Current Orthopaedics (1999) 13, 105-112

1999 Harcourt Brace & Co. Ltd

Mini-symposium: Tibial fractures

(iv) The case for unreamed intramedullary nails

C. Krettek, R Schandelmaier, H. Tscherne

INTRODUCTION

strength) were met by changing from stainless steel to

the titanium alloys.

Intramedullary nailing of long bone shaft fractures is

a generally accepted standard treatment. The conventional 'Kfintscher nailing' technique 1 was restricted to
relatively simple midshaft diaphyseal fractures
because the stabilization was dependent on contact
between the transversely flexible implant and the stiff
bone (nailing principle). Reaming of the medullary
cavity increases the area of contact between the nail
and bone and therefore broadens the indications to
include more complex fracture patterns and more
proximal and distal shaft fractures. However, the
reaming process itself has some inherent biological
disadvantages such as an increase in intramedullary
pressure, and temperature increase 2 causing devitalization of cortical layers and bone necrosis] ,~ especially when excessively performed. The addition of
options for interlocking screws to the nail increased
the mechanical versatility of the intramedullary
implant and further increased the indications to more
proximal and distal and/or more complex fractures.
The development of small-diameter locked
intramedullary nails considerably increased torsional
stiffness of the nail but also reduced its capacity to
'adapt'. With a smaller outer diameter (as low as
9 mm) in the femur, its strength had to be reinforced
to keep the risk of implant failure as low as possible.
Both of these demands (low stiffness and high fatigue

PATHOPHYSIOLOGY OF U N R E A M E D

INTRAMEDULLARY NAILING
Local changes

The insertion of smaller diameter implants also results

in a disturbance of blood supply, but to a lesser extent
than is observed with larger implants. 4 Recently, the
susceptibility to experimental infection after reamed
and unreamed nailing was tested in an animal model.
The results showed a statistically significant higher susceptibility to infection in the group treated by reamed
nails compared to the unreamed nail group) These
findings therefore have implications on the treatment
of tibial shaft fractures with severe soft-tissue injury in
which blood supply is significantly compromised. 6
General changes

The results of ongoing multicenter studies with large

numbers of patients will help determine the actual
level of risk of pulmonary complications. However,
other advantages of unreamed nails are already
emerging. 7,8 During nail insertion, the unreamed nail
acts as a piston and forces the contents of the
medullary cavity either through the fracture gap into
the adjacent tissue or into the venous system. 9
In contrast to reaming, the passage into the canal
only happens once for an unreamed nail whereas passage into the canal is repeated many times for a
reamed nail. The chance of complications is therefore
increase& - to ream for a 14 mm universal nail, the
procedure is carried out twelve times.

C. Krettek MD, Professor; P. Schandelmaier MD; H. Tscherne

MD, Professor,Trauma Department, Hannover Medical School,

D-306623 Hannover,Germany.Tel: +49 511 532 2027;
Fax: +49 511 532 5877; E-mail:Krettek@Compuserve.com
Correspondence to: Christian Krettek

105

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Current Orthopaedics

GENERAL TECHNIQUES
PATIENT POSITIONING
Fracture table or radiolucent standard table with or
without the use of the femoral distractor are alternatives for intraoperative patient positioning for femoral
nailing. The fracture table can put skin and neurovascular structures at risk ~ and set-up time is significant, 11 while 12 avoidance of the fracture table
significantly reduces set-up time. 13In multiply injured
patients, it also allows ipsilateral and/or bilateral tibial
and/or femoral fractures to be treated with a single
positioning and draping technique) 4 A simple frame,
constructed from the tubular external fixator and 4
tube-to-tube clamps, supports the injured leg in the
padded hollow of the knee, resulting in a gross reduction by gravity. 15

The guide pin has to be perfectly positioned. If

misplaced, a second pin is inserted in the corrected
position utilizing the initial pin as a reference. Once
the starting point and direction are perfect, the malpositioned pin is removed. A sleeve protects the soft
tissues from the 13.5-mm diameter reamer.

Antegrade tibial nailing

In the tibia, a 'stab'-incision is made in line with the
medullary cavity (transpatellar approach) at the inferior pole of the patella (knee flexed >90). The proximal-anterior edge of the tibia can be easily identified
by palpating with the tip of the guide pin.
The guide pin is placed through the proximal-anterior edge of the tibia in the direction of the center of
the medullary canal, the protective sleeve is inserted
through the stab-incision, through the patellar ligament and directly onto the bone.

