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Current Orthopaedics (1999) 13, 99 104

© 1999 Harcourt Brace & Co. Ltd

Mini-symposium: Tibial fractures

(iii) Intramedullary nailing: the case for reaming

H.S. Reid, C.M. Court-Brown

INTRODUCTION

the Rush brothers and Otto Lottes, who used
unreamed nails. In the last ten years, however, surgeons in Europe have become polarized into two
camps largely as a result of the introduction of the
AO unreamed nailing systems. These nails stimulated
a considerable amount of research, which was
designed to show the deleterious effect of reaming on
the endosteal vascular supply and intramedullary
pressure. These studies were generally undertaken
using animal models and the results were often contradictory. More recently, a number of clinical studies
have been undertaken to investigate the role of reaming. Reaming therefore remains somewhat controversial and surgeons continue to debate certain aspects
of the technique and its physiological effects.
Important questions include:

Intramedullary reaming was introduced by Gerhard
Kiintscher 1 to allow the insertion of large-diameter
intramedullary nails. His initial nails had no interlocking facility and it was only by reaming the endosteal
cortex into a tube that an intramedullary nail could
obtain purchase on a sufficient length of cortex to successfully stabilize a fracture. There is no doubt that
Kfintscher found reaming to be very useful, but he did
recognize that the technique had potential drawbacks
and he advised against nailing in the presence of fat
embolus. He also advocated care if intramedullary
nailing was used in the multiply injured patient or in
patients who had severe soft-tissue injuries.
Traditional unlocked Kiintscher nailing was found
to be a very useful technique in the management of
femoral fractures but was of less value in the tibia
because the morphological characteristics of many
tibial fractures meant that an unlocked nail could not
adequately stabilize the fracture. The introduction of
locked nails, however, following the work of Klemm
and Schellmann and Grosse and Kempf, meant that
virtually all femoral and tibial diaphyseal fractures
could be stabilized using intramedullary techniques
and the technique of interlocking nailing has become
routine in the management of these fractures.
It is interesting to note that initially the division
between reamed and unreamed 'nailers' was geographic. Europe tended to follow the teachings of
Kfintscher and therefore used reamed nails, whereas
surgeons in the USA were influenced by the work of

1. What is the effect of reaming on the endosteal
blood supply and intramedullary pressure?
Opponents of reaming suggest that its destruction
of the endosteal vasculature is deleterious to
fracture union and that the high intramedullary
pressure associated with its use may precipitate
compartment syndrome.
2. What are the clinical results of using reamed and
unreamed femoral and tibial nails? Are there any
physiological effects of reaming that might be
advantageous to bone union?
3. Does reaming and nailing cause fat embolus and
adult respiratory distress syndrome in multiply
injured patients? Opponents suggest that it does
and that unreamed nails cause less damage than
reamed nails.

Heather S. Reid FRCS, Orthopaedic Registrar; Charles M.
Court-Brown FRCSEd(Orth), Consultant Orthopaedic Surgeon,

Edinburgh OrthopaedicTrauma Unit, RoyalInfirmary of
Edinburgh NHS Trust, Lauriston Place, Edinburgh EH3 9YW,
UK. Tel: +44 (0)131 536 3721; Fax: +44 (0)131 660 4227
Correspondence to:

P H Y S I O L O G I C A L E F F E C T S OF R E A M I N G
Animal studies dealing with the effect of intramedullary reaming on fracture union show conflicting

