Compression Intramedullary Nail Research Articles

Clinical Comparison of Internal Fixation Constructs in Midfoot Charcot Arthropathy

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Midfoot Charcot can lead to instability, deformity and ultimately ulceration that can be limb threatening. Previous authors have described a variety of surgical stabilization techniques and constructs including intramedullary fixation (“beaming”) across the midfoot in varying orientations. More recently, intramedullary compression nails (“IM nail”) have been introduced. In contrast with static screws, these devices provide compression across the joints of the midfoot by engaging a compression mechanism against a fixed interlock screw. To our knowledge no clinical comparison between traditional beaming techniques and modern compression nails for midfoot Charcot has been reported. We hypothesize that using IM nails will result in a higher union rate, and lower reoperation and hardware failure rates. Methods: Our electronic medical record was queried to identify patients from 2016-2021 who underwent midfoot reconstruction. Only patients with midfoot Charcot who underwent extended intramedullary fixation were included. Patients with active ulceration at the time of surgery, Charcot that included the ankle, or external fixation as part of the construct were excluded. IM nails were used exclusively for medial column constructs. Basic demographic information was collected. Radiographs and operative notes were evaluated and construct type and implants used were noted. Radiographs at final follow-up were evaluated for union and hardware complication. Clinical notes were evaluated for weightbearing status, plantigrade foot position, ulceration, and wound care requirements. Finally, all complications and reoperations were recorded. Chi-squared or Fisher’s Exact tests were used as appropriate to compare categorical variables and t-tests were used to compare numerical variables. Results: 48 feet (47 patients) with a median age of 58 years (IQR 50, 64) were included. Diabetes was the Charcot etiology in 34/48 (70.8%) feet. There were 19 beaming and 29 IM nail constructs. Basic demographics and Brodsky classification were equally distributed (p>0.05). Median follow-up time was 1.3 years (IQR 0.8, 2.9). Combined medial and lateral column fixation was performed in 39/48 (81.3%) patients. 52% (25/48) included subtalar arthrodesis. Beaming constructs had higher re-operation rates (57.9% versus 27.6%, p < 0.05), and higher hardware failure rates (57% versus 6.9%, p< 0.001). IM nail group had higher union rates (75.9% versus 31.6%, p = 0.001), and higher rates of full weight-bearing at final follow up (86.2% versus 68%, p < 0.05). Two (4.2%) patients required amputation. Conclusion: In a cohort of 48 feet undergoing midfoot Charcot reconstruction, the use of medial column IM nails was associated with lower reoperation rates, lower rates of hardware failure, higher union rates, and higher rates of full weightbearing at final follow-up compared with traditional screw fixation. Surgeons who treat midfoot Charcot may consider these results when planning their stabilization constructs in this high-risk patient population.

Early outcomes of magnetic intramedullary compression nailing for humeral fractures.

The optimal treatment protocol for humeral shaft fractures at risk for nonunions is controversial. Here, we aim to describe magnetic intramedullary compression nailing as an option for these challenging scenarios and to evaluate its clinical and radiographic outcomes. This retrospective case series was performed at an urban university-based level-1 trauma center. Patients aged 18-65 who underwent fixation of their at-risk humerus shaft fracture using the PRECICE nail were included in this investigation. These fractures are characterized by a persistent distraction gap, minimal callous formation, or malalignment greater than 20 degrees. The study data were collected through a retrospective chart review and review of the radiographic studies. Primary outcome measure was radiographic union. Secondary outcome measures included mechanical failure, nonunion, malunion, medical, and surgical complications. Functional outcome was determined by range of motion and restoration of rotator cuff strength. A total of six patients were included who underwent treatment of their humeral shaft fracture with a NuVasive PRECICE nail after failure of conservative management. After nail placement along with our compression protocol, all patients achieved bony union and experienced favorable outcomes with return to their previous working status. Two complications included a superficial incisional infection treated with antibiotics and a backing out of proximal screw which did not cause discomfort. No other mechanical failures, surgical complications, or medical complications occurred. Early results of controlled compression nailing for humeral shaft fracture demonstrated favorable clinical outcomes. This technique may be utilized for these challenging situations.

