Strategies in Trauma and Limb Reconstruction

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VOLUME 8 , ISSUE 1 ( April, 2013 ) > List of Articles


Expandable intramedullary nails in lower limb trauma: a systematic review of clinical and radiological outcomes

David M. Rose, Toby O. Smith, Dominic Nielsen, Caroline B. Hing

Keywords : Tibial fracture, Femoral fracture, Expandable nail

Citation Information : Rose DM, Smith TO, Nielsen D, Hing CB. Expandable intramedullary nails in lower limb trauma: a systematic review of clinical and radiological outcomes. 2013; 8 (1):1-12.

DOI: 10.1007/s11751-013-0156-9

License: CC BY-NC-SA 4.0

Published Online: 01-12-2016

Copyright Statement:  Copyright © 2013; The Author(s).


This study systematically reviews the evidence-base for the use of expandable nails in the treatment of acute diaphyseal fractures of the lower limb. Both electronic and hand searches were undertaken of the published and grey literature to 1 December 2011. A total of 154 citations were identified, of which 15 were deemed suitable and assessed with the Critical Appraisals Skills Programme tool. A total of 625 nailing procedures were performed in 620 patients: 279 femoral and 346 tibial nails. The expandable nail was found to be significantly quicker to insert than interlocked nails (p < 0.05), and the total incidence of non-union or other complication was 13 and 14 % for expandable femoral and tibial nails, respectively. Notable complications with the expandable nail included fracture propagation on nail inflation in 2.5 % and post-operative shortening in 3.3 %. Device failure secondary to problems with the expansion mechanism was seen in 2.9 %. The rate of non-union and infection following expandable nailing was 3.1 and 1.4 %, respectively. Despite promising initial results, there remains a paucity of good quality studies to support the use of expandable nails over interlocked nails for the treatment of acute diaphyseal fractures of the lower limb.