Mr C.M. Court-Brown
99

McQueen and her co-workers demonstrated that reaming and nailing were not associated with an increased incidence of compartment syndrome. As the diameter of the reamers increased. This suggested that the reaming particles might well have a direct osteoinductive effect. the amount of subperiosteal bone formation was considerably less. In a second experiment. Other researchers have examined the periosteal stimulation associated with reaming. making the clinical conclusions drawn from these animal experiments invalid. 11 In their study. Recently. whereas Grundes 6 et al. it is unlikely that there will be a compartment syndrome. Their results showed no benefit from delaying surgery and indeed delay is one of the factors that may well contribute to compartment syndrome. The other notorious cause of increased compartment pressure is fracture distraction. They also dispelled the myth that surgeons should wait for the intracompartmental pressure to settle before undertaking intramedullary nailing of the tibia. with similar results being found.100 Current Orthopaedics results. Their experiments showed that. Many surgeons diagnose compartment syndrome as being present if the intracompartmental pressure rises above 30 mmHg and the belief that reamed nailing causes compartment syndrome has been reinforced by the observation that compartment pressures are frequently above 30 mmHg immediately after reamed nailing. Small quantities of reaming products were injected into the gluteus maximus muscle of rats who were given an intraperitoneal injection of tetracycline. there was no significant difference in cortical blood flow despite the fact that the dominant afferent supply from the nutrient artery had been destroyed and a proportion of the cortical bone had been reamed out. In his animal studies. his work has been repeated using more sophisticated techniques. This effect was examined further by Tydings and his co-workers who examined reaming products histologically.2 He showed that reaming did interfere with the endosteal vascular supply but that. ReikerSs 5 et al. Subsequent fluorescence studies indicated that the cellular component of the bone reamings reamined viable. have clearly shown that the passage of any instrument down the medullary canal of a long bone will increase intramedullary and therefore intracompartmental pressure. They demonstrated that. Klein et al. McQueen et al. reamings were compared with iliac crest bone graft in dogs and it was noted that there was increased new bone formation from the reamings. The original studies investigating the damage to the endosteal circulation by reaming were undertaken by Danckwardt-Lillestrom. This concept was well known to the fracture surgeons that perfected the techniques of cast and traction management of tibial fractures but seems to have been . It is the reduction of the fracture which elevates the compartment pressure and the longer the delay the more difficult the reduction and the greater the potential for compartment syndrome. One of the other criticisms that continues to be levelled against reaming is that. he used the contralateral leg as a control and he observed that. when the marrow contents were removed by suction. within a few weeks. Clinical studies are clearly required to investigate the overall effect of the reduction in the endosteal vascular supply after reamed nailing. 3 have shown that there is a 70% reduction in endosteal blood flow after reamed nailing compared with a 30% reduction after unreamed nailing. They felt that their results vindicated Trueta's belief that following trauma. however. or other pathological states. it causes compartment syndrome. He also demonstrated that reaming enhanced the periosteal circulation. If a muscle compartment is shortened by the fracture ends overriding. found no difference in healing between reamed and unreamed femoral osteotomies. immediately after intramedullary reaming. the concentration of bone increased. Danckwardt-Lillestrom2 also showed that bone-marrow contents were forced subperiosteally during reaming and he noted that woven bone was formed in these areas. The results of the experiments are unquestionably valid but are often unreasonably extrapolated. Schemitsch et al. reported modest reaming to be preferable to extensive reaming in fracture union in rats. 4 have demonstrated that cortical revascularization occurs after six weeks using an unreamed nail compared with after 12 weeks if a reamed nail is used. Some osteocytes and fibroblasts were observed but no true osteoblasts. The problem with much of the animal work is that the experiments tended to concentrate on only one facet of the fracture repair process. Haas and his co-workers also demonstrated that this was true for unreamed nailing. 12 Compartment pressures may be high after intramedullary nailing but they usually return to physiological levels fairly quickly after the patient is removed from the nailing table. 9'1° They showed that the initial reaming material comprised marrow contents with small amounts of bony trabeculae. Reichert7 and her co-workers investigated the vascular changes produced by reaming intact tibiae in sheep. In addition to demonstrating the effects of reaming on bone blood flow. bone blood flow can become centripetal? Most studies now agree that periosteal blood flow dominates in the early phase of bone-healing and that the repair process proceeds from the periphery until the medullary circulation is re-established. they undertook fasciotomy whenever the intracompartmental pressure rose above 30 mmHg and as a result they had a 42% incidence of fasciotomy. the endosteal blood vessels had returned. by raising the intramedullary pressure. within 30 min there was a sixfold increase in blood flow in the reamed tibia compared with the unreamed contralateral control and they concluded that the enhancement of the periosteal circulation by reaming compensated for any reduction in endosteal blood flow.

