associated with an increased rate of nonunion; the theoretical benefit of preservation of fracture site biology afforded by closed reduction may be outweighed by improved exposure of the fracture site through formal open reduction.
This study found an overall union rate of 91.6%. This is consistent with prior studies evaluating the rate of union following intramedullary nailing of femoral shaft fractures, which have reported rates of nonunion of less than 10%.17,18 The patients undergoing open reduction demonstrated slightly higher rates of nonunion (overall rate, 10.9%). This was not statistically significant. One patient in each treatment group required return to the operating room for treatment of deep infection, with this series of patients having an overall rate of deep infection of 1.9%. This was also consistent with prior studies, which have reported overall infection rates ranging from 1% to 3.8%.12 The current study also found a similar mean hospital stay for patients undergoing open vs closed reduction; however, this statistic did not control for associated injuries or medical comorbidities contributing to overall hospital stay. Mean operative time was longer in the open reduction group; this represented the only statistically significant difference between the two treatment groups.
Selection bias was a major limitation of this study, as reduction technique was determined by the treating surgeon at the time of operative treatment. In addition, due to the retrospective nature of this series without standardized follow-up radiographic analysis, the authors were unable to evaluate the quality of reduction in the open and closed reduction groups to determine if it significantly impacted non-union rates or if it differed between them. Furthermore, this study's relatively small sample limits the generalizability of the findings. A post hoc power analysis was conducted based on a total patient number of 107 and alpha being 0.05; the results demonstrated power (1-beta) of 0.14 for union rate and 0.42 for time to union. Further expansion of this patient series would improve study power and allow for further statistical scrutiny of the treatment groups due to the relatively low rate of complications noted.
Open reduction and intramedullary nailing results in rates of union, time to union, and rates of complications similar to those of closed reduction and intramedullary nailing of closed femoral shaft fractures. Open reduction represents a safe and effective treatment option, particularly when difficulties with closed reduction are present prior to intramedullary nailing.
- Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA. National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury. 2009;40(3):304–308. https://doi.org/10.1016/j.injury.2008.07.017 PMID: doi:10.1016/j.injury.2008.07.017 [CrossRef]19171340
- Enninghorst N, McDougall D, Evans JA, Sisak K, Balogh ZJ. Population-based epidemiology of femur shaft fractures. J Trauma Acute Care Surg. 2013;74(6):1516–1520. https://doi.org/10.1097/TA.0b013e31828c3dc9 PMID: doi:10.1097/TA.0b013e31828c3dc9 [CrossRef]23694881
- Wolinsky PR, McCarty E, Shyr Y, Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma. 1999;46(3):392–399. https://doi.org/10.1097/00005373-199903000-00007 PMID: doi:10.1097/00005373-199903000-00007 [CrossRef]10088839
- Wolinsky PR, Lucas JF. Reduction techniques for diaphyseal femur fractures. J Am Acad Orthop Surg. 2017;25(11):e251–e260. https://doi.org/10.5435/JAAOS-D-17-00021 PMID: doi:10.5435/JAAOS-D-17-00021 [CrossRef]28938339
- Haller JM, Githens M, Scolaro J, Firoozabadi R. Does provisional plating of closed tibia fractures have higher complication rates?J Orthop Trauma. 2017;31(10):554–558. https://doi.org/10.1097/BOT.0000000000000874 PMID: doi:10.1097/BOT.0000000000000874 [CrossRef]28471916
- Harper MC. Fractures of the femur treated by open and closed intramedullary nailing using the fluted rod. J Bone Joint Surg Am. 1985;67(5):699–708. https://doi.org/10.2106/00004623-198567050-00004 PMID: doi:10.2106/00004623-198567050-00004 [CrossRef]3997922
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- Whiteside LA, Stewart K, Jeffery P, Hallett W. The effect of extra periosteal and subperiosteal dissection in fracture healing. J Bone Joint Surg Am. 1978;60:6–31. doi:10.2106/00004623-197860010-00004 [CrossRef]
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Demographic Data of Included Patients
|Characteristic||Closed Reduction (n=70)||Open Reduction (n=37)||Total (N=107)||P|
|Mean age (range), y||36 (17–82)||35.1 (17–87)||35.3 (17–87)||.62|
Complications Associated With Type of Reduction
|Closed Reduction (n=70)||Open Reduction (n=37)|
|Total complications necessitating return to operating room||6||6||.18|
|Revision of fixation||0||1||.35|
|Repair of nonunion||4||5||.15|
|Superficial infection (treated nonoperatively)||1||0||.64|