Elsevier

Injury

Volume 36, Issue 9, September 2005, Pages 1085-1093
Injury

Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis

https://doi.org/10.1016/j.injury.2004.09.012Get rights and content

Summary

The purpose of this study was to use multivariate analysis to evaluate contributing factors affecting deep infection and nonunion of open femoral fractures treated with locked intramedullary nailing (IMN).

We examined 89 open femoral fractures (88 patients) treated with immediate or delayed locked IMN in static fashion at the Kitasato University Hospital from 1988 to 2001. Multiple regression models were derived to determine predictors of deep infection and nonunion. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type (I + II or III), fracture grade by AO type (A or B + C), fracture site (proximal site + distal site or middle site), timing or method of IMN, reamed or unreamed nailing (R versus UR), debridement time (≤6 h or >6 h), existence of polytrauma (ISS < 18 or ISS  18), and existence of floating knee injury (+ or −). The predictive variables of nonunion selected for analysis were the same as those for deep infection, with the addition of deep infection (+ or −).

Five fractures (5.6%) developed deep infections: one Gustilo type II and four type III. Multivariate analysis revealed that only Gustilo type significantly correlated with occurrence of deep infection (p < 0.05). Nonunion occurred in 12 fractures (14.1%). Multivariate analysis revealed that only fracture grade by AO type significantly correlated with occurrence of nonunion (p < 0.02).

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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