enhances the periosteal circulation. have demonstrated that closed and grade 1 open diaphyseal fractures of the tibia treated by unreamed nailing have a longer time to union. reaming was shown to have a significantly higher union rate. This tendency is often minimized by 'minimal reaming' or by 'back-slapping' the nail. They noted the shorter surgical time associated with the use of unreamed nails but concluded that the use of reamed nails in closed tibial fractures was preferable. It is interesting to note that they had 3 (4. 3. also prospectively studied open tibial fractures using reamed and unreamed nails and found that the only statistically significant difference between the two groups of patient was the higher rate of implant breakage in the unreamed group. a higher rate of complications and a greater need for further surgery when compared to a similar group of patients treated by reamed nailing.8%) compartment syndromes in the unreamed group compared with none in the reamed group. 4. CLINICAL STUDIES When examining the clinical studies it is important to separate the results of the management of closed fractures from those of severe open fractures. transiently raises compartment pressures. which form new bone. does not cause an overall reduction in cortical blood flow. they found no significant difference in the rates of infection. does not cause compartment syndrome. They believed it likely that the soft-tissue damage associated with severe open fractures was so great that it would dictate prognosis regardless of the type of nail used to stabilize the fracture. All of the non-unions 101 united after exchange nailing using a reamed nail. There is little doubt that compartment syndrome is one cause of delayed union ~3 and it is possible that raised compartment pressure is one of the factors that causes the high rate of non-union encountered with the use of unreamed nails in clinical studies. causes sub-periosteal extrusion of marrow contents.Intramedullary nailing: the case for reaming Table 1 The effects of reaming on blood flow and compartment pressure Reaming 1. although there was no difference in the rate of infection or compartment syndrome between the reamed and unreamed groups in closed fractures. the unreamed group showed a 20% non-union rate and a 16% malunion rate with a 56% incidence of screw breakage. damages the endosteal circulation. Keating et al. The introduction of unreamed femoral nails prompted a number of prospective clinical studies examining the use of reaming in the femur. 2. Currently. In the closed fracture group. ~8 These results appear to vindicate Court-Brown's initial view that it would be closed fractures that would demonstrate the advantages of reamed nailing. examined reamed and unreamed nailing in both open and closed fracture. 5. The situation appears to be exactly the same in the femur. Tornetta and Tiburzi showed that reamed nailing led to faster healing of distal femoral fractures treated with statically . An obvious consequence of attempting to hammer an 8-mm nail down an 8-mm medullary canal is that the fracture will distract. 16 Finkemeier et al. compartment syndrome or secondary procedures between the reamed and unreamed groups. 15 Unlike the series of Court-Brown et al. They therefore undertook a prospective analysis of closed fractures selecting only Tscherne C1 fractures. Blachut et al. However. There were no infections in either group and in the reamed group there were no non-unions or malunions and virtually no equipment failure. Recently. also undertook a prospective randomized trial comparing reamed and unreamed nailing in closed tibial fractures. Sadowski et al. forgotten by proponents of unreamed nailing of the femur or tibia. they examined all closed fractures regardless of the severity of the injury. There was no difference in patient function at one year but the 20% requirement for secondary surgery in the unreamed group pointed to the clinical usefulness of reaming. This view seemed illogical to Court-Brown and his co-workers. these being the commonest closed tibial fractures presenting to orthopaedic surgeons. ~7In the open group. 6. as the nutrient artery supplying the endosteal vasculature of the long bone diaphyses was almost certainly destroyed in severe open fractures and therefore reaming of the endosteum could have minimal effect. thereby leaving the proximal end of the nail in a prominent position. although an analysis of the fractures did not demonstrate significant differences between the two fracture groups. The effect of the laboratory studies examining vascular changes associated with reaming was to convince many surgeons that reaming would be particularly deleterious in severe open fractures where the bone blood supply was already damaged by the injury. TM Fifty such fractures were randomized to receive a reamed or unreamed nail and followed for one year. The physiological effects of reaming are summarized in Table 1. whereas the effects of soft-tissue damage in severe open fractures would obscure any positive effects from reaming. the literature contains two full studies examining the use of reaming in femoral diaphyseal fractures. Their results showed a statistical trend towards slower union with unreamed nails and a statistically higher incidence of screw breakage. It is interesting to consider whether it is the actual distraction or the associated high compartment pressure which causes the high incidence of non-union associated with fracture distraction. Four of these were presented at the 1996 meeting of the Orthopaedic Trauma Association t9 and each study found that reamed nailing produced better clinical results than unreamed nailing. which returns in a few weeks.

