SUPPLEMENT ARTICLE
Intramedullary Nailing of the Femur: Current Concepts
Concerning Reaming
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Matthew I. Rudloff, MD and Wade R. Smith, MD
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Abstract: Intramedullary fixation has advanced to the standard of
care for fractures of the femoral shaft. Current controversies center on
whether to prepare the intramedullary canal by reaming, particularly
in certain subsets of patients. As understanding of the local and
systemic effects of reaming deepens, there is a role for maximizing
the benefits of intramedullary preparation before nail fixation, while
attempting to minimize the major disadvantages of this technique.
Several treatment strategies have emerged to address the downsides
of intramedullary reaming. The purpose of this review is to discuss
the history and current knowledge of intramedullary reaming with
respect to problems associated with its use and the evolution of
treatment modalities and their clinical applicability for orthopaedic
trauma care.
Key Words: ARDS, fat emboli syndrome, intramedullary reaming,
intramedullary femoral nailing, reamer–irrigator–aspirator, unreamed
nailing
(J Orthop Trauma 2009;23:S12–S17)
INTRODUCTION
Femoral intramedullary nail fixation is currently con-
sidered the ‘‘gold standard’’ for treatment of femoral shaft
fractures in the adult population. Advances in design, tech-
nique, and biologic implications have further expanded the
indications for the use of intramedullary implants.
Reports exist of intramedullary implants in use as early
as the late 19th century, in the form of bone or ivory pegs.
However, it was the work by Gerhardt Küntscher in the 1930s,
which was instrumental in the later progression to modern day
intramedullary nailing systems. His concept of endosteal
intramedullary interference fit for fracture fixation ultimately
led to development of reaming techniques, secondary to the
physiologic variation in canal diameter among the population.
This advancement permitted standardized enlargement of the
intramedullary canal for improved implant contact and the
Accepted for publication January 27, 2009.
From the Department of Orthopaedic Surgery, Denver Health Medical Center,
Denver, CO.
Disclosure: The authors report no conflicts of interest.
Reprints: Wade R. Smith, MD, Director of Orthopaedic Surgery, Department
of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock St,
MC 0188, Denver, CO 80204 (e-mail: wade.smith@dhha.org).
Copyright Ó 2009 by Lippincott Williams & Wilkins
S12 | www.jorthotrauma.com J Orthop Trauma  Volume 23, Number 5 Supplement, May/June 2009
resultant benefits of larger diameter nails. The 1950s and
1960s marked the shift from nonoperative management toward
intramedullary fixation; however, it was not until the 1980s
that the technique enjoyed widespread acceptance after the
advent of locked intramedullary nails by Klemm and
Schellmann. This innovation increased the application for
fractures beyond the isthmus as the implant design controlled
length and rotational alignment through interlocking tech-
nology, relying less on an endosteal interference fit.1
Closed intramedullary nailing with modern interlocking
implants can be performed with or without reaming. Fracture
healing of 98% has been reported with closed nailing tech-
niques. Unreamed nailing allows for better maintenance of the
endosteal circulation at the expense of smaller diameter
implants; in contrast, reamed applications permit a larger
diameter nail, resulting in stronger fixation constructs and
earlier fracture union.2 Although it is clear that interlocking
intramedullary nailing is the standard of care for fractures of
the femoral shaft, debate exists regarding technical aspects of
the procedure, particularly the role of medullary reaming with
regard to local and systemic physiologic consequences and
ultimately the impact upon clinical practice within certain
patient populations. The purpose of this review is to discuss
intramedullary reaming with respect to problems associated
with its use and the evolution of treatment modalities and
clinical advances.
BIOLOGY OF INTRAMEDULLARY REAMING
Long bone circulation is composed of 3 interactive
components. The nutrient artery arises from the peripheral
circulation, entering the diaphysis through a nutrient foramen.
These further subdivide into arteries and arterioles once within
the medullary canal. The metaphyseal circulation stems from
the periarticular plexus, penetrating the metaphysis and then
anastomosing with the endosteal supply originating from the
nutrient artery. Finally, the periosteal capillary network
comprises the remaining vascular supply. Rhinelander et al
described the vascular supply of the diaphyseal cortex. The
inner two-thirds are supplied by the endosteal arteries, whereas
the periosteum supplies the outer one-third.3 Under normal
physiologic conditions, the cortical circulation is centrifugal.