The PRECICE magnetic IM compression nail for long bone nonunions: a preliminary report

IntroductionThe magnetic intramedullary (IM) compression nail is capable of providing sustained compression for the treatment of nonunions of long bones. This ability was previously only possible with the use of external fixation. We asked the following questions: How effective is the IM compression nail at achieving union? How do we know when adequate compression has been attained? Which types of nonunions are good candidates for this treatment?Materials and methodsFourteen patients with nonunions of the tibia (5) or femur (9) were treated with the PRECICE IM compression nail. The average age was 49 years number of previous surgeries was 1.9, 7 were atrophic and 7 normotrophic, 3 were metaphyseal and 11 diaphyseal. All PRECICE IM nails were pre-distracted prior to implantation. Compression was applied post-operatively until the locking bolts were seen on X-ray to be bending or the nail was no longer shortening despite applying the external magnet.ResultsUnion was achieved in 13/14 cases. The time to union was 24.5 weeks (range 11–60). The two proximal tibia metaphyseal nonunions, both deformed into varus (4°) and flexion (10°) after compression was applied with one failing to unite. The distal tibia metaphyseal and diaphyseal nonunions did not deform upon compression. Three patients had positive cultures and were treated with IV antibiotics for 6 weeks followed by 3 months of oral suppression without subsequent infection. No mechanical nail failures were seen.ConclusionsThe IM compression nail was successful at applying compression, preventing deformity, and obtaining union in all diaphyseal and in distal tibia metaphyseal nonunions. Signs of active compression are bending of the locking bolts and failure of the nail to shorten. Proximal tibia metaphyseal nonunion may not be suited for this treatment.

Effect of intramedullary nail compression amount on the union process of tibial shaft fracture and the evaluation of this effect with a different parameter.

This study aims to investigate the effects of different amounts of compression used in intramedullary nailing on the stress values of the fracture surface and time of the union process in tibia diaphysis fractures treated with intramedullary nails. Seventy patients (50 males, 20 females; mean age 34.0±10.7 years; range, 20 to 56 years) who had suffered from tibial shaft fractures between January 2007 and December 2015 were included in the study. Patients who had A2, A3, and B2 type fractures according to AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification and those with closed fractures were included. The patients were divided into three groups. No compression was applied to Group A, dynamic compressive fixation intramedullary nailing was applied to Groups B and C. Amount of applied compression was 1 mm for Group B and 1.5 mm for Group C. Postoperative and follow-up radiographs of patients were evaluated according to Rust criteria, and functional results were evaluated according to Johner-Wrush criteria. Additionally, finite element analyses were performed separately for 1 mm and 1.5 mm compressions that were applied in Group B and C, respectively. The data were analyzed using a statistical software package. Clinical and radiological union was achieved in all patients. The average time of radiological union was 15.05±2.06 weeks in Group A, 12.48±1.42 weeks in Group B, and 11.64±1.63 weeks in Group C. The time of union for the group in which no compression was applied (Group A) was significantly longer than the other groups in which compression was applied (Group B and C) (p<0.001). Functional outcomes were 17 patients (85%) with excellent and three patients (15%) with good-moderate results in Group A, 23 (92%) excellent and two (8%) good-moderate in Group B, and 23 (92%) excellent and two patients (8%) with good-moderate results in Group C. In total, seven patients had knee pain. No infection was seen in any patient. Interlocking compression intramedullary nailing is a very effective treatment method for tibial shaft fractures. As the compression applied by the nail increases, the time of union shortens significantly.

Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot.

Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up. We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70). The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) - Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS). The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190-6.

Enhancement of fracture healing in the rat, modulated by compounds that stimulate inducible nitric oxide synthase

ObjectivesWe investigated the effects on fracture healing of two up-regulators of inducible nitric oxide synthase (iNOS) in a rat model of an open femoral osteotomy: tadalafil, a phosphodiesterase inhibitor, and the recently reported nutraceutical, COMB-4 (consisting of L-citrulline, Paullinia cupana, ginger and muira puama), given orally for either 14 or 42 days.Materials and MethodsUnilateral femoral osteotomies were created in 58 male rats and fixed with an intramedullary compression nail. Rats were treated daily either with vehicle, tadalafil or COMB-4. Biomechanical testing of the healed fracture was performed on day 42. The volume, mineral content and bone density of the callus were measured by quantitative CT on days 14 and 42. Expression of iNOS was measured by immunohistochemistry.ResultsWhen compared with the control group, the COMB-4 group exhibited 46% higher maximum strength (t-test, p = 0.029) and 92% higher stiffness (t-test, p = 0.023), but no significant changes were observed in the tadalafil group. At days 14 and 42, there was no significant difference between the three groups with respect to callus volume, mineral content and bone density. Expression of iNOS at day 14 was significantly higher in the COMB-4 group which, as expected, had returned to baseline levels at day 42.ConclusionThis study demonstrates an enhancement in fracture healing by an oral natural product known to augment iNOS expression.Cite this article: R. A. Rajfer, A. Kilic, A. S. Neviaser, L. M. Schulte, S. M. Hlaing, J. Landeros, M. G. Ferrini, E. Ebramzadeh, S-H. Park. Enhancement of fracture healing in the rat, modulated by compounds that stimulate inducible nitric oxide synthase: Acceleration of fracture healing via inducible nitric oxide synthase. Bone Joint Res 2017:6:–97. DOI: 10.1302/2046-3758.62.BJR-2016-0164.R2.