21They noted that. 3. Group NTI patients had no thoracic trauma but had primary nailing. as reamed intramedullary nailing had become the method of choice for the treatment of femoral fractures and was popular for the management of tibial fractures. Clinical studies clearly illustrate the value of intramedullary reaming in the primary treatment of closed femoral and tibial diaphyseal fractures. The third approach was to compare the physiological effects of nailing and other fixation methods in polytraumatized patients. The clinical usefulness of intramedullary reaming is also demonstrated if the results of exchange nailing in the management of aseptic tibial non-union are analysed. This study caused considerable consternation.1°and later demonstrated by Giannoudis et al. has an equivalenteffectin the femurand tibia. 9.23 While it is accepted that the success of primary intramedullary nailing relates to its enhancement of the periosteal circulation. 25 They found that the use of perilla ketone caused a significant pulmonary injury but that subsequent reamed intramedullary femoral nailing caused no additional significant effect on intrapulmonary shunts. They then theorized that the bone reaming products might be osteogenic as suggested by Tydings et al. it was unlikely to play a role in exchange nailing of non-unions where there was fibrous tissue between the bone ends. to show that reamed nailing of fresh fractures in patients with significant thoracic trauma was associated with a higher incidence of adult respiratory distress syndrome (ARDS). promotesunionin asepticnon-unionfollowingprimary reamedand unreamednailing. Accordingly. Duwelius et al. Firstly. 4. it was Pape et al. This technique is widely utilized by surgeons who prefer primary unreamed nailing and consists of removal of the intramedullary nail. Animal models have failed to show any association between reamed nailing and significant respiratory complications. showed that intramedullary nailing caused minimal . 2° They found that the blood loss was greater in the reamed group but this did not translate into an increased requirement for transfusion. 24 who recently stimulated interest in the orthopaedic world by undertaking a retrospective study which appeared Table2 The effectof reamingas determinedby clinicaltrials Reaming: 1. 21 They concluded that. mixed venous oxygen saturation or dynamic compliance. the authors theorized that there were three possible reasons for the success of secondary exchange nailing given that reaming damages the endosteal vasculature. performed a study of reamed femoral nailing in sheep in which an ARDSlike state had been induced using perilla ketone. undertook a retrospective study of femoral nailing but arrived at the same conclusions. Some workers examined pulmonary function in sheep and dogs while others used transoesophageal echocardiography to investigate the passage of embolic material into the pulmonary and systemic circulations of patients during intramedullary reaming. REAMING AND PULMONARY COMPLICATIONS Kiintscher originally drew attention to the possible embolic consequences of intramedullary reaming and the effects that these emboli might have on the pulmonary circulation. Their conclusion was that the fat embolization that occurs during reamed intramedullary femoral nailing in an appropriately resuscitated sheep does not have a clinically significant effect on pulmonary function even in the presence of severe pre-existing pulmonary dysfunction. However.102 Current Orthopaedics locked intramedullary nails. but that there was more heterotopic bone formation above the greater trochanter after reaming? 2 They concluded that both these observations suggested that reaming was osteogenic. a number of surgeons set out to investigate the association between reaming and respiratory complications. This technique was analysed in detail by CourtBrown et al. a substance that increases pulmonary vascular resistance without changing filling pressures. and the NTII group had no thoracic trauma and secondary nailing. doesnot havethe sameeffectin severeopenfractures. reaming the medullary canal by a further 1 mm and then inserting a larger nail.. The research followed three main paths. Group TII patients had thoracic trauma but secondary nailing performed after 24 h. while this might have an effect on the fresh fracture. Their third suggestion was that bone union was enhanced by stimulation of the periosteal circulation. 2.2 and later by Reichert et al. The incidence of ARDS and mortality was much higher in the TI group. They identified four groups of patients: Group TI consisted of patients who had significant thoracic trauma and who had reamed femoral nailing performed within 24 hours of the injury. although it was felt unlikely that this was the case.. in a similar experiment. Pape and his co-workers examined adult patients treated in the Hannover Medical School who had femoral diaphyseal fractures managed by reamed nailing and who did not die from either head trauma or haemorrhagic shock. Giannoudis et al. 7 They postulated that this was the main reason for the success of exchange nailing. they suggested that the increased stability imparted by the larger intramedullary nail might stimulate union. as suggested earlier by Danckwardt-Lillestrom. not only was the healing time after unreamed nailing prolonged. who showed that exchange nailing promoted union in all closed fractures and in all open fractures up to Gustilo IIIa in severity. stimulatesfractureunionin closedfractures. Wolinsky et al. The clinical effects of reaming are summarized in Table 2. They concluded that there was no advantage to unreamed femoral nailing.

