Closed Intramedullary Nailing Research Articles

Evaluation of Functional Outcome in Adults with Fracture Shaft of Femur Treated by Close Intramedullary Interlocking Nail

Evaluation of Functional Outcome in Adults with Fracture Shaft of Femur Treated by Close Intramedullary Interlocking Nail

Comparison of Closed Intramedullary Nailing and Percutaneous Plating in Distal Tibia Metaphyseal Fractures

Objective: To compare the closed intramedullary nailing and percutaneous plating in distal tibial metaphyseal fractures. Study Design: Retrospective study Place and Duration of Study: Department of Orthopaedics, Sialkot Medical College, Sialkot from 1st July 2019 to 31st December 2021. Methodology: One hundred patients who were suffering from distal metaphyseal fractures of the tibia bone were enrolled. Group A patients underwent closed intramedullary nails while group B were those who were treated through percutaneous plating. Prophylactic antibiotics were given to all enrolled patients until 24 hours’ completion of the surgery. Follow-up of the wound was done from day fifth of the surgery and removal of sutures was performed by 15th day of surgery. Patients were followed up for one and a half year for their AOFAS scoring. Results: There were 58.3% males in Group A presenting a majority while in Group B females were having a majority with 47.5%. There were more left side fractures such as 53% and treated with closed intramedullary nails than through percutaneous plating. There was not a significant difference in the pain, function or alignment in both groups. There were 87% patients in group A which requested implant removal after 15.5 months while 92% of patients from Group B demanded the same. Conclusion: Intramedullary nailing is slightly superior that have reduced post-operative wound complications as compared to plate fixation. Keywords: Nailing, Plating, Fractures, Surgical procedures

One-Stage Closed Intramedullary Nailing for Delayed Femoral Fracture in Multiple Injured Patients.

ObjectiveTo tackle the challengeable dilemma of delayed femoral fracture, a technique of fixator‐assisted closed reduction and intramedullary nailing at one stage was introduced herein and its clinical results were investigated.MethodsA retrospective study was conducted on delayed femoral shaft fracture between February 2008 and January 2017. The multiple injured patients aged from 18 to 60 years with delayed femoral fracture was included. All patients were treated by one‐stage internal fixation technique and followed up for more than 1 year. Outcome measures including the operation time, intraoperative blood loss and limb alignment, healing time of fracture, visual analog scale (VAS), and range of knee motion were recorded and evaluated.ResultsA total of 13 patients (16 sides) with a mean injury severity score (ISS) of 32.77 ± 9.98 (range, 19 to 52) participated in the investigation. The median length of time‐after‐fracture was 38 days (range, 21 to 110 days). The average shortening distance of the fracture ends was 35.48 ± 19.24 mm (range, 10.00 to 79.00 mm). The average surgery time was 192.19 ± 29.38 min for unilateral femoral fracture, with blood loss of 587.50 ± 232.02 ml. The postoperative discrepancy of lower limb was 3.87 ± 2.52 mm. No patient had vascular and neurologic complications due to the lengthening. All fractures healed successfully with a mean time of 2.98 ± 0.57 months. The mean VAS and maximal knee flexion were 1.63 ± 1.09 and 131.25° ± 5.32° at final follow‐up, respectively.ConclusionsOur findings indicated that fixator‐assisted closed reduction and intramedullary nailing at one stage is an effective treatment for delayed femoral fracture with satisfactory functional recovery.

Unusual Occurrence of Incarceration and Breakage of the Coiled Shaft of the Intramedullary Reamer during Closed Intramedullary Nailing of Tibia.