Management of Aseptic Tibial Nonunion

Tibial nonunion remains a significant clinical challenge despite advances in surgical management. New techniques to help manage tibial nonunion include extracorporeal shock wave therapy and percutaneous application of bone marrow aspirate. Management strategies vary based on the type of nonunion: aseptic or infected, and atrophic or hypertrophic. Extracorporeal shock wave therapy has been shown to be as effective as surgical management in patients with stable hypertrophic nonunion. New fixation options include locked plates and intramedullary compression nails. Novel methods of external fixation have been developed for bone graft harvest from the intramedullary canal. Several biologic adjuncts also are available, including bone marrow aspirates, stem cells, and bone morphogenetic protein.

Technique of extracting a compression intramedullary nail that preserves knee arthrodesis

Intramedullary compression nails have recently been developed for knee arthrodesis. These implants have given fusion in 90–100% of cases regardless of the initial diagnosis or experience of the user (Domingo et al. 2004, McQueen et al. 2006, De et al. 2008). However, many clinicians have been reluctant to use this technique due to the perceived difficulty in or impossibility of removing these nails without disrupting the fusion, to allow the management of associated complications such as infection. We present the case of a patient who required removal of a compression intramedullary fusion nail for recurrent infection, in order to describe an easily performed extraction technique that does not disrupt the arthrodesis and that allows definitive management of infection. A 48-year-old man was referred with a painful failed knee arthrodesis that had originally been attempted for failed primary knee arthroplasty secondary to infection. There were no clinical or hematological signs of residual infection, so we proceeded to attempt fusion with an intramedullary compression nail (Wichita Fusion Nail; Stryker). He developed recurrent infection, which was managed with appropriate antibiotics until solid fusion was achieved. We then proceeded to remove the nail 8 months after the fusion procedure and to manage the infection more definitively (Figure 1). Figure 1. A. 8 months after fusion. B. 1 month after nail removal.

Do Locked Compression Intramedullary Nails Improve the Biomechanical Stability of Distal Femoral Fractures?

A distal femur nail with fixed-angle locking screws intends to combine the advantages of angular stability and intramedullary stabilization in extraarticular distal femur fractures. The goal of this study was to analyze whether the locked compression distal femur nail (LCN) was biomechanically more stable than a conventional standard distal femur nail (CN). Both nails were compared on a series of 10 matched pairs of human femora. After setting a distal femur defect fracture, the intramedullary stabilized femur was axially loaded starting from 100 N, increasing in steps of 100 N after every 200 cycles with a triangular frequency of 1 Hz, until a predefined point of failure was reached. The two types of nails showed no significant difference in terms of maximum tolerated load, maximum number of cycles repeated, or axial deformation of the bone-implant construct. The mean load at failure was 2,954 N for the CN and 2,483 N for the LCN. The mean axial deformation for the conventional (14.8 mm) and locked compression nail (15.3 mm) did not differ significantly. Mode of failure was a bony fracture in all specimens predominantly involving the proximal femur. No significant difference in stability between the two compared implants could be demonstrated. The LCN showed comparable characteristics under cyclic axial loading as the conventional distal femur nail. No migration into the articular space or implant failure was observed.

Kniegelenksarthrodese – Lebensqualität und Vergleich der Methoden

The number of total knee arthroplasties (TKA) has exploded in the industrialised countries in the last decade so it is inevitable that complications also rose. Persisting infection after exchange procedures sometimes cannot be cured other than by arthrodesis of the knee. Our aim was to study the results of this surgical intervention on the patients' quality of life. Between 2001 and 2007 90 patients, mean age 69 years (range 20-88), underwent an arthrodesis of the knee. External fixation, compression nail and plate osteosynthesis were used to perform the procedure. In a retrospective cohort study we analysed patients' data comparing the different methods. Sixty patients were asked to fill out two questionnaires, SF-36 score and WOMAC score. Additionally, five free verbalised questions were used to ask for the functional outcome and quality of life. According to the literature our results mark a change of practices over the years. In the last century the external fixation was the procedure of choice to stabilise the leg after implant-associated and post-traumatic infection. Since 2005 intramedullary compression nailing seems to have become superior (28 % - 100 %). Our retrospective cohort study points to the tendency for compression nail arthrodesis after failed and infected TKA. It seems that patients can be mobilised earlier, feel less pain and have a better quality of life with this procedure. These trends need confirmation by prospective randomised studies.