it must be stressed that Trentz's group 29 and Wolinsky and his co-workers 25 have both pointed to the significance of the severity of injury. pneumonia and number of ventilator days. multiple organ failure. 29 They analysed 55 patients who presented with Injury Severity Scores (ISSs) of more than 15 who had femoral or tibial diaphyseal fractures. used a canine model and compared the use of plates and intramedullary nails in femoral osteotomies in dogs in which fat embolism had been induced57 They showed no differences and concluded that the method of fixation had little influence on the outcome of treatment. The patient populations were similar and the conclusion was that the use of reamed intramedullary nailing in multiply injured patients who had a thoracic injury did not appear to increase the incidence of ARDS. 3° They examined four groups of patients. Christie noted that about 10% of patients who had femoral reaming undertaken because of fracture showed moderate or severe embolic events. As with all animal work. Group II patients had significantly more ARDS and more ventilator days than Group IV patients when the raw data were analysed but. Group III patients had a significantly higher incidence of ARDS and number of days on a ventilator than Groups I and II. these researchers found it difficult to reproduce the exact clinical conditions seen in patients and their methodology can therefore be criticized. This study suggests that the degree of injury is important in determining a patient's susceptibility to ARDS and this conclusion is also supported by Wolinsky et al.8 but there was a 25% mortality and a 25% incidence of ARDS. the fractures were nailed within four days of injury. The only fatalities occurred in patients with pathological femoral deposits. In 32 patients. The second group consisted of patients who had chest injuries and had a femoral fracture treated by reamed intramedullary nailing.Intramedullary nailing: the case for reaming pulmonary dysfunction and that there was no difference between reamed and unreamed nailing?6 Schemitsch et al. He also pointed out that about 30% of the normal population can be shown to have a patent foramen ovale and these patients may develop major systemic embolic events leading to sudden death. The mean ISS in the group that was primarily 103 nailed was 21. primary external fixation and secondary nailing should be used. there were no significant differences in pulmonary function. The fourth group consisted of patients who did not have chest injuries in whom the femoral fracture was treated by reamed nailing. However. They classified the embolic events into three types according to their extent: Type 1 events showed emboli associated with clots of at least 8 cm in length. undertook a retrospective analysis of multiply injured patients in two level 1 trauma centres in the USA. The conclusion of this study was that reamed femoral nailing did not increase pulmonary morbidity in chest-injured patients. the mean ISS was 41. in most studies. also undertook a retrospective study of patients with femoral fractures treated by reamed intramedullary nailing. while the other preferred femoral plating. It is obvious that it would be virtually impossible to carry out a prospective study investigating the role of reaming in polytraumatized patients and some of the most impressive data come from a retrospective study undertaken in Switzerland by Trentz and his associates. the incidence of such events did not appear to increase in bilateral reamed femoral nailing or in patients with multiple injuries. The first group had significant chest injuries but no femoral or tibial fractures. A number of workers undertook transoesophageal echocardiography to directly assess the amount of embolic material produced by reaming and intramedullary nailing. pneumonia or death. Type 2 embolic showers showed smaller coagulative masses while type 3 showers did not show evidence of any coagulative events and were characterized by the appearance of mild non-coagulative embolic showers of fine consistency in the right atrium. while the third group of patients had chest injuries and femoral fractures treated by a method that did not involve intramedullary reaming. All of the severe embolic events were associated with femoral surgery with the most serious problems occurring during nailing of femurs with pathological deposits or in patients undergoing cemented hip arthroplasty. Bosse et al. 25 Carlson et al. under most circumstances. Their results showed that Groups I and II had a very similar incidence of ARDS. the uniformity of opinion is impressive. pulmonary embolism. However.8 but there were no deaths and no cases of ARDS. In the group treated with sequential external fixation and later nailing. although the degree of chest injury was no worse. the remaining 23 patients being treated by primary external fixation and secondary intramedullary nailing. Christie and his co-workers in Edinburgh have undertaken much of this work. However. the mean ISS of a patient population is only about 25 and it may well be that reaming does become more problematic in more severely injured patients when the ISS is above 40. Other researchers have strived to ensure that their patients had equivalent ISSs but. 28They have shown that 92% of patients have evidence of fat and marrow embolization during intramedullary procedures. Christie did not encounter anything more than mild type 3 embolic showers during tibial nailing. when the results were adjusted for the ISS. The conclusions of this study were that primary nailing is safe if the patient's ISS is below 25 but if the ISS is greater than 40. . it is possible to make an assessment of the dangers of nailing. intramedullary femoral nailing will not cause significant respiratory problems. 31 One centre favoured intramedullary femoral nailing. The conclusion of these experimental studies must be that. When this is combined with assessment of the patient's respiratory and cardiac function.

