The purpose of this study is to compare the quantity of fat that is released into the venous
system (blood) by reaming the femoral canal during intramedullary nailing of the femur using
two different reaming systems.
Twenty patients who meet criteria for inclusion in this study will be assigned to one of two
groups by means of a computer-generated random number. Group A will consist of 10 patients
who undergo reaming with the Synthes reamer-irrigator-aspirator (RIA). Group B will consist
of 10 patients who undergo conventional reaming with the Zimmer Sentinel reamer.
The patient will be transported to the operating room and will undergo general anesthesia.
After correct positioning of the patient on the radiolucent table, baseline data will be
collected. This data will consist of a transesophageal echocardiogram (TEE) and arterial
A standard lateral approach to the proximal femur will be utilized. The starting point will
be identified using a guide pin and fluoroscopy using standard technique. Though the
resident may perform the approach, the attending surgeon will perform the case from the
opening of the canal with a drill through the completion of reaming. A TEE will be recorded
from the time the initial reamer engages the cortex until it is removed from the bone. A
guide wire will be passed across the fracture site and its position confirmed by
fluoroscopic imaging. The femoral canal will be reamed using either a conventional reaming
technique or the RIA device.
For conventional reaming, successive reamers will be used beginning with an 8mm end-cutting
reamer and increasing by 1.0 mm increments until cortical "chatter" is detected, then
reaming will proceed at 0.5 mm increments for two passes. This is the standard practice
using current technology. A Synthes titanium nail of the appropriate length which is 1.0 -
1.5mm less than the last reaming will be chosen for implantation. TEE will be monitored
during the pass of the first reamer and the last.
For reaming with the RIA, a reamer-irrigator-aspirator of the appropriate size based on
pre-operative evaluation of the femoral canal size will be used to perform a single pass
down the femoral canal. A Synthes titanium femoral nail of the appropriate length will be
selected for implantation. TEE will be recorded during the reaming. An arterial blood gas
will be sent after positioning of the patient, when the guide wire is passed down the
femoral canal and after the proximal locking screws are placed.
Proximal and distal locking screws will be placed in standard fashion. Wound closure and
post-operative care will be according to standard protocols.
The TEE will be evaluated in a blinded manner by two anesthesiology attendings certified to
use and evaluate the TEE. A grading system of 1 through 5 will be used, with 1 representing
little to no fat emboli and 5 representative of a large number of fat emboli. This data
will be forwarded to the principal investigator and used to fill the appropriate data sheet.
Outpatient follow-up will be performed in the usual manner, with sutures/staples being
removed at approximately 2 weeks, and radiographs being obtained at 6 and 12 weeks as the
attending physician deems clinically necessary. Follow-up for both limbs of the study will
be the same as patients not in the study who undergo femoral nailing.
- injuries include isolated or multiple trauma which includes a femur fracture
requiring operative fixation using an intramedullary nail using antegrade approach
- Adult patients ages 19-50 years old
- pathologic fractures
- femoral deformities which would preclude intramedullary nailing
- previous ipsilateral femoral nailing
- pediatric femoral fractures (<19 years old)