It has been experimentally shown that with removal of the
endosteal blood supply, cortical flow reverses to a centripetal
pattern.4
Intramedullary reaming has a detrimental effect on the
local environment of the medullary canal, by obliterating the
endosteal blood supply. Hupel et al evaluated cortical blood
 J Orthop Trauma  Volume 23, Number 5 Supplement, May/June 2009
flow after intramedullary reaming before interlocking nail
fixation of tibial osteotomies in a canine model. Cortical
perfusion was decreased by 83% and returned to baseline at
11 weeks after fixation.5 Smith et al6 have demonstrated that
when compared with other forms of fixation, intramedullary
implants cause significantly lower blood flow to cortical bone
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during the healing process but without any significant differ-
ence in bone remodeling. Schemitsch et al reported the effects
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of reamed versus unreamed locked nailing on the blood flow in
fracture callus and the strength of union in a sheep tibia model.
They revealed that reaming resulted in a significant decrease
of endosteal perfusion compared with the unreamed group;
however, fracture callus perfusion and strength of union were
not different whether reaming was performed or not.7 Further
animal studies have shown that reaming increases cortical
porosity, but no differences were identified regarding new bone
formation at 2, 6, or 12 weeks between reamed and unreamed
comparisons.8 In addition to the effects of reaming on cortical
perfusion, the soft tissue envelope in a fracture environment is
also altered by reaming. Animal investigations, using a frac-
tured sheep tibia model, have shown that muscle perfusion is
significantly greater after reaming.9
Cortical temperature alterations after reaming have been
described, and concerns regarding thermal necrosis and its
resultant impact on healing exist. Henry et al investigated
temperature alterations after intramedullary reaming of
cadaveric femoral and tibial specimens. Results revealed
direct correlation with temperature and incremental increase in
reamer size.10 Baumgart et al11 recommended sequential
reaming in 0.5-mm increments, well-judged utilization of hand
reamers for restricted canal diameters, and maintenance or
replacement of reamers as necessary to minimize heat gen-
eration. There exists direct correlation between temperature
elevation and amount of reaming in the tibia. Tibial canal
diameters of 8 mm reamed to greater than 10 mm showed
statistically significant temperature increases compared with
those with larger diameters, yet no thermal necrosis or osseous
healing problems were noted.12 The authors noted that reaming
a normal size canal did not seem to produce any adverse
clinical events but cautioned that preparation of smaller
diameter canals could potentially produce significant heat
production. Historically, thermal necrosis as a complication of
reaming has been implicated particularly with tourniquet
usage during reaming procedures of the tibia. Tourniquet use
has been presumed to negate the physiologic cooling effect of
blood and tissue fluid flow in the extremity. However, recent
evidence has questioned this practice. Results from a canine
study revealed similar temperature changes both with and
without a tourniquet; the authors showed that the risk of
thermal necrosis was due to the practice of intramedullary
reaming.13 In a prospective randomized trial of tibial intra-
medullary fixation, Giannoudis et al14 demonstrated transient
temperature increases (20 seconds) and no effect upon
temperature was reached whether a tourniquet was applied
when reaming at least 1.5 mm above the selected nail diameter.