Acta Orthop Scand 1994. J Orthop Trauma 1994. Stocker R. Hughes SPF. Banit D. 29. Cortical bone blood flow in reamed and unreamed locked intramedullary nailing: a fractured tibia model in sheep. Kessler S. 10. Meek RN. A new solid unreamed tibial nail for shaft fractures with severe soft tissue injury. 314-316. The effects of femoral intramedullary reaming on pulmonary function in a sheep model. 11:59 66. Blood supply and the rate of healing of tibial fractures. Reiker~s O. Macdonald DA. Kircher M. Tscherne H. 26. Proceedings of the Orthopaedic Trauma Association. has not been shown to have an increased morbidity in clinical trials. Keating JF. Rahn BA. Parker RE et al. Tiburzi D. Blachut Pa. Martino LJ. Louisnille: Orthopaedic Trauma Association. Dwenger A. Christie J. can be shown by echocardiography to cause fat and marrow embolization in 92% of patients. 6. 31. O'Brien PJ. 8: 373-382. the results produced by Trentz 29 are impressive a n d it would seem unnecessarily foolhardy to use i n t r a m e d u l l a r y techniques in patients who present with extensive injuries associated with severe thoracic trauma. 16. 11: 14-17. The effects of reaming o n p u l m o n a r y complications are s u m m a r i z e d in Table 3. 30. A prospectiverandomised comparison of reamed and unreamed nails. 1962. Adult respiratory distress syndrome. Friedl HP. Louisville:Orthopaedic Trauma Association. Jain R. Heterotopic ossification:a comparison between reamed and unreamed femoral nailing. There would appear to be n o disadvantage to the use of nailing or r e a m i n g in m o s t multiply injured patients. Schemitsch EH. Compartment syndrome delays tibial union. Frigg R. Kyle RF. 5. Trueta J. 79A: 194 202. Turchin DC et al. Tech Orthop 1997. A canine model of fat embolism and fracture fixation. A comparative study. J Bone Joint Surg [Am] 1991. does not appear to cause significantpulmonary complications in animal experiments. A prospective study in Tscherne C1 fracture. McQueen MM. Clin Orthop 1974. 20. this will only be necessary in a very small n u m b e r of patients. 21. 79A: 334-341. 128:1-153 3. 8. A n analysis o f the data currently available does n o t s u p p o r t the view that the endosteal damage caused by r e a m i n g is sufficiently severe to discard the technique. Compartment pressures after intramedullary nailing of the tibia. Christie J. 24: 49-54. Christie J. TydingsJD. of unilateral or bilateral femur does not cause significant embolization. Reamed against unreamed nailing of the femoral diaphysis: a retrospective study of healing time. 24(3): 8~103. Giannoudis PV. 2. Hage J. Misinski M. J Bone Joint Surg [Br] i990. Schmal H. McQueen MM. Broekhuyse HM. Keating JF. Smith RM. McCarthy ID. Reaming versus non-reaming in medullary nailing: interference with control circulation of the canine tibia. 9. SchemitschEH. Verecka TE Surgeon randomised. Sadowski C. Alfred R. Furlong AJ. 4. 17. McQueen MM. J Bone Joint Surg [Am] 1997. Schopfer A. 78B: 580-583. Court-Brown CM. I f the surgeon wishes to use a n i n t r a m e d u l l a r y nail for these patients he or she should be aware of the potential problems a n d carefully m o n i t o r the patient peroperatively. The osteoinductive potential of intramedullary canal reamings. it has become clear from b o t h a n i m a l a n d clinical studies that i n t r a m e d u l l a r y r e a m i n g is associated with stimulation of the periosteal circulation a n d improved union. i n t r a m e d u l l a r y nailing should be a b a n d o n e d in favour of other fixation techniques. 25. SwiontkowskiMF. Am J Surg 1987.43: 121-i24. Regel G. 11: 89-92. J Orthop Trauma 1997. Frigg R. Injury 1997. prospective study comparing reamed versus unreamed intramedullary nailing for the treatment of unstable closed and open tibial diaphyseal fractures. 