Introduction:Intramedullary (IM) nailing is a well-established method of treating closed tibia shaft fracture. We hereby describe an unusual incidence of the incarceration of the flexible IM reamer in the distal fracture fragment with breakage of the coiled shaft of the reamer in the proximal third of tibia during closed IM nailing. This case report highlights the usefulness of making a small window in the tibia to aid retrograde removal of incarcerated reamer.Case Presentation:A 26-year-old male patient had road traffic accident and sustained a close fracture of the right distal 3rd tibia along with segmental fracture of the adjacent fibula. The tibia nailing was done under combined spinal and epidural anesthesia. The proximal tibia was approached by a midline incision with splitting of the patellar tendon. The reduction of the fracture fragments was done and the guide wire was inserted. The medullary canal was narrow and hence the initial reaming was started with the smallest available, that is, 8 mm reamer. After crossing the fracture site, we noticed that reamer coiled shaft got broken into multiple pieces in the medullary cavity at proximal 3rd tibia. The fracture site was exposed and a linear osteotomy was done in distal tibial fragment. Through this window, the broken reamer was pushed in the retrograde manner and was delivered out. Most of the broken metal pieces of the reamer shaft were removed with pituitary rongeur. An 8 mm solid IM nail was passed in antegrade manner across the fracture site and was locked distally and proximally. The operative wounds were irrigated and closure was done in layers. The patient was allowed partial weight bearing at 3 weeks post-surgery with gradually progressing to full weight bearing at 10 weeks after confirming clinical and radiological union.Conclusion:To handle this unusual occurrence one needs to stay calm, make a small window to aid retrograde removal of reamer and remove the fragmented pieces of the coiled shaft of the reamer. In tight medullary canal, it is desirable to have smaller diameter reamers, that is, 6 mm during the surgery.

Union in Fracture Tibia Managed with Closed Intramedullary Interlocking Nail, Our Hospital Results

Introduction: The purpose of this research was to present our hospital results in union of fracture Tibia managed with close intramedullary interlocking nail.
 Methods: This research was carried out at Liaquat University of Medical and Health Science Jamshoro Pakistan from June 2020 to June 2021. A total of 250 patients with a closed tibial shaft fracture were recruited from the emergency room and outpatient clinics for this study. Our study's clinical outcomes were categorized as union, nonunion, delayed union, or malunion based on the criteria. All of the patients were given anesthesia, either general or spinal. All of the patients were tracked for a period of nine months.
 Results: In 90–150 days, about 88 percent (220/250) of patients had union, with a mean of 110.68. Union occurred in 11.2 percent (28/250) of patients in 95–109 days, with a mean of 103.38. There were 7.2 percent (18/250) delayed unions and 4.8 percent (12/250) non unions treated with dynamization and bone transplant. The outcomes were outstanding in 88 percent (220/250) of the patients and good in 7.2 percent (18/250). Our patients all had full range of motion in their knees and ankles at the time of their examination.
 Conclusion: We found that this approach is beneficial due to early mobilization (early weightbearing), reduced complexity, good outcomes, and low cost.

Is mini-open intramedullary nailing an effective intervention for adult femoral diaphyseal fractures in odd hours? A prospective case-control functional outcome and radiation safety study.

Closed intramedullary (IM) nailing among various modalities is one of the commonest sought out procedure in current practice for management of femoral-diaphyseal fractures (FDF) following trauma. However, it has some limitations like prolonged procedural duration, high radiation exposure and a steep learning curve. Therefore, with limited resources in odd hours and at a high patient turnover center where closed reduction can be a challenge, we adopted a modified mini-open technique which can overcome the limitations of closed reduction technique. To compare the closed IM nailing and mini-open technique in FDF in terms of radiation exposure, surgical duration, radiological and functional outcome. A total of 100 patients (118 femurs) with FDF (AO 32A1-B2) operated in odd-hours (20:00-06:00 hrs. GMT +5.30) with closed (Group I, n=62) or mini-open (Group II, n=56) IM nailing technique between September 2018 to December 2019 with a minimum follow up of 12 months were included in this study. The functional outcomes were measured using Thoresen scoring system and statistical analysis were performed using paired t-test and χ2 -test. The overall mean patient age was 33.5 years (18-74 years). The mean surgical duration, c-arm shoots for reduction and radiological union time were 71.5 minutes, 21 shoots and 16 weeks, respectively for group I and 47.5 minutes, 9.4 shoots and 18 weeks for group II. There was significant difference between the two groups in mean surgical duration (p<0.05) and c-arm shoots (p<0.05). However, there was no statistical significant difference between time for union, rate of union, functional results and incidence of superficial or deep infection between the two groups. In conclusion, mini-open technique is a safer alternative in patients with FDF at high-volume centers and in odd-hours when the available resources are limited.