IMPLANT SELECTION
Templates are commonly recommended for the preoperative planning of intramedullary osteosynthesis.16
Unfortunately, there is no currently accepted magnification factor for long bones, and figures range from
10% to 20%. In a recent study, the mean magnification
factor in the femur was 1.09 and in the tibia 1.07.17
This discrepancy could result in increased operating
time, additional radiation, and the cost of a second
implant. Implant selection should be based on intraoperative clinical or image intensifier based measurements. 14
INSERTION TECHNIQUES

Surgical approach and entry point

Several textbooks 16,18recommend relatively long incisions for nail insertion. In unreamed nailing, the
approach can be much smaller for three reasons: (1)
the position of the starting hole is not identified by
direct vision; (2) soft-tissue protection from the
reamer is not necessary; and (3) clinical observation
has shown that usually only the most proximal portion of these approaches is used. Stab-incision techniques have been developed for the femur TM and the
tibia. 15In both femur and tibia, care must be taken to
place the approaches in line with the axis of the
medullary cavity. These approaches decrease the
amount of blood loss 19 which is already reduced by
unreamed nailing thereby possibly decreasing the risk
for heterotopic ossification?

Femoral antegrade nailing

In the femur, flexion and adduction of the hip joint
facilitate the approach for antegrade nailing. A 3-cm
'stab'-incision is made approximately 10 15 cm above
the tip of the greater trochanter and directed towards
it. This allows for the insertion of a palpating finger
for digital control alongside the implant.

Retrograde femoral nailing

The principles of stab-incisions and incisions in line
with the center of the distal medullary cavity are
followed (knee flexed 30). A guide-wire is centered in
line with the midline of the medullary cavity using an
image intensifier.
The starting hole for a retrograde femoral nail is in
line with the center of the distal diaphyseal medullary
cavity seen in the AP and lateral C-arm picture. Care
must be taken to avoid injury to the origin of the posterior cruciate ligament (PCL). The important landmark in the lateral view is 'Blumensaat's line', a
radio-dense line representing the cortical bone of the
roof of the intercondylar notch of the femur.
REDUCTION TECHNIQUES
The reduction of femoral fractures is usually more
difficult than tibial fractures for several reasons: (1)
thicker soft tissues and less direct access to bone; (2)
less accessible starting point; and (3) the presence of
the iliotibial tract, which tends to shorten the fracture
if the leg is adducted. The demands of the different
nailing steps almost exclude each other:

Startingpoint and nail insertion are most easily

performed with the proximal fragment in ADduction, but reduction is difficult in this position
due to shortening caused by the iliotibial tract.
Reduction would be easier in AB-duction, whilst
starting point creation and nail insertion is
impossible in the AB-ducted position.

Digital control in reduction of tibia fractures

One of the most effective and sensitive instruments for
the reduction of acute tibia fractures are fingers and
hands. In contrast to the femur, large parts of the
tibia, especially the anteromedial surface and the

The case for unreamed intramedullary nails

107

anterior crest, are located directly beneath the skin

and are easily palpated. Temporary overcorrection
during translation of the fracture zone is sometimes
advantageous and helpful in oblique fractures. With
the tip of the unreamed nail, the distal fragment can
be 'felt' during manipulation. In contrast to the tibia,
the femur is much less amenable for digital manipulation. Therefore, there is a need for reduction instruments and tools.

Reduction aids
Sling techniques. The 'towel-sling' and 'bean bag'
techniques are cheap, easy and non-invasive ways to
manipulate the main fragments. Disadvantages of this
are limited tactile feedback, limited fine regulation of
reduction forces and the need for 'additional hands'. 21

Reduction clamps. The use of reduction clamps

(Matta, King-Tong (Synthes GmbH, Bochum,
Germany)) can be percutaneously used in tibial
fractures.

Schanz screws. The use of temporarily inserted Schanz

screws is an effective way to get direct control of
the bone fragments in femoral or delayed tibial
fractures. 14,15 The three principles are: (1) placement
close to the fracture; (2) uni-cortical or out of the nail
path in the proximal fragment (antegrade nailing); and
(3) connection with T-handles for easier manipulation.

