IM Nailing Research Articles

Redefining Optimal Nail to Medullary Canal Diameter Ratio in Stainless Steel Flexible Intramedullary Nailing of Pediatric Femur Fractures.

The ideal canal fill for flexible intramedullary fixation of pediatric femoral shaft fractures is considered to be 80% based upon relatively few clinical studies. The purpose of this study is to assess the relationship between the summed nail to intramedullary canal diameter (ND/MCD) ratio and alignment at radiographic union following flexible intramedullary nailing (FIMN) of pediatric femoral shaft fractures. An Internal Review Board approved, retrospective review of a consecutive series of patients who sustained a femoral shaft fracture treated by retrograde, stainless steel FIMN was performed at a single level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. ND/MCD ratio was calculated using the sum of the known nail diameters and the measured isthmic diameter. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. ND/MCD ratio was analyzed to determine correlative factors with final radiographic outcomes. In total, 261 children underwent retrograde FIMN at an average age of 8.2 years (range, 2.2 to 17.0 y). ND/MCD ratio of ≥80% was seen in 108 (41.4%) patients. When compared with those with <80% ND/MCD ratio, there were no significant differences in age (8.8 vs. 8.0 y), sex (76.9% vs. 71.0% males), or body mass index (18.5 vs. 17.2 kg/m). There were significantly more length unstable fractures in the <80% ND/MCD ratio group (49.4% vs. 29.7%; P<0.01). Radiographic outcome was no different with respect to coronal angulation (2.7 vs. 3.0 degrees), sagittal angulation (3.0 vs. 3.2 degrees), or shortening (2.5 vs. 4.1 mm). ND/MCD ratio of ≥70% was seen in 176 (67.4%) patients and, when compared with the <70% ND/MCD ratio group, there were no differences in shortening (3.3 vs. 3.9 mm), coronal angulation (2.8 vs. 3.0 degrees), or sagittal angulation (3.0 vs. 3.4 degrees). Finally, 6.9% of the population (18 patients) had ND/MCD ratios <60% and did not demonstrate a significant increase in shortening, coronal, or sagittal angulation compared with groups with higher ND/MCD ratios. No group had an increased rate of infection, implant removal, nonunion, or need for reoperation. In a large series of consecutive patients treated with retrograde stainless steel FIMN there does not appear to be any correlation between the ND/MCD ratio and radiographic outcome. Stainless steel flexible IM nails seem to maintain fracture alignment without an increase in complications at lower ND/MCD ratios than previously reported as "optimal." Level III.

Operative Treatment of 2-Part Surgical Neck Fracture of the Humerus: Intramedullary Nail Versus Locking Compression Plate With Technical Consideration

To compare the outcomes of patients who underwent either open reduction internal fixation with a locking plate and screws or closed reduction internal fixation with an antegrade intramedullary nail (IMN) for displaced surgical neck fracture of the humerus. Retrospective comparative study. Single institute, Level-I academic trauma center. Sixty-nine patients with 2-part surgical neck fracture of the humerus underwent either an IMN (38 patients group A) or a locked plate fixation (31 patients group B). Pain on a visual analog scale, University of California Los Angeles (UCLA) Shoulder Score, American Shoulder and Elbow Surgeons (ASES) score, and active range of motion (ROM). At the 2-year follow-up, there were no significant differences in the visual analog scale pain score (1.3 in group A; 0.9 in group B), ASES score (90.2 in group A; 91.9 in group B), and UCLA Shoulder Score (30.7 in group A; 31.8 in group B) between groups. Active ROM did not differ significantly between groups. There were 3 complications in the IMN group, 1 nonunion requiring autogenous iliac crest bone graft, and 2 cases of screw loosening. For displaced surgical neck fractures of the humerus, both IM nailing and locked plate fixation in patients yielded satisfactory outcomes at the 2-year follow-up with no significant differences in pain or ROM between groups. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary fibular fixation is a versatile tool in the operative management of fractures of the distal tibia and fibula

