Injury (1992)23, (6), 381-387 Prinfed in Greaf Britain 381

Interlocking nailing for fractures of the femur

and tibia

E. Pintorel, N. Mafhlliz and F. Petricciuolol

ICentre Hospitalier d’Annecy, Services de Chirurgie Orthopedique et Traurnatologique, Annecy, France and tDepartment
of Orthopaedics, Newham General Hospital, London, UK

We report our experience in the extensive application of

In 132patients, fractures of the lower limb (71femoral and 61 tibia1
ILN in difficult, unstable, segmental oblique and commi-
fractures) were treated using interkxking nailing (EN) according to Grosse
nuted and spiral femoral and tibial fractures, considering in
anAKempfdtlringtheperiod1986-1989. of&se, 118werefollowedup
some detail the complications of the technique during the
for a median of 19 months [range +32 months). Inpatient stay averaged 9
learning process. A working classification of unstable
days regardks of the jkcture. Consolidation was achieved in approxi-
fractures is given.
mately 3 or 4 month.5from the operation in tibia1 and femoral fractures,
respectively. Tibia1 fractures were fechnically more demanding than
femoral ones, and their average operating time was significantly longer Patients and methods
(73 min versus 51 min). Only one patient had a malunion in malrotation.
Selection criteria
The most serious complication was in a closed upper tibia1 fracture with
Fractures of the femoral and tibial diaphysis were classified
traumatic rupture of the pop&al a&y. Although the nailing was
according to their comminution (Winquist et al., 1984).
technically successjid, an above-knee am@ation had to be cqied out. In
Briefly, a type 1 fracture is a fracture with a small fragment
only one case did the nail fail, and tibia1plating had fo be pnfwmpd. Given
involving one cortex only, while in a type 2 fracture the
thepresent degree of expertise, ILN for fiachtres of the long bones of the
fragment involves one cortex extending into the medullary
lower limb is a safe and relatively easy procedure to pe+rm.
canal. In a type 3 fracture, the fragment extends to both
cortices. A type 4 is a multifragmentaxy fracture. Finally, a
type 5 fracture is similar to type IV, with loss of bone
substance.
Introduction As Winquist et al.‘s (1984) classification does not differen-
Reamed nailing for lower limb fractures is a well-established tiate stable from unstable fractures, all the patients admitted
technique (Kiintscher, 1968; Ki.intscher, 1983), and several in the period 1986-1989 were assessed for fracture stability
reports have evaluated its results (Zucman and Mauer, considering not only bone comminution but its anatomical
1970-71; Donald and Seligson, 1983). Interlocking nailing Iocation as well (Table I and E&k II).
(ILN) for long bone fractures of the lower limb (Klernm and Fractures were thus divided into stable and unstable.
Schellmann, 1972) has greatly increased the scope of the Stable fractures were type 1 and 2 of Winquist et al. (1984)
technique of closed intramedullary nailing (Kempf et al., when they were located in the diaphyseal region. In these
1976; Kempf et al., 1978a; Kempf et al., 1987b), and is now in cases, non-locking nails will suffice. All the patients con-
widespread use. sidered in this study had unstable fractures. These were
ILN widens the surgical indications of nailing, allowing it further divided into fractures unstable in rotation (FUR) and
to be used for comminuted fractures, on fractures too unstable in rotation-compression (FURC). A FUR would
proximal or too distal to be operated on without interlock- have at least 50 per cent of the available cortical bone intact,
ing (Schellmann and Klernm, 1979; Beck, 1985; Kempf et al., and would be located in the lower or upper third of the bone.
1985; Delefortrie et al., 1986; Kempf, 1986), and on aseptic It corresponds to types 1 and 2 of Winquist et al. (1984). A
pseudoarthroses (Grosse et al., 1978). Its main advantages
are the reduction of postoperative infection rates (Winquist Table I. Unstable femoral and tibial fractures according to com-
et al., 1984) and the decreased incidence of non-union minution (Winquist et aI., 1988)
(Hausen and Winquist, 1979).
ILN has reduced the incidence of longitudinal and Femur Tibia
rotatory instability of the fragments (Schvingt et al., 1976;
Kempf et al., 1978b) encountered in non-interlocked closed Type 1 4 2
Tvw 2 17 16
intramedullary nailing. ILN is a well-established technique in 21 16
Tw 3
femoral fractures (Christie et al., 1988; Wiss et al., 1990), and Twe 4 29 27
its role in tibial fractures has been increasingly recognized Twe 6 0 0
(Alho et al., 1990; Court-Brown et al., 1990; Folleras et al., Total 71 61
1990; Hindley et al., 1990).
0 1992Butterworth-Heinemann Ltd
0020-1383/92/060381-07
382 Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 6