Distractor. The distractor is needed for longitudinal

distraction against high resistive forces 22 (especially
helpful in delayed cases). The need for controlling the
sagittal and frontal displacement or rotation is much
less, since the single Schanz screw tends to bend and
rotate. If a distractor is not available, a tube-to-tube
construct and a distraction tool can be used for the
same purpose.

Poller screws. Nailing of metaphyseal fractures is

associated with an increase in malaligment due to
strong muscular forces 23 and residual post-fixation
instability. 15 As there is a large difference between the
implant and metaphyseal diameters with no nailcortex contact, the nail may translate in relation to the
interlocking screws. Blocking screws, placed adjacent
to the nail, have been proposed as a possible solution
for decreasing the translation in both the tibia 15 and
the femur. TM These screws, also termed 'Poller screws'
(PSs) decrease the width of the metaphyseal
medullary cavity, physically blocking transverse nail
translation, and increasing the mechanical stiffness of
the bone-implant construct. 24 Blocking screws can be
used as: (1) an alignment tool; (2) a stabilization tool;
and (3) a manipulation tool.
If used as an alignment tool, the bone-implant construct is sufficiently stable, but malaligned (Fig 1). In
this case, the implant has to be removed temporarily
and PSs placed to prevent this malalignment. The
direction of PS placement is perpendicular to the
direction of potential implant translation.

Fig. 1 'Pollarscrew'techniquefor preventionof axial deformity.

A: Despitethe presenceof an AP screw,displacementin the
frontal plane is possiblein short distal fragmentsand poor bone
stock. The AP screw acts in these casesas a fulcrum.B: Closed
reduction and either uni- or bilateral support with 'Poller'screws
prevents angulationin the frontal plane.
If used as a stabilization tool, the bone-implant
construct with the nail in place is unstable, and may
also be malaligned. In this case, the implant may stay
in place during correction and the PS is placed in a
position of slight over-correction of the deformity.
This is specifically helpful in oblique metaphyseal fractures of the distal tibia and femur, because shear
forces become transformed to compression forces
(Fig. la,b).
If the PSs are used as a manipulation tool, the problem is the correct placement of the implant. This
method be used in situations where a previously
malplaced nail prevents placement of the new nail
into the correct position, because the nail may tend to
slip again into the old nail path. Even if a new correctly placed approach is created, the implant tends to
slip back into the previously created one. In this case
again, the implant has to be removed temporarily, the
PS is placed to block the incorrect path and the nail is
reinserted.

Sequence of locking. During insertion, unreamed nails

frequently push the distal fragment distally resulting
in fracture diastasis (increased risk of compartment
syndrome, prolonged healing and bolt breakage)? 5 In
contrast to major textbook advice, the routine
performance of distal locking first is recommended. 15
This gives the opportunity for application of the
'backstrike technique', which is performed after distal
locking, providing compression of the fracture
fragments (Fig. 2).
Intraoperative alignment control techniques
Length.

In femoral fractures, under image

intensification, the upper margin of the femoral head
is brought into line with the measuring device. This
already has the length of the contralateral femur
marked on it (upper margin of the femoral head to the

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Current Orthopaedics

!
J
t

Fig. 2 Backstriketechniquefor correction of fragmentdiastasis. A & B: Insertion of the unreamednail in the distal main fragmentresults
in diastasis. B: This is correctedwith the 'backstriketechnique': distal lockingfirst with three lockingbolts (increasingstrength). C: Careful
backstrokes under fluoroscopiccontrol until main fragments are reduced or planned length is achieved.D: Proximallocking accordingto
fracture pattern and fracture location.
lower margin of the lateral femoral condyle).
Subsequently, the amount of length correction
required is read off. By using the sliding hammer, limb
length can be continuously changed in both
directions. For other simple fractures (generally A2/3
and B2/3), there is usually no need for length
measurement and fragment positioning can be
achieved using the 'reverse coaptation' or 'backstrike'
techniqueJ 5 Clinical comparison of the length of the
tibia is much easier to evaluate than the femur and is
usually sufficiently evaluated by clinical means.