To study the results of humeral Enders nail in diaphysial fracture of humerus

Introduction: It is generally admitted that most humeral shaft fractures can be managed successfully by non-operative methods. Whenever operative treatment is required, a choice has to be made between plate osteosynthesis and intramedullary nailing. Fixation with plates requires extensive dissection and is complicated by the proximity of the radial nerve and the risk of mechanical failure in osteopenia bones. Biomechanically intramedullary nail is a better implant. They are subjected to smaller bending loads and are less likely to fail by fatigue, they act as load sharing devices, stress shielding with resultant cortical osteopenia is minimum, refracture after implant removal is rare and they do not require extensive exposure Methods: We have done a prospective study of 30 patients with Fracture shaft Humerus stabilized with intramedullary nail of Enders type by antegrade approach. These nails were available in 3 & 3.5 mm diameter and in lengths ranging from 18-28 Cms. The nail by design had proximal band of 6 degrees (apex medial band) to accommodate offset of the infusion portal with the medullary canal. Results: Study shows more incidences of Humerus fractures in young patients as it is active age group in the society, more prone to vehicle accidents and falls. Most of the fracture of shaft humerus unites in 10-14 weeks and in minor cases more than 18 weeks were observed for union. Most common complication associated with operative method of fracture shaft humerus is non union. Joint involvement in form of shoulder or elbow stiffness can occur in small number of cases. There are no cases of infection noted in our study Interpretation and Conclusion: Internal fixation by close intramedullary nail for fractures involving middle two third shaft of humerus is a good technique if facilities are provided for image internsifier machine in operation theater. In comparision to other operative techniques close intramedullary nailing is less invasive with minimal blood loss and hardly any chance of infection. This technique gives rotational as well as torsional stability to fractured bone humerus, allowing faster practice of physiotherapy to achieve full range of motion and power.

System integration of a fluoroscopic image calibration using robot assisted surgical guidance for distal locking process in closed intramedullary nailing of femur

&lt;span&gt;Distal locking procedure is one of the most complex tasks in close intramedullary nailing operation which requires fluoroscopic image to interpret 2-D distal locking position on image related to 3-D distal locking position on the patient site. Hence the surgeon has to perform the distal locking process by using multiple fluoroscopic images which causes a lot of x-ray exposure to the patient and surgeon and is a time consuming task. This paper presents the system integration of a fluoroscopic image calibration using robot assisted surgical guidance. The system integration consists of three parts; distal locking recovery, fluoroscopic calibration and tracking, and robot assisted surgical guidance. The distal locking-hole recovery algorithm is based on characteristic information of the major and minor axes of distal locking hole. The fluoroscopic calibration and tracking is modeled as pin-hole projection model to estimate a projection equation based on optical tracking system. The robot-assisted surgical guidance is developed to overlay a trajectory path using a laser beam for reducing the problem of hand – eye coordination on most surgical navigation system. We integrate each part to complete a surgical navigation system for distal locking process. The experiment of system integration is conducted to validate the accuracy of distal locking axis position and orientation. The results of the system integration shows a mean angular error of 1.10 and mean Euclidean distance in X-Y plane error of 3.65 mm.&lt;/span&gt;

A comparative non-randomized study between locking compression plate and intramedullary nail-in the management of distal tibial fractures

37.8% of tibia fractures occur in the distal tibial region. Due to the poor soft tissue envelope and precarious blood supply in the distal tibial region, there is a very high incidence of complications like non-union, delayed union and wound dehiscence, with increased secondary procedure rate especially after implant failure. Literature review shows that there is no optimal treatment (implant) for the management of these fractures. Nailing provides lesser chances of wound dehiscence but fails in providing adequate stability. Compression plating provides increased complication due to bulky implants causing wound dehiscence. Some of it is offset by locking compression plate. Hence we decided to study which implant would be ideal to treat these fractures with the best functional outcome and low incidence of complications.This was a prospective study of 72 patients who had unilateral, displaced fracture of distal tibia. 41 patients where managed with intra-medullary interlocking nailing and 31 patients were managed with locking compression plate osteosynthesis.The incidence of complications was found to be higher in nailing when compared to that of plating. 2 of patients developed non-union in nailing. 4 of patients developed implant failure and required secondary procedures in nailing group when compared to 1in LCP group which was attributable to poor biomechanical construct.25 age matched pairs of patients were selected from each group and were assessed with the help of modified Klemm and Borner scoring system. Based on this scoring system the results were analyzed for the study group. Patients in the locking compression plate osteosynthesis group yielded scores that were significantly higher than the nailing group and were found to be statistically significant with a p value of < 0.05. 76% had excellent results, 16% had good results and 4% had fair results in the plating group when compared to 24% excellent results, 40% good results, 20% fair results and 16% poor results in the nailing group.The results of current study show statistically advantageous for locking compression plate osteosynthesis when compared to close intramedullary interlocking nailing for distal third of tibia fractures. With decreased incidence of complications &secondary procedure in LCP group. Particularly in MIPPO with LCP group did much better as no secondary procedures were required. A multicentric study with large population is necessary to confirm this.

