J Gandhara Med Dent Sci

ORIGINAL ARTICLE

OUTCOME OF STATIC VERSUS PRIMARY DYNAMIC CLOSED ANTEGRADE REAMED

INTRAMEDULLARY INTERLOCKING NAIL IN FEMORAL SHAFT FRACTURES:

A PROSPECTIVE COHORT STUDY

, Sajjad Haider

Kher Muhammad

, Muhammad Sarwar Khan

2 1

, Abdullah

, Zia Ullah Jan

, Aiman Ali

ABSTRACT

OBJECTIVES

This study aimed to compare fracture-healing rates in short oblique and

transverse femoral shaft fractures treated with closed antegrade reamed

intramedullary interlocking nails in static versus dynamic mode.

METHODOLOGY

A prospective comparative cohort study was conducted at Muhammad

Teaching Hospital, Peshawar, including 72 patients with femoral shaft

fractures (AO 32A2 and 32A3) and (Gustilo-Anderson I, II, IIIA) treated with

either static (Group A) or dynamic (Group B) reamed antegrade interlocking

intramedullary nails. Patients were followed for 24 weeks postoperatively.

The primary outcome was fracture-healing time, assessed using clinical and

radiological criteria.

RESULTS

The mean healing time was signicantly shorter in the dynamic group (16.6 ±

4.0 weeks) compared to the static group (19.1 ± 4.4 weeks, p = 0.019).

Healing at 24 weeks occurred in 94.4% of the dynamic group, compared with

77.8% in the static group (p = 0.035). Surgery duration was also signicantly

shorter in the dynamic group (47.3 ± 9.0 minutes vs. 54.9 ± 7.9 minutes, p <

0.001). Subgroup analysis showed faster healing in dynamic nailing for

females (p = 0.013), patients ≤40 years (p = 0.010), left-sided fractures (p =

0.049), lower third fractures (p = 0.021), and transverse fracture pattern (p =

0.008).

CONCLUSION

Dynamic intramedullary nailing is associated with signicantly faster healing

and shorter surgery duration in short oblique and transverse femoral shaft

fractures. Further multicentric studies with larger samples and extended

follow-up are warranted.

KEYWORDS: Dynamic Interlocking Nail, Femoral Shaft Fracture, Healing

Time, Static Interlocking Nail

How to cite this article

Muhammad K, Khan MS, Haider S,

Abdullah, Jan ZU, Ali A. Outcome of

Static Versus Primary Dynamic

Closed Antegrade Reamed

Intermedullary Interlocking Nail in

Femoral Shaft Fractures: A

Prospective Cohort Study. J Gandhara

Med Dent Sci. 2026;13(1):23-26.

Date of Submission:

Date Revised:

Date Acceptance:

Senior Registrar, Department of

Orthopaedic Surgery, Muhammad

Teaching Hospital

Consultant, Department of

Orthopaedic Surgery, Muhammad

Teaching Hospital

Correspondence

Sajjad Haider, Senior Registrar,

Department of Orthopaedic Surgery,

Muhammad Teaching Hospital

+92-331-9059136

haidersajjad544@gmail.com

INTRODUCTION

Femoral shaft fractures occur at a rate of 1 per 10,000

people and are typically caused by high-energy trauma,

leading to signicant morbidity and physical

impairment due to mal-alignment, limb shortening, or

prolonged immobilization

1,2,3,4,5

. The management of

femoral shaft fractures is anatomical reduction and

functional recovery of the extremity.

Operative

treatment using interlocking intramedullary nails oers

biomechanical and biological advantages and remains

the gold standard over plating and external xation,

achieving union rates near 100%.

7,8

Two intramedullary

techniques, antegrade and retrograde, are commonly

used. There remains debate over static versus primary

dynamic nailing modes and reaming versus

nonreaming.

9,10

Reamed nails are associated with faster

healing and a lower risk of nonunion.