2. 23. Injury 1993. Praxis der Marknagelung. . J Bone Joint Surg [Am] 1997. Czermak B. J Bone Joint Surg [Br] 1995. Pulmonary effects of fixation of a fracture with a plate compared with intramedullary nailing. WolinskyPR. J Bone Joint Surg [Am] 1997. Court-Brown CM. 72B: 395 397. Femur fractures in chest-injured patients: is reaming contraindicated? J Orthop Trauma 1998. 28:15 18. J Bone Joint Surg [Br] 1995. Reamed intramedullary femoral nailing after induction of an °ARDSlike' state in sheep: effect on clinicallyapplicable markers of pulmonary function. Effects of graded reaming on fracture healing. I n severe open fractures. J Bone Joint Surg [Am] 1997. any advantage from r e a m i n g is more t h a n outweighed by the considerable soft-tissue problems. McQueen MM. 65: 32-36. The treatment of femoral shaft fractures using intramedullary interlocked nails with and without intramedullary reaming: a preliminary report. Kowalski MJ. Templeman DC. Injury 1993. Grogaard B. Duwelius PJ. 12: 164-168. If there is any suggestion of p u l m o n a r y problems. Skjeldal S. REFERENCES 1. The acute vascular response to intramedullary nailing: Microsphere estimation of blood flow in the intact ovine tibia. O n the contrary. Its use in aseptic tibial nonunion. Grundes O. Arch Orthop Trauma Surg 1990. 12. 18. 14. Furlong AJ. 1997. This p h e n o m e n o n has been d e m o n s t r a t e d in closed fractures a n d it is likely to occur in less severe open fractures as well. 11. Huckfeldt R. Reichert ILH. 3: 53-56. Reiker~ts O. Reamed or unreamed nailing for closed tibial fractures. Bosse MJ. Court-Brown CM. Stuttgart: Schattauer. Christie J. of femur with metastatic deposits can cause fatal embolization in 10% of patients. Finkemeier CG. Broekhuyse HM. Peter R. Mechanical effects of intramedullary reaming in pinned osteotomies in rats.104 CurrentOrthopaedics Table 3 The effect of reaming on pulmonary complications Reaming: 1. Mullins RJ et al. Kircher M. Blood flow and healing studied in rat femur. 77B: 407411. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. Martino LJ. 79A: 799-809. Pape H-C. Curr Surg 1986. 13. Sturm JA. Reaming of the medullary cavity and its effect on diaphyseal bone. Interlocking intramedullary nailing of open fractures of the tibia. Schandelmaier P. 12:169 176. Danckwardt-Lillestrom G. Lozman J. TydingsJD. 77B: 490493. 5. may be harmful in the very seriously injured patient. O'Brien PJ. Influence of thoracic trauma and primary femoral intramedullary nailing on the incidence of ARDS in multiple trauma patients. 4. 6. The coagulative effects of fat embolisation during intramedullary manipulative procedures. 105:11 26. Kaehr D. Kiintscher G. 1997.pneumonia and mortality followingthoracic injury and a femoral fracture treated either by intramedullary nailing with reaming or with a plate. Senft D. 28. Carlson DA. Meek RN. Tech Orthop 1996. Rodman GH. 3. Reamed or unreamed intramedullary for closed and open grade 1 tibial shaft fractures. 27. Trentz O. Acta Orthop Scand Suppl 1969. Lozman J. Exchange intramedullary nailing. Primary fixation and delayed nailing of long bone fractures in severe trauma. Tseherne H. 24. Klein MPM. However. MacKenzie EJ. Court-Brown CM. Viability of intramedullary canal bone reamings for continued calcification. 58: 249-252. Will E. Utfing SE. 22. 7. Acta Orthop Scand 1987. Louisville. J Orthop Trauma 1989. I n most surgeons' practice. Schmidt AM. Smith RM. Le Coultre B. Perren SM. 15. J Orthop Trauma 1998. 1997. Injury 1997. Giannoudis PV. Blachut PA. Haas N. 79A: 640-646. 28: 9-14. Alfred R. Reimer BL et al. 153:306 309. 79A: 984-996. Krettek C. J Bone Joint Surg 1996. Tornetta P. 19.