Category: Ankle, Trauma Introduction/Purpose: Intramedullary fixation of the fibula has been proposed as a minimally invasive alternative to traditional plate fixation in fractures of around the ankle. Previous studies have demonstrated a low complication rate, particularly when both distal locking and trans-syndesmotic screws are used. More recently, they have been used to act as a lateral buttress to prevent valgus malunion in fractures of the distal tibia and fibula. After four years of using fibular intramedullary devices in our unit we set out to audit our practice. Methods: We retrospectively searched our electronic operation database for operations in which fibular nails were used, from their first use in our unit in 2012 through to the end of 2016. Electronic operative and clinic notes were reviewed. We gathered basic demographic information and classified fractures according to the AO/OTA system, and studied pre- and post-operative radiographs for evidence of malunion. Results: Eighteen cases were identified. Median age at surgery was 66 (Range 23 to 83 years). Seven patients smoked, one was diabetic. Fibular nails were used in six in AO type 44 and twelve in AO type 42 and 43 fractures. Five were open. Fibular nails were used alongside tibial IM nails, tibial bridging plates, percutaneous tibial fixation and a tibial circular frame and were chosen because of concerns about poor soft tissues or wounds over the lateral side. Twelve cases had syndesmotic fixation. Median follow-up was five months (range 0-48 months). One nail was removed to compress a tibial fracture. All fractures united with no progressive malunion. One prominent distal locking screw was removed and one superficial wound infection required oral antibiotics. Conclusion: We have expanded the use of this device beyond the technique originally described. It’s use has been demonstrated across a range of fractures about the distal tibia and fibula in a variety of different operations with excellent results. Minimally invasive fibular nailing is particularly useful in patients with poor soft tissues or where there is high risk of post-operative infection.

Internal fixation of fracture both bone forearm: Comparison of dynamic compression plate and IM nail

Open reduction and internal fixation can be considered as the treatment of choice if there were no contraindications for this because it is important to maintain length, opposition, axial alignment and rotational alignment if a good range of movement of forearm is to be restored. This is achieved in the present study. Anatomical reduction and internal fixation of forearm fractures can facilitate restoration of function. Any axial or rotatory malalignment or any narrowing of interosseous space produces disproportionate loss of pronation and supination. In addition proximal and distal radioulnar joints do not function properly if there is significant shortening of either bone. 50 cases of fracture both bones forearm were attended in the casualty and OPD and admitted in the hospital were treated by open reduction and internal fixation with Dynamic Compression Plate and Intramedullary nailing by Square nail. The study was conducted between June 2016 to May2017 at Pravara Rural Hospital, Loni. 25 cases were treated by open reduction and internal fixation with dynamic compression plate, and 25 cases were treated with closed or open reduction and internal fixation with IM nails. Most common age group recorded in our study 20-30 (46%), and 32 (64%) cases are Male and 18 (36%) cases are Female. Anderson Scoring System 25 cases of DCP 76% were excellent, 24% were satisfactory and 25 cases of Intramedullary nailing with square nails 56% were excellent, 16% were satisfactory, 20% were unsatisfactory, 8% had failure results. Open reduction and plating fixation of fracture both bone forearm are better than intramedullary nailing. To conclude DCP offers excellent results in displaced diaphyseal fracture of forearm bone in adults and to be considered as first line of management.

Result of intramedullary interlock nailing in fracture proximal third tibia in rural hospital