10,11

Concerns

exist that static interlocking may hinder healing due to

stress shielding and altered biomechanics, transferring

load through the implant instead of the fracture site,

which may reduce callus formation

. Conversely,

dynamic nailing allows micromotion, encouraging bone

healing and early weight bearing, although it may be

less rotationally stable and cause limb shortening

12,13,14

This study compares static and primary dynamic

reamed intramedullary interlocking nailing techniques

for fracture healing speed in patients with short oblique

and transverse femoral shaft fractures. Given the high

volume of such cases in our center, this study aims to

provide local evidence to guide surgical decision-

making and improve patient outcomes.

22-12-2025

21-12-2025

30-09-2025

https://doi.org/10.37762/jgmds.13-1.795

January - March 2026

J Gandhara Med Dent Sci

METHODOLOGY

This prospective study was conducted in the

Department of Orthopaedics and Trauma at Muhammad

Teaching Hospital, Peshawar, after obtaining formal

approval from the Institutional Ethical Review Board.

The study duration extended from 1st July 2023 to 31st

December 2024. A total sample size of 72 patients was

calculated using the WHO sample size calculator, with

36 patients allocated to each group, based on a 90%

power of the test, a 5% level of signicance, and

previously reported mean union times of 16.11 ± 3.09

weeks for static interlocking nails and 19.37 ± 5.13

weeks for dynamic interlocking nails. Patients were

recruited using a non-probability consecutive sampling

technique. All patients presenting with femoral shaft

fractures, irrespective of the mechanism of injury, were

screened for eligibility. Inclusion criteria comprised

patients aged 18-65 years with closed fractures or open

femoral shaft fractures of Gustilo-Anderson grades I, II,

or IIIA, involving a single limb, presenting within 48

hours of injury, deemed t for surgery (ASA physical

status I or II), and willing to comply with the follow-up

protocol. Patients were excluded if they had

pathological fractures, polytrauma with multiple long

bone injuries, previous surgery on the same limb,

Gustilo-Anderson grade IIIB or IIIC open fractures,

neurovascular compromise, or if they were lost to

follow-up before completion of 8 weeks. Upon

presentation to the Accident and Emergency

Department, all eligible patients underwent initial

assessment and resuscitation in accordance with

Advanced Trauma Life Support (ATLS) guidelines.

After hemodynamic stabilization and administration of

parenteral analgesia, a detailed clinical evaluation was

performed, followed by standard radiological

assessment, including anteroposterior and lateral

radiographs of the entire femur with adjacent joints.

Fractures were classied using the AO/OTA

classification system for fracture morphology and the

Gustilo-Anderson classication for open fractures.

Closed fractures were temporarily stabilized using a

long posterior back-slab or skin traction, whereas open

fractures underwent prompt wound debridement and

intravenous antibiotic therapy prior to temporary

stabilization. All patients underwent surgery performed

by the same orthopedic surgical team using a

standardized operative technique. Closed antegrade

reamed intramedullary interlocking nailing was carried

out under image intensier guidance, with the same nail

design used for both groups. The only intended

dierence between groups was the locking method,

determined intraoperatively by the primary surgeon. In

the dynamic locking group, locking screws were placed

in the fragment closest to the fracture site, whereas in

the static locking group, one proximal and two distal

locking screws were applied. Standardized

perioperative antibiotic prophylaxis and postoperative

analgesia protocols were followed. Postoperative

rehabilitation, including physiotherapy and progression

of weight bearing, was guided by the xation mode and

individual clinical assessment. Patients were followed

up at two-week intervals during the rst month and

subsequently on a monthly basis for a total duration of

six months. Fracture healing was assessed using both

clinical and radiological criteria. Clinical union was

defined by pain-free weight bearing, absence of

tenderness, and lack of abnormal movement at the

fracture site, while radiological union was determined

by the presence of bridging callus in at least three out of

four cortices and a Radiographic Union Score for Tibial

fractures (RUST) of ≥7. To minimize observer bias, all

radiographs were independently assessed by an

observer not involved in patient management.