Radiation Exposure to the Surgeon, Surgical Assistant, and Scrub Nurse During Closed Intramedullary Nailing of Long Bones-Does It Vary Depending on the Experience of the Surgeon?

To assess radiation exposure (RE) to the surgical team and fluoroscopy time (FT) during closed nailing of long bone fractures performed under fluoroscopic guidance with regard to surgeon's experience. Prospective observational study. Level-1 trauma center. Surgical team, comprising a surgeon, a surgical assistant, and a scrub nurse, for closed nailing procedures performed in 202 consecutive closed tibial and femoral diaphyseal fractures. Dosimeter provided to each member of surgical team. Surgeon experience level (trainee, senior registrar, and consultant). RE (microsieverts) to the surgical team and FT (minutes) were recorded from the dosimeter and fluoroscopic unit, respectively, and correlated with surgeon's experience. In tibial nailing, mean RE (in µSv) per procedure to surgeon, surgical assistant, and scrub nurse was 15.2, 9.2, and 2.0 for trainees, 14.5, 8.1, and 1.6 for senior registrars, and 13.6, 7.4, and 1.5 for consultants, respectively. In femoral nailing, mean RE per procedure to surgeon, surgical assistant, and scrub nurse was 181.6, 113.6, and 37.1 for trainees, 110.1, 66.7, and 20.4 for senior registrars, and 79.9, 30.9, and 12.5 for consultants, respectively. RE to the surgeon was highest followed by surgical assistant and scrub nurse irrespective of operating surgeon's experience in both tibial and femoral nailing (P < 0.001). In tibial nailing, there was a significant difference in FT only for the stage of guide wire passage (P = 0.041), whereas in femoral nailing, total FT (P < 0.001), nail entry verification (P = 0.02), guide wire passage (P = 0.013), nail introduction (P = 0.006), and distal locking (P < 0.001) showed a significant difference. RE was maximum for operating surgeon and least for scrub nurse irrespective of operating surgeon's experience in both femoral and tibial nailing. FT and RE to the surgical team decreased with increasing experience of the surgeon in femoral nailing. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Characteristics and Surgical Outcomes of Intertrochanteric or Subtrochanteric Fractures Associated with Ipsilateral Femoral Shaft Fractures Treated with Closed Intramedullary Nailing: A Review of 31 Consecutive Cases over Four Years at a Single Institution.

PurposeTo evaluate the clinical characteristics of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures and assess the surgical outcomes of a novel, closed intramedullary nailing surgical approach designed to minimize fixation failure.Materials and MethodsBetween May 2013 and April 2017, 31 patients with intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures treated with closed intramedullary nailing or long proximal femoral nail antirotation (PFNA) were enrolled in this study. Preoperative data included age, sex, injury severity score, body mass index, location of shaft fracture, injury mechanism, accompanying traumatic injury, walking ability before injury, and surgical timing. Perioperative outcomes, including follow-up period, types of intramedullary nails, number of blocking screws used, operation time, and blood loss were assessed. Radiologic outcomes, including union rate, time from surgery to union, and femoral shortening, and clinical outcomes, including hip flexion, walking ability, and Harris hip score were also evaluated.ResultsA total of 29 unions (93.5%) were achieved. The time to union was 16.8 months (range, 11–25 months) for hip fractures (15.7 weeks for intertrochanteric fractures and 21.7 weeks for subtrochanteric fractures) and 22.8 months for femoral shaft fractures. There were no significant differences in surgical outcomes between the two groups except for type of intramedullary nail.ConclusionClosed intramedullary nailing in the treatment of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures may be a good surgical option. However, fixation of femoral shaft fractures might not be sufficient depending on the implant design.