Aim: Tibia is one of the most commonly fractured bone. Proximal third tibial fracture account for 5% to 11% of tibial shaft fracture. Treatment of proximal third fracture tibia is complex and problematic. Techniques include plate fixation, external fixation and intramedullary nailing. Purpose of this paper is to review and compare IM Interlock nailing technique in treatment of fracture proximal third tibia with other available techniques. Materials and Methods: Study involved 33 patients (24 male and 9 females) operated between year 2012 and 2016 in SRTR Medical College and rural hospital, Ambajogai. An age between 18-70 year was selected for the study. Male to female ratio was 3:1. There were 27 simple fractures and six had open injury (4 with gustillo1 and 2 with gustillo 2). Fractures were classified on basis of fracture pattern as simple undisplaced, displaced, comminuted, and segmental. Fractures extending into articular surface were excluded from our study. Patient was in supine position with knee in figure of four posture. A 4 cm vertical midline incision was taken on patellar tendon. Patellar tendon was retracted medially. Entry made just in front of inter meniscus ligament with curved awl, after removal of piece of infrapatellar pad. Entry point was much higher than techniques described in other interlocking nailing. Tibia IM interlock nail of suitable size was inserted with manual rotation and proximal and distal locking done with locking screw. Polar screw and reaming was not used in our cases. In the case of nonunion, broken implants were removed and nail used, bone graft was done. In the case of hypertrophic nonunion IM nail was used and 1cm fibula excision. Post operatively patients were ambulated with crutches NWB and later PWB to FWB as per the pain threshold of the patient. Follow-up of patients were done at regular intervals and final angulations in four planes were studied. Reduction greater than 5 degree in any plane was considered as mal reduction Results: The average hospital stay was 3-7 days. There was only one postoperative superficial infection, which healed with antibiotics and dressing. No patient had deep infection, neurovascular injury, implant failure or screw loosening. Union time was average 16 weeks with union rate of 94%. Majority of the patient with fractures (88%) shows painless wt bearing and radiological evidence of healing between 12-16 weeks. About 91% pt. showed more than 120-degree knee range of motion at final follow up. The nonunion cases took 16-20 wks for union. Postoperative angulations were within five degree in all planes, and no secondary procedure was required to achieve union or correct malunion. Conclusion: Tibia IM intramedullary nailing is a safe and effective technique of fixation with good outcome. Alignment can be well maintained despite short proximal segment because the interlock IM nail, triple diameter screw that provides better stiffness and stability in axial and rotatory plane.

Functional Outcome of Intramedullary Interlocking Nail and Plate Fixation in the Surgical Management in Distal Tibia Fracture: A Comparative Study

Background : On the basis of the fracture location in the bone distal tibia fractures have the second highest incidence of all tibia fractures after the mid-shaft fracture of tibia[1]. we conducted this study comparing functional outcome of intramedullary interlocking nail and locking plate fixation in the surgical management of extra-articular distal tibia fracture. The Patients with Distal tibia fracture were grouped in two. Group I patients were treated with Intramedullary interlocking nail; Group II patients were treated with open reduction and internal fixation with Plating. We Assessed patients with Functional recovery between two treatment modality intramedullary interlocking nail and locking plate fixation in the surgical management of extra-articular distal tibia fracture. Material and method: A prospective study was conducted in department of orthopaedic. All patients attending the orthopaedic department with extra-articular fracture of distal tibia who met the inclusion criteria were counselled regarding the disease and the study and those willingly consenting to participate in the study were selected. A total of 42 subjects were consecutively recruited for the study. The Patients with Distal tibia fracture who came to our hospital Grouped into Group I and Group II. For each Group, patients were selected consecutively. Group I (n=21) patients were treated with Intramedullary interlocking nail; Group II (n=21) patients were treated with open reduction and internal fixation with Plating. Clinical follow-up examination was performed at 4 weeks, 6 weeks, 10 weeks, 3 months, 6 months and 1 year. All patients were assessed clinically and radiographically with following terms such as tenderness at fracture site, abnormal mobility, infection, pain on movement of knee and ankle joints and antero-posterior and lateral radiographs of the leg for union of fracture. Assessment of the patient with Functional recovery was done with American orthopaedic foot and ankle surgery (AOFAS) minimum 6 months after injury. Result: Our study showed that the mean operating time in nail i.e. Group I was 102.14 minutes, where in Group II 96.67 minutes. Mean union time in Group I was 18.43 weeks and 21.43 weeks in Group II. 2 patients had wound problem in group II. 3 patients complained knee pain from Group I. 3 patients had delayed union, 2 patients had malalignment, and one patient had non-union in Group I. 2 cases had superficial infections and delayed wound healing in Group II. Mean operating time and mean time of healing between Group I and Group II were statistically significant (p&lt;0.05). 6(28.57%) patients had secondary procedure in nailing group. 3 patients had bone marrow aspiration, 2 had nail exchange and one case undergone dynamisation. The functional outcome was assessed by American ankle and foot score (AOFAS). In our study, 12 (57.14%) patients had excellent, 6 (28.58%) patients had good, 2 (9.52%) had fair and 1(4.76%) patients had poor functional outcome from Group I. In group II, 11(52.38%) patients had excellent, 8(38.1%) patients had good and 2(9.52%) patients had fair outcome. The comparison of the various parameters of this study with other published data shows that the results were comparable. Conclusion: Based upon the findings of the present study, both the methods studied are suitable treatments in the surgical management of extra-articular distal tibia fracture. IM nailing shows lower rate of delayed wound healing and superficial infection but more likely to require additional surgeries to achieve union, and probably will have more complaints of pain in their limbs or knee. While plating avoids malunion and knee pain but the functional and efficacy outcomes appear to be similar between the two treatment groups. Therefore, the choice of surgical procedure should be based on the surgeon’s expertise, the clinical circumstances, and especially the patient’s injury pattern.