Frontal-sagittal plane. The recently described 'cabletechnique' gives adequate information about the
frontal plane axis. 26'27 With the patella-directed
anteriorly, the center of the femoral head and ankle
joint are visualized fluoroscopically and marked on
either the skin or the surgical sheets. The cautery cable
is then spanned between these two points with the
image intensifier centered on the knee joint. Using the
projection of the position of the cable, varus/valgus
alignment can be determined (Fig. 3). The sagittal
alignment is determined using a lateral fluoroscopic
image.
Rotation. (I ) Clinical assessrnent of femoral malrotation.
Preoperatively and before draping, the rotation o f the
intact limb is established with the knee and the hip
flexed at 90 . Intraoperatively, after nailing and
temporary locking of the fractured bone, rotation is
checked again. However, the insertion handle does not
allow hip flexion of 90 , therefore the handle has to be
removed prior to this test (Fig. 4).
Alternatively, with the foot of the operating table
flexed down, the examination can be done with the

Fig. 3 Cable techniquefor control of frontal plane alignment.

knee flexed at 90 , but the hip extended. This allows

the insertion handle to remain fixed to the nail and
makes secondary corrections easy. Sources of error in
this method include unrecognized positional changes
of the pelvis during surgery. These must be taken into
account.

Rotation." (2) Radiographic assessment of femoral

malrotation. Recently, several signs have been
described for the assessment of femoral rotational

The case for unreamed intramedullary nails

109

Techniques for prevention or secondary correction of

malalignment

f"

In the case of proximal or distal metaphyseal fractures, the relatively loose contact and resulting 'play'
between locking screws and nail can be used for correction of malalignment. An increase in stiffness of
the bone-implant construct can be obtained with temporary external fixator devices, Poller screws, or
plates.

Fig. 4 Clinicaldeterminationof rotation intraoperatively

depending on lockingtechniqueand position.

alignment. These include the 'lesser trochanter shape

sign', cortical step sign, and diameter difference
sign.I4.26

a. Lesser trochanter shape sign. The position of the

uninjured lesser trochanter posteromedial behind
the proximal femoral shaft has a typical
radiographic appearance in AP radiographs, which
is strongly dependent on rotation of the femur.
Preoperatively, the shape of the lesser trochanter
from the limb (with the patella directed anterior or
the leg resting free over a table hinged at the knee)
is analysed and stored in the image intensifier's
memory. Before locking the distal main fragment
(again with the patella directed anterior or the leg
resting free over a table hinged at the knee), the
proximal fragment is rotated (Schanz screw)
around the nail until the shape of the lesser
trochanter of the ipsilateral side is the same as the
contralateral shape 14(Fig. 5).
b. Cortical step sign. In the presence of a rotational
deformity, cortical structures of the proximal and
distal fracture fragments can be projected with
different thicknesses 14(Fig. 6).
c. Diameter difference sign. This sign can be positive
at levels where the diameter is oval, rather than
round. In these cases, transverse diameter of
proximal and distal fracture fragments are
projected with different diameters 14(Fig. 6).
Rotation: (3) Clinical assessment of tibial malrotation.
Similar to the femur, during clinical assessment of
rotational deformities of the tibia, the surgeon has to
be aware that the tibia can rotate in the knee joint and
that the indicator 'foot' consists of several joints. Tibial
rotation should be checked with the knee in flexion and
the foot dorsiflexed. However, besides the comparative
analysis of foot position, range and symmetry of foot
rotation has to be taken into account. 28

Callus deformation by temporary external fixation. A

temporarily applied external fixator (conventional
trans-cortical pins or pinless fixator) is used for a
stepwise correction of the deformity and its
maintenanceY
'Poller' screws. Again, analogous to the temporary
external fixator technique, the relatively loose contact
and the resulting 'play' between interlocking screws
and nail can be used as an internal solution. After
acute, single-step slight over-correction of the
deformity, re-displacement of the nail is prevented by
so called 'Poller' screws, which are bicortically placed
on one side of the nail with the help of the radioucent
drillY In the case of a malpositioned starting point,
these PSs can block the old starting point and avoid
'slipping' back of the implant or instruments.
Fibula osteosynthesis. Metaphyseal fractures with
same level fibular fractures have been shown to have
higher rates of delayed union compared to fractures at
different levels. In these cases, the stabilization of the
fibula increases the stiffness of the bone-implant
construct and helps prevent at problems with healing
and malalignment.
Implant rotation. In the case of unhealed varus or
valgus deformities, the curve in the implant
proximally can be used for correction. ~4,'5,29 After
temporary removal of the distal and proximal locking
screws, the main fragments can be rotated around the
implant to a limited degree. The locking screws are redrilled and replaced after the correct alignment is
obtained. This procedure can change both the
varus-valgus alignment and recurvatum, which may
not always be desired (Fig. 7).
FIXATION TECHNIQUES