Reaming has been associated with intramedullary
pressure increases and bone marrow embolization. The
intramedullary canal is characterized by a physiologic positive
pressure, which is found to be up to 65 mm Hg in humans.15
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Intramedullary Nailing of the Femur
Passage of a reamer affects intramedullary pressure, a mech-
anism analogous to a piston within a cylinder. There is
agreement that the most significant pressure spikes occur
during the primary reamer passage. Furthermore, pressure
increases are greatest when the reamer engages the distal
fracture fragment, particularly if the fracture is noncommin-
uted and proximal as there is less probability that venting can
occur through the fracture.15 Experimentally, reaming has been
associated with pressure increases ranging from 300 to 1000
mm Hg in animal models, and in clinical evaluations of
patients with femur fractures, pressures have been noted to
range from 140 to 830 mm Hg.16 Danckwardt-Lillieström
et al,17 in a microangiographic study of rabbit tibia, observed
that the increased intramedullary pressures after reaming
resulted in bone marrow occlusion of the intracortical vascular
channels, thus impairing circulation resulting in variable depth
of cortical necrosis. Wozasek et al experimentally evaluated
intramedullary pressure changes and fat intravasation after
reamed nailing using pressure monitoring and echocardiog-
raphy in a sheep model. They concluded that although reaming
significantly increased the intramedullary pressure, fat intra-
vasation was greatest during nail insertion.18 Further exper-
imental evidence suggests that marrow content embolization
was associated with the rise in intramedullary pressure and
occurred to a lesser degree with unreamed procedures.19 In
a clinical trial, Kröpfl et al exhibited a significant increase in
intramedullary pressure after reamed nailing in contrast to
unreamed procedures. Furthermore, they concluded that bone
marrow embolization correlated with the escalation of
intramedullary pressure and was less common with unreamed
nailing group compared with the reamed control group.20
Therefore, rises in intramedullary pressure after reaming
likely, in part, contribute to embolization of marrow contents.
The potential autograft phenomenon deserves mention.
Frölke et al21 displayed that 24% of intramedullary reaming
debris was deposited at an artificial gap created in the femora
of sheep. Reaming debris is composed of bone trabeculae and
bone marrow stroma, histologically. Hoegel et al22 indicated
sheep osteoblast survival after reaming in a laboratory culture.
Human reaming contents contain multipotent stem cells
capable of growth and propagation in vitro, based on recent
evidence.23 Inverse correlation exists between extent of
reaming and the viability of reaming debris, reaming to 1 mm
below the canal diameter results in a greater viable bone
mass percentage.24 Considerable increase in growth factors has
been demonstrated after intramedullary reaming. Giannoudis
et al25 recorded increased intramedullary levels of vascular
endothelial growth factor, platelet-derived growth factor-
betabeta, insulin-like growth factor-I, and transforming growth
factor-I after reaming compared with unreamed samples. The
autograft effect is likely multifactorial, taking into consider-
ation local delivery of reaming debris in combination with
increased growth factors believed to be instrumental in bone
healing.
Recent attention has focused on the biologic systemic
complications of reamed intramedullary nailing, particularly
upon the pulmonary system. Several authors have documented
bone marrow emboli in the pulmonary system through the use
of echocardiography.26–30 The pathophysiology of pulmonary
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 Rudloff and Smith J Orthop Trauma  Volume 23, Number 5 Supplement, May/June 2009
damage seems to be multifactorial. Mechanical occlusion of
the pulmonary vasculature, changes in pulmonary artery
pressure, and coagulation incited by intramedullary debris and
fat have all been proposed as potential pathways for
pulmonary damage.16,31,32 Others believe pulmonary damage
to be potentiated by detrimental effects of fat molecules upon
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the pulmonary endothelium, leading to further inflammatory
activation.16 Furthermore, Pape et al32,33 showed reaming to
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be associated with increased polymorphonuclear leukocyte
activation and triglyceride embolization in a traumatized sheep
model. The authors concluded that in the face of lung injury
and hemodynamic shock, alternative methods of fixation could
avoid further injury. Hildebrand et al34 reported their findings
that reamed nailing in a lung contusion animal model resulted
in significant increases in lung edema, pulmonary vascular
permeability, and polymorphonuclear leukocyte activation
compared with femora stabilized with an external fixator. In
contrast, other animal studies have concluded that intra-
medullary reaming caused mild transient increase in pulmo-
nary vascular resistance; however, it did not further impair
sheep in a pulmonary contusion model.35
Other authors have provided insight into the stimulatory
effect that reaming imparts upon the immune system.
Giannoudis et al36 found elevated serum interleukin (IL)-6
and elastase during nailing procedures, but there was no
statistical significance between reamed and unreamed groups.
In addition, increased IL-10 levels and decreased HLA-DR
expression have been demonstrated after reamed intramedul-
lary femoral fixation.37 Elevated prothrombin time, activated
partial thromboplastin time, prothrombin fragments,
D-dimers, and decreased fibrinogen levels after reamed
intramedullary nailing of the femur and tibia provide evidence
for alteration of coagulation and fibrinolytic mechanisms.38
Intravascular fat generates a complex interaction of immune
modulation and mechanical consequences that cumulatively
manifest as furthered pulmonary injury, which is the major
disadvantage of intramedullary reaming.