Prevalence and risk factors for re-interventions following reamed intramedullary tibia nailing

IntroductionThis study aimed to identify the prevalence and the risk factors for re-interventions following reamed intramedullary nailing (IMN) of tibial shaft fractures. Patients and methodsWe retrospectively analysed a prospectively populated data of adult patients that underwent reamed intramedullary nailing for stabilization of tibial shaft fractures over a period of three years. Exclusion criteria were immature patients, pathological and periarticular fractures. Data collected included patient demographics, mechanism of injury, open or closed injury pattern, ISS, perioperative complications, reintervention characteristics (time, cause, number), smoking habits, medical co-morbidities and progress to radiological fracture union. Fractures were classified according to AO/OTA system. The cohort of these patients was divided in two groups: Group 1 included the patients who healed uneventfully and Group 2 included the patients who underwent a re-intervention for the healing of the fracture. A logistic regression analysis model was used to assess the odds ratio (OR) of identified risk factors predicting the necessity of re-interventions. Results181 (129 male) patients with a mean age of 37 (range 16–87) met the inclusion criteria. 30 patients were excluded due to inadequate follow up, leaving 151 patients for the study group. 119 patients were included in Group 1. 32 (21.2%) patients who had at least one re-intervention (range 1–3) were included in Group 2. The most common causes for re-intervention were aseptic non-union (31.3%) and removal of implants due to soft tissue irritation/anterior knee pain (31.3%), followed by early metalwork failure (12.5%), infected non-union (9.4%), correction of rotational deformities (9.4%) and canal intramedullary sepsis with evident fracture healing (6.3%). 29 (25.8%) from the study cohort patients sustained an open fracture and 8 of them underwent a re-intervention (20.5% of interventions). Incidence of fracture pattern 42-B, C was statistically significant greater in the reintervention (40.6%) compared to the non-re-intervention group (23.53%) (p = 0.026). Risk factors predicting the need for re-interventions included the type of fracture B, C (p = 0.026 OR: 2.528, range: 1.117–5.721) and increased alcohol consumption (p = 0.027/OR: 2.618, range: 1.116–6.141). ConclusionFracture pattern and alcohol abuse were highly predictive for re-interventions following reamed IM nailing for stabilization of acute tibial shaft fractures.

Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures: A modified candy-package wiring technique

IntroductionThe purpose of this study was to introduce a new surgical technique, that involves modified Candy-package wiring followed by IM nailing fixation and to determine the clinical and radiological results obtained in patients with unstable intertrochanteric fractures with a lesser trochanter fragment. Materials and methodsThis study included 22 patients who were undergone proximal IM nailing with lesser trochanter wiring between January 2014 to June 2015. All patients were treated with minimally invasive technique of candy-package wiring for lesser trochanter fragments. The mean age was 75.8 years (range, 53–88) and average follow-up period was 15.1 months (range, 12–24). Each patient was followed up for a minimum of 12 months and their clinical and radiological results were analyzed. ResultsThe mean period required for fracture union was 16.6 weeks. (range, 8–25) and union was successfully completed in all cases. The WOMAC scores at the last F/U visit (average; 45.4, range; 21–75) were not significantly different to pre-trauma status (average; 36.5, range; 19–59) (p=0.087). In comparison of ambulatory capacity prior to trauma, ambulatory aggravation was noted in four cases (18.2%), and eighteen cases (81.8%) was sustained walking ability of prior of trauma. Wiring breakage was found in two cases and heterotrophic ossification in one case. There were no functional deficeit related to the radiologic finding in these patients. With regard to postoperative complications, were no cut-outs, breakage, or pullout of screws. ConclusionWhen surgically repairing unstable intertrochanteric fractures with lesser trochanter comminution using proximal IM nailing method, the modified Candy-packaging wiring technique increases the fixation force at the fracture site. Thus, through this technique, both firm fixation of the lesser trochanter and more stable bony union were obtained.

Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases

IntroductionNo objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other. Material and methodsThis was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN). ResultsAfter an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group. ConclusionIf the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area. Level of evidenceIV, retrospective study.

Management of paediatric femoral shaft fractures with titanium elastic nails

Femoral shaft fractures are the most common major paediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fractures, personality, age and cost. Non-surgical management usually with early spica cast application is preferred in younger children. Surgery is common for the school age child and for patients with high energy trauma. In the older child, traction followed by casting, external fixation, flexible IM nails and plate fixation have specific indications. Potential complications of treatment include shortening, angular or rotational deformity, delayed union, non-union, overgrowth, infection, skin problems and scarring. Risks of surgical management includes refracture after external fixator or plate removal, osteonecrosis after rigid IM nail fixation and soft tissue irrigation caused by ends of flexible nails.

Influence of sagittal plane malpositioning of the patella on anterior knee pain after tibia intramedullary nailing.

Anterior knee pain (AKP) is one of the most common complications after tibia intramedullary surgery. We evaluated changes in patellar tendon length after tibia intramedullary nailing surgery using a transtendinous approach and assessed the importance of nail position in relation to the anterior tibial cortex and joint line. Two surgeons blinded to patients' pain status measured both the knee Insall-Salvati and Caton-Deschamps indexes on 30° flexion lateral knee X-rays of 33 patients. Superior nail prominence (the distance from the proximal tip of the nail to the tibial plateau) and anterior nail prominence (the distance from the anterior tip of the nail to the anterior tibial cortex) were measured on the CT. Clinical assessment showed that 10 patients (30%) had AKP at the last follow-up. HSS and Lysholm scores and the incidence of AKP were similar between patients whose IM nails were removed and those who still had them. HSS score, Insall-Salvati, and Caton-Deschamps indexes were significantly lower in the operated extremity than in the healthy limb at last follow-up. No association was demonstrated between AKP and nail position in relation to the anterior tibial cortex or tibial plateau. According to our study, although the patellar tendon shortened significantly on the affected side compared with the contralateral side, these measurements did not correlate with the presence or absence of pain. AKP and functional knee scores after tibia IM nailing using a transtendinous approach were not associated with nail position in relation to the anterior tibial cortex or tibial plateau. Level 3 (Case control study).

A simple method for fashioning an antibiotic impregnated cemented rod for intramedullary placement in infected non-union of long bones.