Statistical analysis was performed using SPSS version

25. Categorical variables were expressed as frequencies

and percentages and compared using the chi-square test,

whereas continuous variables were presented as mean ±

standard deviation and compared using independent

sample t-tests. Post-stratification t-tests were applied

where appropriate, and a p-value of less than 0.05 was

considered statistically signicant.

RESULTS

A total of 72 patients with femoral shaft fractures were

included in the study. The cohort's mean age was 39.4 ±

9.2 years, with a predominance of male patients

(62.5%). Right-sided femoral fractures were more

frequent, accounting for 62.5% of cases. The middle

third of the femoral shaft was the most commonly

involved fracture site (40.3%), followed by the distal

third (31.9%) and proximal third (27.8%). According to

the AO/OTA classication, transverse fractures (32A3)

were the most prevalent fracture pattern, observed in

51.4% of patients. Among open fractures, Gustilo-

Anderson type II injuries were the most frequent

(37.5%). Road trac accidents were identied as the

leading mechanism of injury, accounting for 59.7% of

cases. Comparative analysis demonstrated no

statistically signicant dierences between t he static

interlocking nail group (Group A) and the dynamic

interlocking nail group (Group B) with respect to age,

gender distribution, fracture side, fracture location, AO

fracture type, Gustilo-Anderson classication, or

mechanism of injury (p > 0.05 for all), indicating

baseline comparability between the two groups. At 24

weeks postoperatively, the fracture union rate was

significantly higher in the dynamic xation group

(Group B), with 94.4% of patients achieving union,

Outcome of Static Versus Primary Dynamic Closed

January - March 2026

J Gandhara Med Dent Sci

compared to 77.8% in the static fixation group (Group

A) (p = 0.035). Additionally, the mean time to fracture

union was signicantly shorter in Group B (16.6 ± 4.0

weeks) compared to Group A (19.1 ± 4.4 weeks),

demonstrating superior healing eciency with dynamic

interlocking nailing (p = 0.019). Operative duration also

diered signicantly between the two groups. Patients

treated with dynamic locking had a shorter mean

operative time of 47.3 ± 9.0 minutes, whereas those in

the static locking group had a longer operative time of

54.9 ± 7.9 minutes. This dierence was statistically

highly signicant (p = 0.001). Subgroup analysis

revealed that dynamic interlocking nailing was

associated with signicantly faster fracture healing

across several patient and fracture characteristics.

Female patients treated with dynamic xation had

significantly shorter healing times than those receiving

static xation (p = 0.013). Similarly, patients aged 40

years or younger in Group B achieved union

significantly earlier than their counterparts in Group A

(p = 0.010). With respect to fracture characteristics,

patients with left-sided femoral fractures and those with

fractures involving the distal third of the femur showed

significantly faster healing in the dynamic xation

group (p = 0.049 and p = 0.021, respectively).

Furthermore, among patients with transverse fractures

(AO/OTA 32A3), those treated with dynamic

interlocking nails had a markedly shorter mean healing

time (14.9 ± 2.8 weeks) than those managed with static

locking (18.9 ± 4.7 weeks), with this dierence

reaching strong statistical signicance (p = 0.008).