Table II. Femoral and tibial fractures according to stability always used at the beginning of the rehabilitation pro-
gramme.
Femur Tibia Patients presenting with symptoms suggestive of deep
vein thrombosis were allowed to stand and walk only after
Unstable in rotation 21 22 full symptomatic resolution. Sedentary workers returned to
Unstable in rotation- 50 39
work 45 days ( f 6, range 35-53 days) after the operation,
compression
and heavy labourers 105 days ( f 13, range 88-124 days)
Total 71 61
after the operation.
Swimming was encouraged after skin healing. Cycling
was allowed when the patient could walk without aids.
Non-contact sports training was allowed after 6 months, if
FURC would have less than 50 per cent of the available the patients were completely asymptomatic. Contact sports
cortical bone intact, regardless of its location. It generally training was allowed 8 months after the operation, and
corresponds to types 3, 4 and 5 of Winquist et al. (1984). competition 12 to 15 months after the beginning of training.
However, no type 5 fractures of Winquist et al. (1984) were Dynamization was performed at 9 to 12 weeks post-
included in this study. operatively. Four fracture/nail configurations were not
Patients younger than 16 years, patients in whom another dynamized due to extensive comminution at the fracture
long bone of the lower limb needed internal fixation, and site.
patients with signs of ligamentous knee instability were
excluded from the study. Table III. Assessment system
A total of 132 patients satisfied the above criteria, and
underwent ILN of their fractures. Of these patients, 71 Pain (30 points)
Walking
sustained femoral fractures, and the remaining 61 tibial None 15
fractures (T&Z I and Tabk U). Mild 10
Moderate 5
Surgical management Severe 0
All patients were operated on within 24 h of admission,
At rest
except patients with grade I and II open fractures (seven None 15
femoral and 10 tibial) (Miiller et al., 1979), who were treated Mild 10
within 6 h of admission. Patients with grade III open tibial Moderate 5
Severe 0
fractures (three cases) were operated on after their skin
lesions resolved (2-3 weeks). In these latter cases, length Function (17 points)
and alignment were maintained using a calcaneal Steinmann Walking
Walking and standing unlimited 12
pin. 500 mt. standing > 30 min 10
Surgical technique was strictly the one described by 100-300 mt, standing 15-30min a
Grosse et al. (1978), Kempf et al. (1976), Kempf et al. <lOOmt 4
(1978a), Kempf et al. (1978b) and Pintore (1987). The Unable to walk 0
operative procedures were performed with the patient in the Stairs
supine position by surgeons of differing experience, ranging Unlimited 5
Supported 2
from resident to senior staff surgeons. A standard image
intensifier was used to insert the interlocking screws using a Range of motion (45 points)
jig. The medullary cavity was not washed out after reaming Ankle (for tibia1 fractures only)
40% 10
it l-1.5 mm more than the diameter of the nail, and a suction 50% 11
drain was used only for femoral fractures. The patients’ 60% 12
positioning time and operating time were recorded. 70% 14
The length of the nail to be used in each case was Full 15
determined preoperatively by measuring the length of the Knee
contralateral uninjured bone on radiographs, and sub- 40% 10
50% 11
tracting 2 cm for both the femur and the tibia. The range of
60% 12
length of the nails used was 38-42 cm for the femur, and 70% 14
3(F-34 cm for the tibia. Of the nails, 92 per cent were 13 mm Full 15
in diameter. Hlfor femoral fractures only)
Immediately after the operation, each patient was 10
examined by the surgeon in the operating theatre to check 50% 11
for deformity and stability of the fracture site. Rotatory and 60% 12
70% 14
angular deformity and leg length discrepancy were evalu-
Full 15
ated comparing the operated with the non-operated side.
Subtraction
Postoperative management One cane 1
In some patients, a plaster-of-Paris back slab was applied One crutch 2
Two crutches 3
after the operation, and maintained for 24 h after nailing. Full
weight bearing was allowed to FURS on the second Deformity (5”= 1 point)
Varus
postoperative day. FURCs were allowed immediate weight Valgus
bearing of up to 10 per cent of their body weight for 2 weeks Recurvatum
after operation. According to their clinical and radiological Flexion
appearance, they gradually progressed to full weight bear- Excellent: 72 or more; Good: 49-71; Fair: 40-46; Poor: 39 or less.
ing 6 to 8 weeks after operation. Sticks and crutches were
Pintore et al.: Interlocking nailing of femur and tibia 383