The intramedullary insertion of antibiotic impregnated PMMA rods, beads or nails are widely used and accepted modality of treatment for chronic osteomyelitis of long bones. But at times it becomes difficult to insert and remove these antibiotic delivery systems owing to narrowed medullary canals. Here we present a technique for preparing PMMA rods with diameter ranging from 6mm to 3mm. These rods could easily be placed in narrow intramedullary canal of long bones with chronic osteomyelitis or infected non-union. We have used high viscosity bone cement (Simplex P) along with two antibiotics (cefuroxime and vancomycin) for preparing cement rods. Food grade straw and low profile teflon tube guide wire exchanger used in IM nailing were used as mold. Ilizarov wire, 1mmK wire and 24 gauge stainless steel wire were used as internal support core material for imparting strength. We used this technique in seven cases and were successful in treating infection of long bones of upper and lower limbs (femur). With average follow up of 7.28 months rate of union in our series was 71% (five cases). Four cases (57%) had no evidence of infection and two cases (29%) had control of infection and in one case (14%) infection was still there but union was achieved.

Evaluating Outcome of Distal Tibia and Fibula Fractures Treated with Intra Medullary Nailing

Choice of best treatment in tibiofibular fractures should be based on many affecting factors such as age, wound contamination's, presence of associated conditions and availability of stabilization devices. This study is aimed to evaluating outcome of distal tibia and fibula fractures treated with intra medullary nailing in Firoozgar hospital during 2012-2014. In this cross- sectional study which was conducted in Firoozgar hospital in 2012-2014, 40 patients with distal tibiofibular fractures who was candidate for IM nailing were evaluated. Operation was done by intramedullary nailing method. Patients were followed up at 2 weeks, 1, 3, 6 and 12 month after surgery. Radiographic evaluation of union in tibia with anteroposterior and lateral view, as well as complications was assessed in each visit. Data were enterd to SPSS and were analyzed. Fifty patients with mean age of 34.67 (SD= 12.98) years (46 (92) male and 4 (8) female) were evaluated. Four (10) patients remained non- union from whom 3 (7.5) underwent ORIF treatment. Mean time of complete union achievement was 6.34 (SD= 3.54) months. Fourteen malunion were seen in this study that 1 (7.14) was varus (7°) and 13 (92.85) were valgus. No cases of deep infection, nerve injury or compartment syndrome were seen. We conclude that reamed, locked IM. nailing is a good method for achieving union in distal tibial fractures. High rate of union, low complication and deformity correction was seen with this method. © 2016, Oriental Scientific Publishing Company. All rights reserved.

Introducing a novel surgical tool to facilitate IM nailing – Femoral Antegrade Starting Tool (FAST)

Introducing a novel surgical tool to facilitate IM nailing – Femoral Antegrade Starting Tool (FAST)

Finite element analysis of a pseudoelastic compression-generating intramedullary ankle arthrodesis nail

Tibio-talo-calcaneal (TTC) arthrodesis is an end-stage treatment for patients with severe degeneration of the ankle joint. This treatment consists of using an intramedullary nail (IM) to fuse the calcaneus, talus, and tibia bones together into one construct. Poor bone quality within the joint prior to surgery is common and thus the procedure has shown complications due to non-union. However, a new FDA-approved IM nail has been released that houses a nickel titanium (NiTi) rod that uses its inherent pseudoelastic material properties to apply active compression across the fusion site. Finite element analysis was performed to model the mechanical response of the NiTi within the device. A bone model was then developed based on a quantitative computed tomography (QCT) image for anatomical geometry and bone material properties. A total bone and device system was modeled to investigate the effect of bone quality change and gather load-sharing properties during gait loading. It was found that during the highest magnitude loading of gait, the load taken by the bone was more than 50% higher than the load taken by the nail. When comparing the load distribution during gait, results from this study would suggest that the device helps to prevent stress shielding by allowing a more even distribution of load between bone and nail. In conditions where bone quality may vary patient-to-patient, the model indicates that a 10% decrease in overall bone modulus (i.e. material stiffness) due to reduced bone mineral density would result in higher stresses in the nail (3.4%) and a marginal decrease in stress for the bone (0.5%). The finite element model presented in this study can be used as a quantitative tool to further understand the stress environment of both bone and device for a TTC fusion. Furthermore, the methodology presented gives insight on how to computationally program and use the unique material properties of NiTi in an active compression state useful for bone fracture healing or fusion treatments.