Interlocking screws
In unreamed nailing, all fractures undergo both proximal and distal interlocking. Stable patterns are locked
in a dynamic mode (Fig. 8). Distal interlocking can be
done with a free-hand technique (radiolucent drill) or
with the help of the mechanical distal aiming device
(DAD). Proximal interlocking is performed with an
attached guide. As far as possible distal interlocking
screws should be used for the following reasons.

Toggling: due to the manufacturing process, there

are dimensional tolerances in nail interlocking

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Current Orthopaedics

Fig. 5 Intraoperative radiological determination of rotation. A: Preoperatively, before positioning the patient, the shape of the lesser
trochanter of the contralateraI side is stored in the image intensifier's memory (patella-oriented anterior). B: Before locking the second main
fragment, the patella is oriented anterior, while the proximal fragment is rotated until the shape of the lesser trochanter of the ipsilateral
side fits the contralateral shape. C: In case of an external rotation deformity, the shape of the lesser trochanter is diminished. D: In case of
an internal rotation deformity, the shape of the lesser trochanter is enlarged.

A'
Fig. 6 Other intraoperative radiological signs of rotation
malalignment. A: Cortical step sign: in the presence of a rotational
deformity, cortical structures of proximal and distal fragments can
be projected with different thickness. B: Diameter difference sign:
this sign is positive at levels, where the diameter is oval, rather than
round shaped. In these cases, transverse diameter of proximal and
distal main fragments are projected with different diameters.

holes as well as in interlocking screws. This results

in a toggling p h e n o m e n o n between screws and
nails, instability and malalignment, since the nail
can shift along the longitudinal axis o f the screw.
Screw breakage: fatigue failure is dependent on
material, design, surface finishing, cross-sectional
area as well as on the a m o u n t o f applied load and
n u m b e r o f cycles. In the vast majority o f cases,
screw breakage is without clinical consequences.
Since the distal interlocking screws are usually the
weak part o f small diameter nail systems, all
attempts should be taken to increase mechanical
strength in this area. The easiest, cheapest and
m o s t effective way is to use the full range o f
locking options in the distal end o f the nail, i.e.
three screws in the tibia and two in the femur.

Fig. 7 Implant rotation for correction of axial deformity. Bolts

have to be removed before implant rotation. Implant is rotated
according to the direction of deformity, which corrects
malalignment in the coronal (frontal) plane.

Techniques for interlocking hole placement: (1)

Radiolucent drill. The radiolucent drill ( R D ) allows
drilling under image intensifier control. Special threefluted drill bits with tips reduce the tendency to slip
off the b o n e surface.

Techniquesfor interlocking hole placement." (2) Distal

aiming device. Recently, a radiation-independent
proximally m o u n t e d distal aiming device has
been developed for unslotted intramedullary nails.
Unslotted nails have been shown to have no
significant insertion related implant torque 3. The
distal aiming device ( D A D ) is based on an aiming a r m
which is readjusted to the deformed nail t h r o u g h a
distal working channel and an asymmetric spacer? 1 In
a prospective r a n d o m i z e d study, the D A D and the
R D in the hands o f an inexperienced surgeon were
compared. In the aiming system group c o m p a r e d to
the free-hand technique, the total operation time,

The case for u n r e a m e d intramedullary nails

l 11

change o f treatment after external fixation;

pathological fractures.

[.

However, there are still several biological and

mechanical concerns about or contraindications
against nailing, which include:
infection at the entry site, medullary canal, pin
sites or fracture;
there is still ongoing discussion, regarding the
degree o f p u l m o n a r y injury (AIS>4:35; ISS > 29
and A I S > 3 : 36) above which multiply injured
patients should be stabilized by methods other
than by reamed or u n r e a m e d intramedullary nails.
If initially stabilized by external fixation, our centre
would routinely change this fixation to (unreamed)
i.m. nailing after recovery o f the patient.
fracture location, where locking bolt fixation is
insufficient.