Titanium elastic nailing in shaft femur fracture in paediatric patients

Background: Paediatric shaft femoral fracture can be treated either conservatively or by internal fixation. Complications inherited with cast management and advantages of the intramedullary nailing in long bone fracture, resulted in increased use of this technique for paediatric shaft femur fracture. We conducted a retrospective study of the patients treated with close intramedullary nailing by using titanium elastic nail in shaft femur fracture for paediatric patients.Materials & Methods: During 2013 and 2016, we have conducted a retrospective study of 40 diaphyseal fractures of femur using closed titanium elastic nail (TEN), in paediatric patients(24 male and 16 female). Patients’ evaluation was done using Flynn criteria, resumption of school and associated complications.Results: With minimum follow-up period of 6 months, 92.5% of the patients had shown radiological union by 4 to 6 weeks with resumption of school by 8 weeks. According to Flynn criteria, excellent results were achieved in 31 (77.5%) patients, good result in 8 (20%) and poor result was present in 1(2.5%) case.Conclusions: Titanium elastic nailing in paediatric patients with shaft femur fracture is a safe, simple and reproducible technique with minimum complications, leading to early return to preinjury level with minimum morbidity.

Closed intramedullary nailing with percutaneous cement augmentation for long bone metastases.

The purpose of the study was to investigate whether closed intramedullary (IM) nailing with percutaneous cement augmentation is better than conventional closed nailing at relieving pain and suppressing tumours in patients with metastases of the femur and humerus. A total of 43 patients (27 men, 16 women, mean age 63.7 years, standard deviation (sd) 12.2; 21 to 84) underwent closed IM nailing with cement augmentation for long bone metastases. A further 27 patients, who underwent conventional closed IM nailing, served as controls. Pain was assessed using a visual analogue scale (VAS) score pre-operatively (pre-operative VAS), one week post-operatively (immediate post-operative VAS), and at six weeks post-operatively (follow-up post-operative VAS). Progression of the tumour was evaluated in subgroups of patients using F-18-fludeoxyglucose (F-18-FDG) positron emission tomography (PET)/computed tomography (CT) and/or bone scintigraphy (BS), at a mean of 8.8 and 7.2 months post-operatively, respectively. The mean pain scores of patients who underwent closed nailing with cement augmentation were significantly lower than those of the control patients post-operatively (immediate post-operative VAS: 3.8, sd 0.9 versus 6.0, sd 0.9; follow-up post-operative VAS: 3.3, sd 2.5 versus 6.6, sd 2.2; all p < 0.001). The progression of the metastasis was suppressed in 50% (10/20) of patients who underwent closed nailing with augmentation, but in only 8% (1/13) of those in the control group. Percutaneous cement augmentation of closed IM nailing improves the relief of pain and limits the progression of the tumour in patients with metastases to the long bones. Percutaneous cement augmentation while performing closed IM nailing has some advantages for long bone metastases. Cite this article: Bone Joint J 2016;98-B:703-9.

Intermittent low-dose administration of recombinant human parathyroid hormone (1-34) promotes the expression of Osterix during early stage of fracture healing

Objective To study the effects of intermittent low-dose administration of recombinant human parathyroid hormone (1-34) [rhPTH(1-34)] in the expression of Osterix (Osx) during early stage of fracture healing. Methods Forty-eight 2-month old male Sprague-Dawley rats were underwent close unilateral femoral fracture and intramedullary nail fixation. The subjects were divided into 2 equal groups randomly: treatment group undergoing subcutaneous injection of rhPTH(1-34) 10 mg/kg/d immediately after the operation and control group undergoing subcutaneous injection of normal saline of the same dose. Six rats in each group were sacrifice at 2, 7, 14, and 21 days after operation. X-ray photography study was conducted at 7, 14 and 21 days. Tissue RNA and protein were extracted from the bone tissues of bilateral femurs and the expression levels of Osx mRNA and protein were evaluated via real time quantitative PCR and Western-blotting. Results Fracture healing was significant at 14 days after operation, and the progress of fracture healing was better in the rhPTH(1-34) group than in the control group at 14 and 21 days. The relative expression of Osx mRNA and protein in the fractured femurs of the rhPTH(1-34) group (5.02±0.5 and 10.03±0.8 for Osx mRNA, 3164.03±131 and 3509.02±126 for protein) at 14 and 21 days after the operation were significantly higher than those of the control group (2.30±0.4 and 4.01±0.7 for Osx mRNA, 1053.04±121 and 2721.03±123 for protein). However, there was no significant difference at 2 and 7 days after operation between the rhPTH(1-34) and control group. Conclusion Intermittent low-dose administration of rhPTH(1-34) up-regulates the expression levels of osteogenesis-specific Osx mRNA and protein in rats. It will accelerate the early phase of fracture healing process. Key words: Fracture healing; Teriparatide; Gene expression

