Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis
Introduction
Since the development of Küntcher's closed technique of intramedullary nailing (IMN) to treat fractures,18 reamed IMN, is widely regarded as the treatment of choice for patients who have a closed fracture of the femoral shaft.13, 15 Formerly, IMN to an open fracture of the femur was considered to be contraindication. Several authors5, 14 stated that an intramedullary implant with reamed procedure and disruption of the endosteal supply in combination with a contaminated wound could easily result in a high deep infection rate and prolong the time required for fracture healing. Recent reports,2, 19, 24 however, revealed good outcomes of IMN for open femoral shaft fractures with low infection rates and no other complications. In addition, unreamed IMN has been used as an alternative treatment for open fractures.4, 17 No one has determined the range of severity of open fractures that can be treated using IMN. Also, there is controversy over whether IMN should be performed immediately or after a delay.
We previously used univariate analysis to identify contributing factors affecting deep infections and nonunions in open femoral fractures treated with IMN.31 In the present study, we document newer cases in addition to the previously reported cases, and use multivariate analysis to evaluate factors affecting deep infections and nonunions of open femoral fractures treated with locked IMN.
Section snippets
Clinical materials
We retrospectively reviewed 88 patients with 89 open femoral shaft fractures treated with locked IMN in the Department of Orthopedic Surgery and Trauma Centre, Kitasato University Hospital, between 1988 and 2001. Some of these cases were reported previously.31, 32
Seventy-two patients were male and 16 patients were female. The mean age of the patients at the time of injury was 24.8 years (range, 15–62 years). Eighty-one patients were injured in motor vehicle accidents (59 were injured in
Deep infections
Five (5.6%) of the 89 open femur fractures developed deep infections. Two of these infections were caused by both Staphylococcus aureus and methicillin-resistant S aureus (MRSA); two were caused by MRSA alone, and one was caused by S aureus alone. The deep infections occurred in one Gustilo type II (2.3%, 1/43) and four type III (16.7%, 4/24).
Results of multivariate analysis of deep infection are shown in Table 3. The predictive logistic regression equation for deep infection was as follows:
Discussion
As a conventional approach of IMN for open femoral fractures, Chapman5 advocated delayed nailing until 1 week after closure or coverage of the open fracture wound. However, delayed surgical stabilisation for open femoral fractures associated with polytrauma or severe soft-tissue injury is problematic. In polytrauma patients, immediate or early stabilisation is important for prevention of pulmonary complications.3, 10 In type-III open femoral fractures, closed treatment alone is not sufficient
Acknowledgement
We would like to thank T. Sasahara in Division of Bio-statistics, Department of Microbiology, School of Medicine, Kitasato University, for his help with the statistic analysis.
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