Fig. 8 Principleof the aiming process of the DAD. A: The nail,

fixed to the insertion handle, is connected to the distal aiming arm
at a preset length. Through a stab incision, a 6-mm contact hole is
drilled. Cancellous bone is removed with an L-shaped curette. B:
An anterior spacer is inserted through the contact hole and
pressed against the nail and connected with the aiming arm. C:
Both transverse drill sleeves are centered to the transverse locking
holes. D: The lower distal transverse hole is drilled and the drill is
left in place. E: In the medial cortex, the upper transverse hole is
enlarged to 6 mm (a medial spacer is inserted). F: An expander
wire is inserted, expands the tip of the medial spacer and locks it
to the nail. G: After the anteroposterior hole has been drilled, the
holes are measured and the screws placed in the following order:
anteroposterior hole, lower transverse hole, and upper transverse
hole. H: Contact hole and screw position at the end of the locking
procedure.
distal locking time, total fluoroscopy time and screw
placement time were statistically less (Fig. 8).

Dynamization
I n the femur, d y n a m i z a t i o n o f statically locked nails is
rarely necessary2 z33 I n the tibia, routine dynamization
is r e c o m m e n d e d in c o m b i n a t i o n with b o n e graft for
certain fracture patterns with a high risk o f delayed
fracture healing. 34 It is probably preferable to
' d y n a m i z e ' the fracture during initial surgery by distal
locking first and then 'impacting' the main fragments
by gentle blows o f the h a m m e r ('backstrike technique') 14'I5(Fig. 2).

INDICATIONS AND CONTRAINDICATIONS

Recent developments o f u n r e a m e d nails in different
sizes have widened the indications for nailing in terms
o f location, fracture pattern, soft-tissue d a m a g e and
c o n c o m i t a n t injuries, including:
closed and o p e n fractures;
dia- and metaphyseal fractures;

RESULTS
The results o f our series o f u n r e a m e d femoral nails
are shown in Tables 1 and 2. Between January 1991
and December 1994 we conducted a prospective study
o f the U F N in 124 patients (133 femurs). We excluded
19 femurs which underwent a corrective osteotomy or
which were the site o f a pathological fracture, another
19 which were fixed with the spiral blade and 2 in
which we used the Miss-A-Nail system. A n o t h e r 14
fractures could not be included as the patients were
lost to follow-up. Consequently, 79 fresh fractures
formed the basis o f this study. The average follow-up
period was 18.4 m o n t h s (9-48 months).
The average patient age was 29 years (16-67 years).
There were 57 m e n and 22 women. The fractures
were classified according to the A O classification.
The majority had complex fractures: type A = 16;
type B = 40; type C = 23. There were 3 proximal shaft
fractures, 59 in the mid shaft and 17 distal.
The closed soft-tissue injury was classified as
G O / G 1 = 25, G I I = 35. The 19 open fractures were
classified according to Gustilo and Anderson: grade I

Table 1 Complications in use of unreamed femoral nails

Intraoperative complication

(%)

Femoral neck fracture

Extension fracture
Bending of bolt
Other technical difficulties
Lung embolism (favourable outcome)

3
4
2
2
1

4%
5%
3%
3%
1%

2
3
1
1
1

3%
4%
1%
1%
1%

Postoperative complications
Displacement of fracture
Breakage of boIt
Breakage of nail
Infection
Deep thrombophlebitis

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Current Orthopaedics

Table 2 Outcome of use of unreamed femoral nails

Outcome (according to Neer)

(%)

Excellent
Satisfactory
Unsatisfactory
Failure

58
14
5
2

73%
18%
6%
3%

15.

16.
17.

= 10 f r a c t u r e s ; g r a d e I I = 6 ( o p e n f r a c t u r e , skin
wound > 1 cm, soft-tissue injury limited to fracture
site); a n d g r a d e I I I = 3 f r a c t u r e s ( g r o u p O I I I A = 3,
O I I I B =1).
T i m e to c o n s o l i d a t i o n c r i t e r i a w e r e as follows: clinically stable femur, p a i n l e s s w a l k i n g w i t h o u t w a l k i n g
aids a n d solid u n i o n r a d i o l o g i c a l l y b e t w e e n at least
t h r e e o f f o u r cortices. T h e a v e r a g e t i m e to h e a l i n g w a s
12.7 w e e k s (4-31 weeks). N o p s e u d a r t h r o s e s o r ' n o n
unions' were encountered.

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