Nail removal was performed routinely at an average of 21
months for the femoral fractures, and 23.2 months for the
tibial fractures after the primary operation.
Clinical assessment
Patients were seen as outpatients 4 weeks after discharge.
They were subsequently reviewed at 3, 6 and 12 months
after the operation, and at 6-monthly intervals thereafter
until full healing of the fracture and of the bony screw holes.
More frequent or longer follow-up was because of the
patient’s clinical status, or the surgeon’s request. On each
appointment, a formal prearranged assessment was carried
out by a resident (Ekeland et al., 1988) (TubleIIT). Radio-
graphs of the operated bone in two views were taken at each
visit, and assessed by a radiologist who was given no clinical
details other than ‘operated on.. . (date)‘. Healing was
defined clinically as full painfree range of motion of all the
joints of the operated limb and painless full weight bearing.
Radiographic healing was defined when mature callus was
present, bridging across the fracture.
A malunion was defined as shortening greater than 2 cm,
or angular deformity greater than IO”, or rotational deform-
ity greater than 15” (Alho et al., 1990). Results were graded
as excellent, good, fair or poor.
ning of the study were always significantly longer than at
the end (I’< 0.03) for both the femur and the tibia. It took 1
year to reduce significantly, and maintain constant, the
above variables in the femur. Two years were necessary to
reduce patients’ positioning time and operating time in tibial
fractures.
Tibial fractures were found to be technically more
demanding than femoral fractures. The clinical results are
summarized in TubkN. Closed reduction was always
achieved intraoperatively.
Intraoperative complications
In three cases, the drill bit broke in the popliteal fossa. The
drill was removed through a small incision in the posterior
aspect of the knee after turning the patient at the end of the
operation.
In two femoral fractures, excessive arm traction was
applied when trying to reduce the fracture. This resulted in
C5-C6 bra&al plexus neurapraxia resolving in less than 1
week.
In two patients aged 80+, the perineal post caused
pressure sores on the operating table.
In one further case, the nail perforated the femoral cortex,
and had to be re-routed.

Statistical analysis Immediate postoperative complications

The data were entered in a database program (DBase III) on
an IBM compatible personal computer. Statistical analysis
was performed using Systat (Leland, 1988). Descriptive
statistics are given& one standard deviation and range
when appropriate. Data were analysed using the x2 test and
one-way analysis of variance (ANOVA) to assess the
differences in age, delay between injury and operation, time
between the operation and full weight bearing and time
between operation and dynamization. Significance was set
at P< 0.05.
Results
In two cases, excessive traction produced neurapraxia of the
sciatic nerve, which resolved within 6 weeks.
Isolated deep vein thrombosis of the calf, confirmed by
venogram, occurred in three cases. They were treated with
limb elevation, elastic bandage and continuous intravenous
heparin infusion. They resolved within 2 to 4 weeks, and did
not influence the final result.
In two cases, both in the tibia, the nailing was not
technically correct. The anatomical axis of the limb had to be
subsequently restored by removing the nail and performing
a renailiig operation 2 weeks after the first operation.
In one case, with a closed upper tibial fracture compli-