CLINICAL COMPLICATIONS ENCOUNTERED IN
FEMORAL NAILING
Fat embolism syndrome is typically characterized by
acute hypoxia, confusion, and petechial rash. It is well
established that intramedullary reaming and instrumentation
result in increased canal pressures, with subsequent extrav-
asation of marrow contents into the systemic circulation.
Schemitsch et al39 have shown that intravascular fat continues
in the circulation of the lungs, kidneys, and brain for 72 hours
after canal reaming and pressurization in their canine model.
The origin of fat emboli syndrome has been called into
question by Mudd et al40 who revealed no myeloid tissue in
lung sections of patients suffering from blunt trauma. They
concluded that soft tissue injury is the foremost source. Fat
emboli occur in approximately 90% of trauma patients,
although only 1%–5% of patients display clinical fat embolism
syndrome.41 Bilateral femoral fractures and pathologic
fractures of the femur pose higher risks for development of
fat embolism syndrome.42 Several hypotheses have been
proposed to explain the neurologic findings in patients with fat
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emboli syndrome. These include hypoxia, paradoxical
embolization, changes in the blood–brain barrier, and cerebral
edema.43,44 Additionally, activation of coagulation pathways
and microvascular occlusion are felt to contribute to the
inflammatory response through direct interaction with the
pulmonary endothelium.41
Adult respiratory distress syndrome (ARDS) is another
potential complication after intramedullary fixation of the
femur, particularly in the multiply injured patient. This
devastating acute respiratory failure is currently defined by
pulmonary edema without pulmonary hypertension and acute
onset hypoxemia (PaO2:FiO2 ratio # 200 mm Hg) by the
American–European Consensus Conference.45 With an in-
cidence of greater than 100,000 cases per year in the United
States, mortality rates range from 30% to 40%.45 Similar to fat
emboli syndrome, much attention has been focused on
whether intramedullary reaming produces a ‘‘second-hit’’
phenomenon, placing multiply injured patients at risk for end-
pulmonary damage such as ARDS. Data presented by Pape
et al46 in 1993 suggested that in patients with severe chest
trauma, there was a 33% increased incidence of ARDS and
21% mortality versus 7.7% and 4%, respectively, in trauma
patients without chest injury who underwent stabilization of
femoral shaft fractures with primary reamed intramedullary
nailing. This sparked further animal and clinical investiga-
tions, which, at times, demonstrated conflicting reports.
In a sheep model with induced pulmonary insult, Wolinsky
et al47 found no clinically significant effect of reamed
intramedullary nailing procedures when monitoring markers
of pulmonary function. Some authors maintain that reamed
intramedullary nailing is not a major cause of ARDS or
multiorgan system failure in patients with concomitant thoracic
injuries.48 In a comparison of reamed nail versus plate fixation
of femoral shaft fractures, Bosse et al49 showed no difference
with respect to ARDS, pneumonia, pulmonary emboli,
multiorgan failure, or death in patients with a chest injury.
Systemic inflammatory response syndrome is charac-
terized by an altered host systemic immune defense after
trauma, which predisposes to increased vulnerability to infec-
tion, sepsis, and organ failure. Increased understanding of the
body’s physiologic response to trauma has led to development
of the first- and second-‘‘hit’’ models. Patients sustaining
severe trauma (first hit) are therefore theoretically in danger of
further systemic insults (second hit) from a variety of stresses
including prolonged surgical procedures. This massive hyper-
inflammatory response is orchestrated through complex
interactions and activations of the innate immune system,
which can result in unbiased injury to host tissue after severe
trauma.50 With respect to intramedullary nailing, reaming has
been postulated as the causative agent in intramedullary
pressurization, fat embolization, and subsequent activation of
immune mechanisms. Authors have correlated elevated IL-6
levels and systemic inflammatory response score with greater
risk for systemic complications and are useful additions to
clinical assessment in polytraumatized patients.51 Further-
more, increased IL-6 levels have been demonstrated locally
after intramedullary reaming.52 The feasibility of routine
serum monitoring of these inflammatory markers is yet to be
determined.