Table 1: Comparison of Fracture Healing and Surgical Outcomes

Between Static and Dynamic Interlocking Nail Groups

Parameter Group A

(Static)

Group B

(Dynamic)

P-Value

Healing at 24 weeks 77.8% 94.4% 0.035

Mean healing time

(weeks)

19.1 ± 4.4 16.6 ± 4.0 0.019

Surgery duration

(minutes)

54.9 ± 7.9 47.3 ± 9.0 0.001

Table 2: Subgroup Analysis Demonstrating Signicantly Faster

Healing with Dynamic Interlocking Nailing

Subgroup Group with Faster

Healing

P-Value

Female gender Dynamic (Group B) 0.013

Age ≤ 40 years Dynamic (Group B) 0.010

Left-sided fractures Dynamic (Group B) 0.049

Distal third femoral fractures Dynamic (Group B) 0.021

Transverse fractures

(AO/OTA 32A3)

Dynamic (Group B) 0.008

DISCUSSION

The management of femoral shaft fractures with

interlocking nails, particularly in transverse and oblique

patterns, has yielded variable outcomes in the existing

literature. Our study adds to this body of evidence,

showing a statistically signicant dierence in healing

time between static and dynamic interlocking nail

groups. Specically, the dynamic group demonstrated a

mean healing time of 16.59 ± 3.95 weeks, compared to

19.14 ± 4.40 weeks in the static group. This dierence

may be attributed to the biomechanical behavior of the

fixation modes. In static nailing, the implant functions

primarily as a load-bearing device, transferring axial

forces through the locking screws rather than across the

fracture site.

9,19

This mechanical setup can reduce callus

formation and delay the healing process

. In contrast,

dynamic nailing allows controlled micromotion at the

fracture site, promoting fragment alignment and

stimulating accelerated callus formation.

6,20,21

At the 24-

week follow-up, 94.2% of patients in the dynamic

group achieved radiographic union, compared to 77.8%

in the static group (p < 0.05), highlighting the clinical

relevance of this biomechanical dierence. Our

findings are consistent with previous studies. Khalid

and Hashmi reported excellent outcomes in 66.7% of

dynamic nailing cases, compared with 42.8% for static

nailing, aligning with our own observations. Similarly,

Qureshi et al.

13, 22

reported excellent results in 84% of

dynamic group patients and only 22% in the static

group, further supporting the benets of dynamization.

Study by Khalid et al. found earlier healing in the

dynamic group (around the 15th week) compared to the

22nd week in the static group, which closely resembles

our ndings.

Their results are supported by Khalid

and Hashmi, who reported healing times of 20 weeks

for dynamic and 24 weeks for static nailing. On the

other hand, not all ndings in literature support the

superiority of dynamic nailing. Khan and Ahmad, for

example, observed better healing outcomes in the static

group (mean healing time of 16.11 weeks vs 19.37

weeks in the dynamic group).

However, their study

involved a smaller sample size (25 patients per group)

and a mean follow-up of six months, which may limit

the reliability of their conclusions. In our subgroup

analysis, we observed that females in Group B

(dynamic) healed signicantly faster than those in

Group A. Additionally, fractures located on the left

side, in the lower third of the femur, and of the

transverse pattern (32A3) also healed faster in Group B,

with statistically signicant p-values (<0.05). These

findings further classify the impact of dynamization on

healing, depending on individual fracture characteristics

and patient demographics, and are supported by the

outcomes reported by Khalid et al.

LIMITATIONS

Outcome of Static Versus Primary Dynamic Closed

Our study has limitations, including a small sample size,

short follow-up period, and single-center design with the

same surgical team, which may limit the generalizability

of the ndings.

January - March 2026

J Gandhara Med Dent Sci

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Outcome of Static Versus Primary Dynamic Closed

CONCLUSIONS

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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Dynamic interlocking nailing resulted in faster fracture

healing and shorter surgery time than static nailing,

supporting its use in femoral shaft fractures; however,

larger multicenter studies are needed to conrm these

ndings.

Kher Muhammad

Muhammad Sarwar Khan

Sajjad Haider

Abdullah

Zia Ullah Jan

- Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical

Revision; Final Approval

- Concept & Design; Data

Acquisition; Data Analysis/Interpretation; Drafting

Manuscript; Final Approval

– Concept & Design; Data Acquisition; Data

Analysis/interpretation; Drafting Manuscript; Critical Revision;

Final Approval

– Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

– Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

Aiman Ali – Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

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