Static locking was carried out in 89 patients; 50 (38 per cent)

in femoral and 39 (29 per cent) in tibial fractures. Of the 132
patients operated on, four patients with a tibial fracture and Table IV. Data on 118 patients followed until fracture healing
six with a femoral fracture were lost to follow-up 6 to 13
Femur Tibia
months after the operation. Three patients died, and one
refused to attend outpatients clinic after the 6-month Average consolidation time (months) 4.1 3.3
postoperative appointment; he was completely asymptoma- Full range of movement 55 41
tic, and had fully resumed his work and leisure activities. Reoperation
Data on long-term follow-up of 118 patients are thus Delayed union 2 -
Incorrect nailing 1 1
presented (Table IV and Table V). The median follow-up was
Loss of fixation 1
19 months (range 9-32 months). Removal of nail 2s 19
Average inpatient stay was 8.7 days ( f 7.4; range 3-29 Malunions
days) for femoral fractures, and 9.8 days ( f 6.9; range 5-32 Varus angulation (> lo”) 2 1
days) for tibial fractures (NS). For both sites, consolidation Recurvatum angulation
Leg length inequality (> 1 cm) : 2
was achieved within 3 months in uncomplicated cases. One - 1
Amputations
fracture healed in malrotation. Knee pain 12 21

Operative results
The average time between a patient’s entrance to the
operating theatre and skin incision was 35 f 6.8 min for Table V. Overall results
femoral fractures and 41 f 11.3 min for tibial fractures
Femur Tibia
(P= NS). The average duration of the operative procedure
was 5 I f 14 min for femoral fractures and 73 f 22 min for
Excellent 20 16
tibial fractures (P= 0.04). At the end of the study, patients’ Good 39 35
positioning time and the operating time of the first ten Fair 9 6
operations of each of the 4 calendar years of the study for Poor 3 4
both the femur and the tibia were compared using ANOVA. Total 71 61
Patients’ positioning time and operating time at the begin-
 384 Injury: the British journal of Accident Surgery (1992) Vol. 23/No. 6

Figure 1. a, The only case in which a nail broke. This occurred in an uncooperative, mentally
retarded patient. b, The proximal fragment was removed, and fib&r osteotomy and tibial plating
performed. Valgus deviation and posterior displacement resulted.