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 J Orthop Trauma  Volume 23, Number 5 Supplement, May/June 2009
Traumatic brain injuries account for significant mor-
bidity and mortality among trauma patients, and these patients
pose a dilemma with regard to femoral fracture fixation as
well. Controversy exists regarding optimal timing for fracture
care in this patient population. Stahel et al53 cautioned that
patients with brain injuries are particularly susceptible to
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further insult precipitated by hypotension or hypoxia, and
therefore, a damage control approach is advocated. These
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second hits may be in the form of early definitive fracture
fixation. In contrast, other authors recommend early total care
with intramedullary nailing during the first 24 hours after
injury, citing no increase in neurologic disability.54,55
EVOLUTION OF VARIOUS TREATMENT
MODALITIES TO ADDRESS CLINICAL
PROBLEMS WITH REAMING
Skeletal traction deserves historical mention as a defini-
tive treatment option. Traction is associated with prolonged
hospitalization, increased costs, malalignment, extended time
to union, and complications stemming from extensive bed rest.
There are no current universal indications, in the adult popula-
tion, for treatment of femoral shaft fractures to union with
traction. Its application may permit temporization until defini-
tive fixation is achieved, but its use confines patients to bed and
makes general care difficult. With the accepted benefits of
early mobilization, operative stabilization has decisively
surpassed the routine use of traction for definitive treatment.
Reaming permits enlargement of the intramedullary
canal in preparation for a larger diameter nail than would be
otherwise possible. Controversy exists regarding the systemic
consequences of reaming, and this has fostered discussion of
the advantages and disadvantages of intramedullary prepara-
tion. Proponents argue that reaming is advantageous because it
allows for larger diameter implants and theoretical ‘‘auto-
grafting’’ at the fracture site. Larger nails provide greater
torsional and bending rigidity, have better stability as a result
of greater canal fill, and decreased time to union.1 Tradi-
tionally, stainless steel unreamed nails were of small diameter
and therefore had a higher probability of implant failure from
decreased biomechanical properties. Clatworthy et al com-
pared 23 patients without reaming and 22 with reaming. All
nails were 10 mm in diameter, and a 13% implant failure rate
was discovered, recommendations were offered for larger
diameter nails to minimize this complication.56 A multicenter,
randomized, prospective study by the Canadian Orthopaedic
Trauma Society compared nonunion rates between femoral
nailings performed with and without reaming. Their data
revealed a 4.5 times greater chance of nonunion when reaming
was not employed.57 Others have shown a decreased healing
time, reaming averaged 20.5 weeks and, in contrast, non-
reamed healing with a mean of 26.9 weeks.58
Nonetheless, unreamed nailing has gained popularity
secondary to the potential deleterious systemic effects of
reaming the canal. Increases in intramedullary pressure and
subsequent fat embolization are major drawbacks to the
reaming process. In an isolated injury, this may not upset
the immune balance and no untoward systemic effects may
be realized. In multiply injured patients who have already
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Intramedullary Nailing of the Femur
sustained a substantial ‘‘first hit,’’ avoidance of reaming might
minimize hyperstimulation of a primed immune system after
trauma. Therefore, in certain instances, the risk to benefit ratio
must be contemplated to determine whether a surgeon is
willing to accept minimizing systemic risks at the expense of
prolonged healing and increased likelihood of nonunion.
Reaming results in elevated temperature and pressure
within the intramedullary cavity, which may adversely affect
bone healing. Advancements in reamer understanding led to
design improvements in an effort to minimize complications.