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  1. Alho A, Benterud JG, Høgevold HE, Ekeland A, Strømsøe K (1992) Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures. Clin Orthop Relat Res 277:243-250
  2. Hooper GJ, Keddell RG, Penny ID (1991) Conservative management or closed nailing for tibial shaft fractures. A randomised prospective trial. J Bone Joint Surg (Br) 73(1):83-85
  3. Christie J, Court-Brown C, Kinninmonth AW, Howie CR (1988) Intramedullary locking nails in the management of femoral shaft fractures. J Bone Joint Surg (Br) 70(2):206-210
  4. Court-Brown CM, Christie J, McQueen MM (1990) Closed intramedullary tibial nailing: its use in closed and type I open fractures. J Bone Joint Surg (Br) 72:605-611
  5. Lepore S, Capuano N, Lepore L, Romano G (2000) Preliminary clinical and radiographic results with the Fixion intramedullary nail: an inflatable self-locking system for long bone fractures. J Orthopaed Traumatol 3:135-140
  6. Bi Q, Zhu DJ, Qiu BS, Hong JF, Zhang SJ, Xia B (2007) Comparative study on treatment of midshaft tibial fracture with expandable and interlocking intramedullary nails. Chin J Traumatol 10(4):228-232
  7. Lepore L, Lepore S, Maffuli N (2003) Intramedullary nailing of the femur with an inflatable self-locking nail: comparison with locked nailing. J Orthop Sci 8(6):796-801
  8. Capelli RM, Galmarini V, Molinari GP, De Amicis A (2003) The Fixion expansion nail in the surgical treatment of diaphyseal fractures of the humerus and tibia. Our experience. Chir Organi Mov 88(1):57-64
  9. Ben-Galim P, Rosenblatt Y, Parnes N, Dekel S, Steinberg EL (2007) Intramedullary fixation of tibial shaft fractures using an expandable nail. Clin Orthop Relat Res 455:234-240
  10. Zoccali C, Di Francesco A, Ranalletta A, Flamini S (2008) Clinical and radiological midterm results from using the Fixion expandable intramedullary nail in transverse and short oblique fractures of femur and tibia. J Orthop Traumatol 9(3):123-128
  11. Fortis AP, Dimas A, Lamprakis AA (2008) Expandable nailing system for tibial shaft fractures. Injury 39(8):940-946
  12. Ozturk H, Unsaldi T, Oztemur Z, Bulut O, Korkmaz M, Demirel H (2008) Extreme complications of Fixion nail in treatment of long bone fractures. Arch Orthop Trauma Surg 128:301-306
  13. Panidis G, Sayegh F, Beletsiotis A, Hatziemmanuil D, Antosidis K, Natsis K (2003) The use of an innovative inflatable selflocking intramedullary nail in treating and stabilizing long bone fractures. Technique-preliminary results. Osteosynth Trauma Care 11:108-112
  14. Pascarella R, Nasta G, Nicolini M, Bertoldi E, Maresca A, Boriani S (2002) The Fixion nail in the lower limb. Preliminary results. Chir Organi Mov 87(3):169-174
  15. Smith WR, Ziran B, Agudelo JF, Morgan SJ, Lahti Z, Vanderheiden T, Williams A (2006) Expandable intramedullary nailing for tibial and femoral fractures: a preliminary analysis of perioperative complications. J Orthop Trauma 20(5):310-314
  16. Steinberg EL, Geller DS, Yacoubian SV, Shasha N, Dekel S, Lorich DG (2006) Intramedullary fixation of tibial shaft fractures using an expandable nail: early results of 54 acute tibial shaft fractures. J Orthop Trauma 20(5):303-309
  17. Bekmezci T, Baca E, Kaynak H, Kocabaş R, Tonbul M, Yalaman O (2006) Early results of treatment with expandable intramedullary nails in femur shaft fractures. Acta Orthop Traumatol Turc 40(1):1-5
  18. Kapoor SK, Kataria H, Boruah T, Patra SR, Chaudhry A, Kapoor S (2009) Expandable self-locking nail in the management of closed diaphyseal fractures of femur and tibia. Indian J Orthop 43(3):264-270
  19. Cilli F, Mahiroğullari M, Pehlivan O, Keklikçi K, Kuşkucu M, Kiral A, Avşar S (2009) Treatment of femoral shaft fractures with expandable intramedullary nail. Ulus Travma Acil Cerrahi Derg 15(4):383-389
  20. Johner R, Wruhs O (1983) Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res 178:7-25
  21. Canadian Orthopaedic Trauma Society (2003) Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am 85-A:2093-2096
  22. Clatworthy MG, Clark DI, Gray DH, Hardy AE (1998) Reamed versus unreamed femoral nails. A randomised, prospective trial. J Bone Joint Surg (Br) 80:485-489
  23. Selvakumar K, Saw KY, Fathima M (2001) Comparison study between reamed and unreamed nailing of closed femoral fractures. Med J Malaysia 56:24-28
  24. Tornetta P, Tiburzi D (2000) Reamed versus nonreamed anterograde femoral nailing. J Orthop Trauma 14:15-19
  25. Blachut PA, O'Brien PJ, Meek RN, Broekhuyse HM (1997) Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg (Am) 79:640-646
  26. Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF (2000) A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma 14:187-193
  27. Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM (1997) Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 79:334-341
  28. Larsen LB, Madsen JE, Hoiness PR, Ovre S (2004) Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow up. J Orthop Trauma 18:144-149
  29. Bhandari M, Guyatt G, Tornetta P, Schemitsch EH, Swiontkowski M, Sanders D, Walter SD (2008) Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg (Am) 90(12):2567-2578
  30. Beazley J, Mauffrey C, Seligson D (2011) Treatment of acute tibial shaft fractures with an expandable nailing system: a systematic review of the literature. Injury 42(Suppl 4):S11-S16
  31. Chapman MW (1998) The effect of reamed and nonreamed intramedullary nailing on fracture healing. Clin Orthop Rel Res 355:S230-S238
  32. Heim D, Regazzoni P, Tsakiris DA, Aebi T, Schlegel U, Marbet GA, Perren SM (1995) Intramedullary nailing and pulmonary embolism: does unreamed nailing prevent embolization? An in vivo study in rabbits. J Trauma 38(6):899-906
  33. Wozasek GE, Simon P, Redl H, Schlag G (1994) Intramedullary pressure changes and fat intravasation during intramedullary nailing: an experimental study in sheep. J Trauma 36(2):202-207
  34. Kröpfl A, Davies J, Berger U, Hertz H, Schlag G (1999) Intramedullary pressure and bone marrow fat extravasation in reamed and unreamed femoral nailing. J Orthop Res 17(2):261-268
  35. Giannoudis PV, Tzioupis C, Pape HC (2006) Fat embolism: the reaming controversy. Injury 37(4):S50-S58
  36. Pape HC, Dwenger A, Regel G, Schweitzer G, Jonas M, Remmers D, Krumm K, Neumann C, Sturm JA, Tscherne H (1992) Pulmonary damage after intramedullary femoral nailing in traumatized sheep-is there an effect from different nailing methods? J Trauma 33(4):574-581
  37. Pape HC, Regel G, Dwenger A, Krumm K, Schweitzer G, Krettek C, Sturm JA, Tscherne H (1993) Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma. J Trauma 35(5):709-716
  38. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN (2000) External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopaedics. J Trauma 48(4):613-621
  39. Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, Krettek C, Reed RL 2nd (2002) Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma 53(3):452-461
  40. Maher SA, Meyers K, Borens O, Suk M, Grose A, Wright TM, Helfet D (2007) Biomechanical evaluation of an expandable nail for the fixation of midshaft fractures. J Trauma 63(1):103-107
  41. Bek D, Demiralp B, Tunay S, Sehirlioğlu A, Ateşalp AS (2008) Removal of a bent inflatable femoral nail: a case report. Acta Orthop Traumatol Turc 42(3):211-213
  42. Siegel HJ, Sessions W, Casillas MA (2008) Stabilization of pathologic long bone fractures with the Fixion expandable nail. Orthopedics 31(2):143
  43. Rose DM, Smith TO, Nielsen D, Hing CB (2013) Expandable intramedullary nails for humeral fractures: a systematic review of clinical & radiological outcomes. Eur J Orthop Surg Traumatol 23(1):1-11
  44. Phillips AW, Patel AD, Donell ST (2006) Explosion of Fixion® humeral nail during cremation: novel “complication” with a novel implant. Injury Extra 37:357-358
  45. Ward C (2004) Fixion intramedullary nailing system problems encountered at St Faith's Crematorium. Resurgam 47:150
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