Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures

Objective: To determine the effectiveness of exchange reamed nails for treatment of aseptic femoral delayed unions and nonunions. Design: Retrospective chart review. Patients: Nineteen patients admitted to the Carolinas Medical Center Level I trauma center from 1990 to 1996 for repair of femoral shaft fracture nonunion following contemporary locked nailing performed at least six months previously. These patients showed no radiographic evidence of progression of fracture healing for three months and had clinical symptoms of nonunion. Intervention: Exchange reamed nails to treat ununited femoral shaft fracture. Main Outcome Measurements: Radiographic and clinical evidence of union of the fracture or of the necessity for additional procedures. Results: In 53 percent of the patients the secondary procedure resulted in fracture union, whereas in 47 percent, one or more additional procedures were required. Eight of the nine fractures that did not unite with exchange nailing united after a subsequent procedure (bone grafting, compression plating, or nail dynamization). Neither the type of nonunion, the location of the shaft fracture, the use of static Versus dynamic cross-locking, nor the use of tobacco products was statistically predictive of the need for additional procedures. Conclusions: Reevaluation of routine exchange nailing as the recommended treatment for aseptic femoral delayed union or nonunion may be required. A significant number of patients who undergo reamed exchange nailing will require additional procedures to achieve fracture healing.