Biomechanical data have shown that that blunt reamers cause
increased positive and negative intramedullary pressure peaks,
increased torsional strain, and 2.8 times greater cortical heat
generation.59 Typically, the thermal energy generated during
reaming is below the threshold that produces bone necrosis.60
In addition, mechanical loading of the femur is optimized by
using narrow reamer shafts, long lead head taper, and enlarged
cutting flutes.61 The design features reduced intramedullary
pressure by 37% and as high as 58% with hollow reamers in
biomechanical experiments.62 Addition of a flexible narrow
drive shaft further reduces intramedullary pressure.63 Reaming
to a lesser degree or with smaller diameter reamers does not
avoid intramedullary pressure increases.64 Data also suggest
that reaming at slow driving speeds and high revolutions
results in the least intramedullary pressure increase.65
Reduction of intramedullary pressure gave way to inves-
tigations centered on suction and venting of the canal during
reaming, in hopes to reduce pressure and ultimately the
embolic load inherent in standard reaming practices. Intra-
medullary pressure is dependent upon the flow rate of the
medullary cavity contents, as the reamer/canal relationship
functions as a hydraulic piston, as described by Stürmer.64
Venting, examined in animal studies, decreases canal pressure
during reaming, yet the clinical effectiveness for trauma patients
remains unknown as the pressure threshold for embolization
of marrow contents in humans is yet to be established.66,67
Intramedullary viscosity was reduced by the irrigation–
suction technique, resulting in a significant decrease in canal
pressures.64,68 Joist et al69 discovered significantly less pul-
monary resistance, intravenous fat, and lower pulmonary fat
load histologically with a rinsing–suction reamer.
Building on the success of medullary irrigation and
suction, development of the reamer–irrigator–aspirator (RIA)
(Synthes, Paoli, PA) ensued in the 1990s,70 designed as a
single-pass reamer with capability to irrigate and simulta-
neously aspirate reaming debris for collection.70 Husebye
et al71 exhibited significantly decreased intramedullary pres-
sures with RIA compared with a standard reamer. In contrast,
Higgins et al72 generated greater pressures with RIA applica-
tion, which the authors attributed to possible outflow obstruc-
tion. Biomechanical data suggest that, despite no differences
in healing, callus formed from RIA aspirates resulted in
marked improvement in stiffness and strength.73 Pape et al
compared standard reaming and RIA with regard to pulmonary
dysfunction of lung-injured sheep receiving intramedullary
fixation. The RIA cohort demonstrated no significant increase
in polymorphonuclear leukocyte activation or D-dimer levels,
concluding that evacuation of the canal debris minimizes fat
intravasation and the associated systemic alterations upon
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 Rudloff and Smith J Orthop Trauma  Volume 23, Number 5 Supplement, May/June 2009
immune and coagulation pathways, which are implicated in
end-organ damage after trauma.74
Introduction of the RIA has impacted the practice of
intramedullary nailing. Although it is not in routine use for
femoral nailing procedures, RIA may prove advantageous for
certain applications. Its role as a bone graft harvester is now
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becoming a viable alternative to traditional autograft proce-
dures.70 Experimentally, aspiration of the medullary canal
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results in decreased intramedullary pressure and lower emboli-
zation of marrow contents. Given the inflammatory potential
for extravasated intramedullary fat, RIA may serve as an
alternative to standard reaming for femoral fracture fixation in
patients at risk for systemic complications, but maintaining the
benefits of a reamed intramedullary device. However, validity
of this function clinically remains to be determined.
CONCLUSIONS AND SUMMARY OF BEST
PRACTICES FOR INTRAMEDULLARY
FEMORAL NAILING
Reamed intramedullary fixation has matured into the
treatment of choice for femoral shaft fractures. With regard to
reaming, it is imperative that surgeons pay close attention to
technique and the equipment, always considering the biologic
implications both locally and systemically. Reaming should be
performed at slow driving speeds and high revolutions with
sharp reamer heads to avoid inadvertent intramedullary heat
and pressure generation. Routine use of RIA, though
theoretically advantageous, has yet to be thoroughly inves-
tigated in prospective randomized studies and cannot be
recommended for routine fracture care.
The ideal algorithm for femoral shaft fractures should
adhere to several principles based on current literature.
Orthopaedic clinical evaluation of injured patients requires
identification and understanding of injuries outside the
musculoskeletal system. The general condition of the patient
after trauma needs to be kept in mind during clinical decision
making regarding fracture fixation. For the isolated fracture,
surgeons should subscribe to a treatment algorithm of early
total care as this has been shown to be beneficial. In the
multiply injured patient, however, caution must be exercised to
ensure that further injury caused by iatrogenic intervention be
minimized. Therefore, in the face of multisystem trauma,
identification of the ‘‘at risk’’ patient is paramount. In these
circumstances, damage control with temporary stabilization by
external fixation allows for further resuscitative efforts before
definitive treatment.
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