The Results of Closed Intramedullary Nailing for Intra-articular Distal Tibial Fractures

To evaluate the long-term radiological, clinical, and functional result of the intramedullary nailing in intra-articular distal tibia fractures. Retrospective clinical study. Level II Trauma Hospital. Between December 2000 and December 2006, 185 consecutive intra-articular distal tibia fractures were admitted in our institution. Fifty fractures were included in the study. According to the OTA classification, there were 28 (56%) fractures type 43 C1 and 22 (44%) type 43 C2. All fractures were treated with closed static intramedullary nailing with distal locking. In 37 (74%) patients, reduction of the articular extension of the fracture with additional internal fixation preceded the nailing. Fibula fixation was applied in 32 (64%) fractures. Routine dynamization of the fixation was performed in all cases at a mean time of 10 weeks postoperatively. The mean follow-up was 42 months (range: 36-54 months). Leg length, tibia alignment, articular reduction, and ankle arthrosis were assessed radiographically. The clinical outcome was assessed using the Olerud-Molander score. The functional limitation was assessed using the musculoskeletal functional assessment. All fractures healed at an average of 16.3 weeks (range: 14-28 weeks). Anatomic reduction of the articular surface was obtained in all fractures. The average coronal plane deformity was 0.74 degree (range: 0-4 degrees) and the average sagittal plane deformity was 0.62 degree (range, 0-4 degrees). The mean Olerud-Molander score was 92.8/100 (range: 80-100). The average short musculoskeletal function assessment score was 34.55 ± 31.88 (range: 0.8-96). Intramedullary nailing augmented with minimal internal fixation is a safe alternative for the treatment of distal tibial fractures with a simple articular extension. Because all objectives of the treatment were obtained, the results did not deteriorate over time. Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

A tip to reduce the malrotation of the spiral tibial fracture intraoperatively

Tibial spiral fractures treated by closed intramedullary (IM) nailing are at risk for malrotational deformities. The purpose of this study was to examine a method to minimize the risk of tibial malrotation during closed IM nailing of spiral tibial fractures. This trial is done through 24 patients of spiral tibial fractures with a mean age of 38.5 years (range 26-63 years). The patients were divided into two groups. One group the fractures were reduced by rotating the distal locked nail to obtain rotational alignment and another group by the standard assistant rotated technique. All the patients were evaluated with CT scans postoperatively. The parameters such as rotational values, operative and radiation exposure time were recorded and compared between two groups. Mann-Whitney test was used to test the significance of these parameters. The group using the tip had a smaller mean rotational value, which was (6.8° ± 2.1° vs. 11.8° ± 5.2°; P < 0.01). The mean operative time was not statistically different (70.6 ± 4.4 vs. 63.0 ± 2.9 min; P > 0.05), so did the mean radiation exposure time (48.1 ± 4.2 vs. 42.6 ± 4.8 s; P > 0.05). The described technique of rotating the nail after initial distal interlocking can correct rotational abnormalities in spiral tibial shaft fractures in the premise of not increasing the operative and radiation exposure times statistically.

Is there a place for open intramedullary nailing in femoral shaft fractures?

Background:Femoral shaft fractures are among the most common fractures following high trauma injuries. Different kinds of treatment have been suggested for these injuries.Aim:The aim of this study was to compare the results femoral fractures treated by mini open and close intramedullary nailing (IMN) technique.Materials and Methods:A total of 48 adult patients were operated due to fracture of the femur with close or open IMN technique between September 2010 and September 2011. 23 patients operated with close. IMN technique was included in Group I while 24 patients operated with mini open IMN technique constituted Group II. In Group I, all patients. Were operated on the fracture table in the supine position while in Group II, all patients underwent surgery on standard tables in the lateral position.Results:The mean age of patients was 27.3 years, ranging between 16 and 62. The mean age of the close nailing and open nailing groups was 30.5 and 24.5 respectively (P = 0.052). Only one patient from the open nailing group failed to unite. The mean time for union in close and open nailing groups was 13 + 2.4 and 17.7 + 2.3 weeks respectively (P = 0.001). No infection or limb length discrepancies were observed in the two groups.Conclusion:Although close nailing is the preferred methods in most cases, but in poly-traumatized patients or in centers where there are no fracture tables or C-arm, open nailing is a good option.