Tibiotalocalcaneal Arthrodesis with a Compressive Retrograde Intramedullary Nail: A Report of 34 Consecutive Patients

Tibiotalocalcaneal arthrodesis is a treatment modality for severe arthrosis and malalignment of the hindfoot. Complications, such as delayed union and nonunion, are well-known risks of the procedure. Arthrodesis can be done with a plate, screws, an external fixator, or an intramedullary nail. Compression with an intramedullary nail was the focus of this report. Thirty-four consecutive patients (23 men and 11 women) with an average age range of 57 (range 25-77) years had tibiotalocalcaneal arthrodesis using retrograde intramedullary compression nail fixation. Mean followup was 24 (range 6 to 43) months. One patient died of an unrelated cause, but 30 (91%) of the remaining 33 patients answered the questionnaire. Bony consolidation was achieved in 26 (76%) patients, the mean time to fusion being 16 weeks. Five patients (15%) had complications and seven (20%) had repeat surgery. Of the 30 patients who responded to the questionnaire, three patients (10%) evaluated the overall result subjectively as being of no benefit and 27 (90%) as improved. The visual analog scale (VAS) score for preoperative pain was 66 at rest and 83 when walking, and the mean postoperative scores were 19 and 32, respectively (p<0.001). Tibiotalocalcaneal arthrodesis with a compressive retrograde intramedullary nail is an effective and safe procedure for patients with severe malalignment or arthrosis of the hindfoot. It is essentially a salvage procedure, and most patients benefit from it, but excellent results are rare.

Torsional stability of intramedullary compression nails: Tibial osteotomy model

Studies comparing intramedullary compression nailing to conventional dynamized intramedullary nailing contend that better clinical outcomes of intramedullary compression techniques result from greater rotational stability of fracture or osteotomy sites. However, there appears to be no experimental evidence that rotational stability is improved with intramedullary nail compression. This study evaluated the effect of intramedullary nail compression on cadaveric and composite tibial fragment rotation above and below a mid-tibial transverse osteotomy. Twelve composite and four matched pairs of human cadaveric tibiae were randomized into either a compression group or a non-compressed dynamized group. A bi-axial servo-hydraulic testing machine applied 5Nm of internal and external torque (2Nm/s) under constant axial loads of 375N and 750N. Rotation along each tibia and at the osteotomy site was recorded from the trajectories of infrared emitting diodes rigidly attached along the tibial shaft. In comparison to dynamized nails, intramedullary nail compression significantly reduced the rotation at the osteotomy site in both human (8.9 degrees reduction; P=0.007) and composite tibiae (2.5 degrees reduction; P=0.039) under 750N of axial load. A similar result was noted for simulated half-body weight loads (375N) for both composite (3.0 degrees reduction; P=0.009) and human tibiae (10.5 degrees reduction; P=0.003). Intramedullary nail compression more effectively reduced tibial fragment rotation about a mid-tibial osteotomy than conventional dynamized intramedullary nails because intramedullary nails created more osteotomy site compression than the application of body weight to tibiae instrumented with dynamized intramedullary nails.

Biomechanical Evaluation of Primary Stiffness of Tibiotalar Arthrodesis with an Intramedullary Compression Nail and Four Other Fixation Devices