cated by traumatic rupture of the popliteal artery, a vein

grafting procedure, performed after nailing, was not suc-
cessful, and an above-knee amputation was carried out 2
weeks after nailing.
Delayed postoperative complications
The interlocking nail was removed in 45 patients 16 to 19
months after full fracture healing had taken place.
In one patient, a minor superficial infection ensued around
the skin overlying the distal tibial screws. The wound was
curetted, and treated with antibiotics for 2 weeks, healing
uneventfully. Retropatellar fat pad infection occurred 1 year
after the operation in one patient with diffuse furunculosis.
The nail was removed, antibiotics administered, and a
Sarmiento functional cast brace applied for 3 weeks. Recov-
ery was uneventful. Reflex sympathetic dystrophy was
found in two patients. It resolved within 6 weeks.
The nail broke in one case (Figtlre I). This was due to
malpositioning of the nail. The proximal nail fragment was
removed, and a fibular osteotomy was fixed internally with a
plate. The patient was kept in an above-knee non-weight-
bearing plaster-of-Paris cast for 8 weeks. This resulted in
some valgus and posterior displacement of the distal tibial
fragment (Figtrre 1). In two cases, at 6 months bone grafting
of the fracture site was performed because of delayed union.
Shortening of about 2 cm occurred in four cases, resulting
in proximal migration of the nail under the patellar tendon
(two cases) and the greater trochanter (two cases). This was
due to early dynamization in con-minuted fractures
(FigureZ). The nails were removed after sound union was
achieved,
In one case, there was a marked varus deviation of a
femoral fracture. The patient was kept partial weight bearing Figure 2. JZarlydynamizaton produced shortening of the femur
until full consolidation, which occurred in the 4th postopera- of about 2 cm.
Pintore et al.: Interlocking nailing of femur and tibia
tive month. In one case of open Grade II tibial fracture, a
compartment syndrome of the leg developed. It was treated
with extensive fasciotomy. Finally, in two cases with
subtrochanteric fractures, one being a pathological fracture,
consolidation occurred with a varus deformity.
Clinical assessment
The results of assessment are given in Table I/. Over 80 per
cent of the patients were found to have at least a good result.
In only seven cases was there a poor outcome.
A secondary ANOVA of the 22 fair and poor .vs the
excellent and good results was performed using age, delay
between injury and operating time, time between operation
and full weight bearing, and time between operation and
dynamization of the nail as covariates. A non-statistically
significant trend towards greater age and longer time
between operation and full weight bearing was identified.
Discussion
ILN of fractures of the long bones of the lower limb has
proved to be an excellent method of treatment. In the tibia,
knee pain seems to be the main problem associated with the
technique (Court-Brown et al., 1990) and is generally
experienced with kneeling. Its incidence is significantly
higher than in the femur. In several cases, it may require
removal of the nail, but it rarely interferes with work. The
present series compares favourably with recent ones (Court-
Brown et al., x990), both for its incidence and for the need to
remove the hardware. In the femur, ILN may be associated
with a high rate of complications, especially in elderly
patients (Moran et al., 1990).
Most of the complications in the present series were not
directly related to the nailing, but reflected more general
problems. However, the great majority of the patients were
provided with immediate stable fixation, early mobilization,
rehabilitation and return to work.
The great majority of technical problems were encoun-
tered in the initial phase of the learning curve, when errors
have a high prevalence. More recently, as the technique has
been well standardized, and the experience acquired
matured, very few complications have occurred. When this
happened, they were largely unavoidable and largely
unpredictable. Given the technical expertise achieved after 4
years of application of ILN, we feel that the procedure has
become safe in our hands and, given the proper support,
relatively easy to perform. This is shown by the significant
reduction in patients’ positioning time and operating time
between the beginning and the end of this study.
Recently, Brumack et al. (1988a, 1988b) have published
their experiences using the classification of fractures
developed by Winquist et al. (1984). We have outlined
above a classification scheme which allows a rapid therapeu-
tic plan, based on the morphological appearance of the
fracture site and its location.
In stable fractures, an unlocked nail will suffice. In FURCs
static ILN is recommended. In FURS, dynamic ILN will be
performed, as rotation is by definition well controlled by
proximal or distal locking, and there are no risks of
shortening with nail migration (Kempf et al., 1976). The
classification is also indicative of a strategy to adopt in the
postoperative management of these patients. Grosse and
Kempf proposed dynamizing all statically locked fractures
between the 9th and the 12th postoperative week (Grosse et
al., 1978; Kempf et al., 1985; Kempf, 1986). At the beginning
of our experience, we followed this practice. However, the
385
four cases of shortening were due to early dynamization,
and we are now more cautious in dynarnization in type 4
fractures. Some fractures are never dynamized.
According to Grosse and Kempf, ILN can be applied to
any fracture of the lower limb provided that at least 3-4 cm
of bone is intact proximally and distally to the fracture site
(Kempf et al., 1976; Grosse et al., 1978; Kempf et al., 1978a;
Kempf et al., 1987b; Kempf, 1986).
Many of the reported malunions were due to dynamic
locking of unstable fractures (Thorensen et al., 1985).
Unfortunately, at the beginning of the study we dynamized
some of the fractures too early. In these cases, the callus was
probably not mature enough to bear the full body-weight,
and shortening occurred. At present, we statically lock all
nails in comminuted fractures to start with, and dynamize
them only when radiographic findings of mature callus are
unequivocal.
The patients who showed a poor or fair result were 16 per
cent of the total, which is higher than that found by other
authors (Winquist et al., 1984; Thorensen et al., 1985;
Court-Brown et al., 1990; Wiss et al., 1990). This could be
due to the stringency of the selection criteria applied, to the
inclusion in the study of all the patients operated on from the
very first moment the technique was introduced in the
department, when the technique was not properly standard-
ized, and to surgeons at different stages of training perform-
ing the operation.
Statistical analysis revealed a non-significant trend of
these patients to have been allowed full weight bearing after
the operation only after a longer time than the patients in
the excellent and good result groups. Whether this is due to
their greater age, to underlying medical conditions or to the
complexity of the surgery performed is not clear, but
rehabilitation programmes should probably take this issue
into consideration.
Acknowledgements
Many thanks are given to Drs J. Dayez and G. Melere,
Chirurgiens Orthopedistes et Chefs de Service, Centre
Hospitalier d’Annecy, Services de Chirurgie Orthopedique
et Traumatologique, Annecy, France, for allowing us to
report on patients under their care.
Mr C. Blakeway FRCS, Consultant Orthopaedic Surgeon,
Poole General Hospital, England, gave us precious advice
when writing this report.
Dr Gabriella N. M. Giudici helped greatly in preparing
the manuscript.
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