In Reply to: Queries Regarding Local Erythropoietin Injection in Tibiofibular Fracture Healing

Dear Editor, In reply- We would like to thank Dr. Duedal Rolfing for his keen observations. We hope that this study encourages prospective scientific publications. Erythropoietin (EPO) is a glycoprotein produced by the kidney which promotes the formation of red blood cells in the bone marrow. Recent studies have determined additional roles of EPO in tissue survival and cellular proliferation (1-3). EPO may accelerate bone formation and contribute to fracture healing (2). Despite this fact, the subject is still in debate (3). Tibial fractures are of the most common fractures in orthopedics and delayed union in long bones is mostly seen in the Tibia (4, 5). Not only is EPO effective in bone healing, but also it is effective in the long term (2). We have done a five-year long-term study and EPO dose was chosen based on our experience in a pilot study. Our treatment regime was as EPO (4000 IU), three ampoules were injected in one group into the fracture site two weeks after the operation and under sterile conditions and guide of C-arm. However, in obese patients (BMI > 30) we injected five ampoules. Of course, we consulted with the EPO manufacturer and used their recommendations. Based on the pilot study which lasted one year, we concluded lower dosages in obese patients were not sufficient and we used higher dosages in our recent study. Patients with multiple lower injuries, metaphyseal and isolated tibial, pathologic, comminuted, osteoporotic and open fractures were excluded. Also patients under treatment with steroids, anticoagulants, nonsteroidal antiinflammatory drugs, calcium channel blockers and nicotine were also excluded from the study. All patients underwent surgical fixation by close intramedullary nailing. All of our cases were patients with closed fracture type A,B of AO classification including all subgroups of A1,A2,A3 and B1,B2,B3.There was no significant difference between case and control groups in soft tissue healing. The patients were followed after EPO injection by physical examination and radiographic imaging every four weeks until union was confirmed. According to the radiographic studies, the mean union period was 19.35 ± 2.66 weeks in the EPO group compared to 21.50 ± 3.18 in the placebo group (P = 0.01). As the mean time was 20 weeks for union, we did five x-ray exam per patient with four weeks intervals which has been recommended (6).

Results of Closed Intramedullary Nailing using Talwarkar Square Nail in Adult Forearm Fractures.

The aim of the study was to evaluate results of closed intramedullary nailing using Talwarkar square nails in adult forearm fractures. We prospectively evaluated 34 patients with both bone forearm fractures. The average time to union was 12.8 (SD +3.2) weeks with cast support for a mean of 8.2 weeks. Union was achieved in 31 out of 34 patients. Using the Grace and Eversmann rating system, 17 patients were excellent, 10 were good, and 4 had an acceptable result. Three patients had non-unions, 2 for the radius and one for the ulna. There were two cases of superficial infection, one subject had olecranon bursitis, and one case of radio-ulnar synostosis. Complication rates associated with the use of square nails were lower compared to plate osteosynthesis and locked intramedullary nails. To control rotation postoperatively, there is a need for application of an above-elbow cast after nailing. Adult radius-ulna fractures, square nail, closed intramedullary nailing, radius-ulna nailing.

Closed Intramedullary Nailing of the Femur in the Lateral Decubitus Position

Closed intramedullary nailing is the standard of care for femoral shaft fractures and the technique now has broader applications with the proliferation of cephalomedullary instrumentation for the treatment of intertrochanteric and subtrochanteric femur fractures. Nailing in the lateral decubitus position has several advantages, but we are unaware of a detailed, contemporary description of the surgical technique published in the English language literature.A retrospective review of 158 patients treated with intramedullary nailing in the lateral position by a single surgeon over a 3-year period was performed. Clinical and radiographic outcomes were evaluated. In a group of 58 diaphyseal femur fractures, there were three rotational malreductions and one limb length discrepancy that required operative intervention. All but one were recognized and corrected intraoperatively on placing the patient supine. In a group of 100 primarily geriatric intertrochanteric, subtrochanteric, or peritrochatneric fractures managed with a cephalomedullary device, there were two lag screw cutouts, one nonunion, and one hardware failure. All of these required revision surgery. There were no rotational or length malreductions that required correction. There were no injuries to the perineum or contralateral leg, nerve palsies, or traction-related complications. Lateral positioning obviates the need for a fracture table, makes it easier to establish a starting point for an intramedullary device, and facilitates conversion to an open procedure without repositioning should this become necessary. This study demonstrates that the technique is safe and effective with an incidence of complications comparable with fracture table and supine positioning.