Many techniques of tibiotalar arthrodesis have been described. Screw fixation is widely used. At our center, intramedullary compression nailing has been successfully used for over 10 years. The question to be answered by this study was whether tibiotalar arthrodesis with a compressed intramedullary nail was superior, in terms of primary stiffness and fusion-site compression, to selected other techniques. Plane fusion surfaces were machined in third-generation synthetic composite tibiae and the bodies of anatomically correct tali; fixation was with a compressed external fixator (cEF), an uncompressed interlocking nail (uIN), a compressed interlocking nail (cIN), and two different three-screw techniques (ST1 and ST2); three specimens per construct were tested. The compressed contact surface of each construct was measured with pressure-sensitive film and expressed as a percent of the available fusion-site area. Construct stiffness was tested in dorsiflexion/plantar flexion (D/P), varus/valgus (V/V), and internal rotation/external rotation (I/E), analyzing 20 cycles per loading mode. Compressed surface area: cIN 80% +/- 10.7; cEF 60% +/- 8.6; ST2 59% +/- 4.4; ST1 55% +/- 6.1; uIN no discernible compression. The greatest primary stiffness in D/P was obtained with the cIN (p < 0.001), followed by ST1. In V/V, ST1 and the cIN had the greatest primary stiffness; the two techniques did not differ significantly. Stabilization with the cEF was significantly better (p < 0.001) than with ST2. In I/E, the cIN produced the greatest primary stiffness (p < 0.001), followed by the two screw techniques, which did not differ significantly between themselves. The uIN had the least primary stiffness in all directions tested. In this biomechanical study, the cIN and ST1 were superior, in terms of primary stiffness in tibiotalar arthrodesis, to the other techniques tested. In D/P and I/E, the cIN construct was significantly stiffer than the ST1 construct, whose I/E rigidity might, however, be enhanced by a fourth, horizontal screw. Intramedullary compression nailing offers stable tibiotalar arthrodesis fixation with a large bony contact area and may enhance the likelihood of successful tibiotalar arthrodesis.

Biomechanical investigation of the primary stability of intramedullary compression nails in the proximal tibia: experimental study using interlocking screws in cryopreserved human tibias

The biomechanical properties of the proximal tibia with respect to the application of compressible intramedullary nails were examined in a biomechanical model using human cadaver bones. A reference level was examined histomorphometrically in 24 cryopreserved human tibias. Three series of single or double interlocking fixations were tested at various distances from the tibial plateau. Yield strength, rigidity of the bone stock, maximum load, and compression distances were determined during axial strain. The positioning of the interlocking screws had a considerable influence on maximum load and deformation behavior of the bone. The double interlocking tended to display the best stability in the bone stock, and the distally placed single interlocking method was next best. Failure of the bone stock was observed with significant variations in compression distance and load, with great variations between individual specimens. The stability of the bone stock could not be accurately predicted using such clinical parameters as the patient’s age, bone dimensions, radiographic parameters, and bone density. When using a tibial compression nail, the proximal interlocking screw should be placed relatively distal to achieve adequate support. It is possible to apply compression with one proximal interlocking screw under low preload or, preferably, with two interlocking screws.

Dynamic compression nail: a preliminary report.

BackgroundInterlocking nailing, which has become the method of choice for treating fractures of the femoral and tibial shafts, still lacks ability to provide the important contact-compression at the fracture. An intramedullary compression nail is described, which provides axial compression at the fracture site with tightening of the specially designed distal interlocking screw. This uses the same principle as dynamic compression plating.MethodsThe study included 11 femoral and tibial nailings performed for various clinical applications such as acute fractures, non-unions and malunions.ResultsAll the fractures attained radiological union, with good skeletal continuity across the fracture, within an average time of 13 weeks in fresh fractures and 18 weeks in non-unions.ConclusionsActive compression through intramedullary compression nailing has great utility for treating non-unions where it provides greater degree of impaction of its irregular ends. This may prove greatly advantageous to the fracture union through increased stability and the osteogenic potential, particularly when utilized in combination with the small diameter unreamed nails.

Treatment of Nonunion of the Femur Shaft with Intramedullary Compression Nail

Treatment of Nonunion of the Femur Shaft with Intramedullary Compression Nail

大腿骨近位部骨折に対するハックステップ髄内釘の使用経験

We treated three cases of subtrochanteric fractures of the femur with the Huckstep intramedullary compression nail. Two cases were fresh comminuted fractures and the other was a case of non-union that had been surgically treated twice using compression hip screws. We determined the type of subtrochanteric fracture according to Seinsheimer's classification.The two fresh cases achieved early weight bearing within three weeks after surgery. Good bony union was obtained in all three cases and no complications such as shortening, angular deformity or rotational malalignment occurred.

Treatment of subtrochanteric fractures of the femur: a study of intramedullary compression nailing

The results of prospective treatment of 31 patients with subtrochanteric fractures using the Derby intramedullary nail are presented. The nail design, plus cerclage wires in unstable cases, allows axial compression of the fracture, to give rigid fixation and load-sharing between bone and nail. Twenty-seven patients were followed up for an average of 21.7 months. There were no mechanical failures of the nails, and all 27 fractures united, two in minimal varus. Relatively early mobilization of the patients with isolated fractures occurred.