Fractures diaphysaires des deux os de l’avant-bras chez l’adulte : une comparaison clinique et biomécanique de quatre ostéosynthèses distinctes

BackgroundAlthough there have been a small number of studies reporting single bone fixation of either radius or ulna as well as hybrid fixation, the paucity of data for the hybrid fixation method still remains. HypothesisHybrid fixation with plate and IM nailing would achieve good fixation and functional outcome, minimal damage to soft tissues and lower re-fracture risk. Materials and methodsForty cadavers (20 males, 20 females; mean age: 68.06, SD: 1.58 years) were selected in biomechanical study under axial loading, bending loading, and torsional loading. Eighty-seven patients (47 males, 40 females; mean age: 38.03±0.88 years) were enrolled in the clinical study and randomly received different fixation: both-bone plate fixation or both-bone intramedullary nailing, plate fixation of ulna and intramedullary nailing of radius and intramedullary nailing of ulna and plate fixation of radius. ResultsIn the biomechanical study, intramedullary nailing of ulna and plate fixation of radius had similar results with that using both-bone plate method under axial, bending and torsional loading (all P>0.05), suggesting the more stable fixation compared with the other two groups (all P<0.05). In clinical research, both-bone intramedullary nailing was related to shortest operative time, smallest wound size and periosteal stripping area compared with other three groups (P<0.05). Patients receiving intramedullary nailing of ulna and plate fixation of radius showed the lowest incidence of postoperative complications and the best functional recovery outcome comparing with other three groups of patients (both P<0.05). ConclusionThe hybrid fixation method of intramedullary nailing of ulna and plate fixation of radius showed good stability in biomechanics, fewer complications and better functional clinical outcomes. Level of evidenceLevel II, prospective randomised study.

Adult diaphyseal both-bone forearm fractures: A clinical and biomechanical comparison of four different fixations

BackgroundAlthough there have been a small number of studies reporting single bone fixation of either radius or ulna as well as hybrid fixation, the paucity of data for the hybrid fixation method still remains. HypothesisHybrid fixation with plate and IM nailing would achieve good fixation and functional outcome, minimal damage to soft tissues and lower re-fracture risk. Materials and methodsForty cadavers (20 males, 20 females; mean age 68.06, SD 1.58years) were selected in biomechanical study under axial loading, bending loading, and torsional loading. Eighty-seven patients (47 males, 40 females; mean age 38.03±0.88years) were enrolled in the clinical study and randomly received different fixation: both-bone plate fixation or both-bone intramedullary nailing, plate fixation of ulna and intramedullary nailing of radius and intramedullary nailing of ulna and plate fixation of radius. ResultsIn the biomechanical study, intramedullary nailing of ulna and plate fixation of radius had similar results with that using both-bone plate method under axial, bending and torsional loading (All P>0.05), suggesting the more stable fixation compared with the other two groups (All P<0.05). In clinical research, both-bone intramedullary nailing was related to shortest operative time, smallest wound size and periosteal stripping area compared with other three groups (P<0.05). Patients receiving intramedullary nailing of ulna and plate fixation of radius showed the lowest incidence of postoperative complications and the best functional recovery outcome comparing with other three groups of patients (Both P<0.05). ConclusionThe hybrid fixation method of intramedullary nailing of ulna and plate fixation of radius showed good stability in biomechanics, fewer complications and better functional clinical outcomes. Level of evidenceLevel II, prospective randomised study.

Healing Time and Complications in Operatively Treated Atypical Femur Fractures Associated With Bisphosphonate Use: A Multicenter Retrospective Cohort.

The purpose of this study was to characterize demographics, healing time, and complications of a large series of operatively treated atypical femur fractures. Retrospective multicenter review. Seventeen academic medical centers. Bisphosphonate-related fractures as defined by American Society of Bone and Mineral Research. Fractures had to be followed for at least 6 months or to union or revision. Operative treatment of bisphosphonate-related fracture. Union time and complications of treatment, as well as information about the contralateral limb. There were 179 patients, average age 72, average body mass index 27.2. Average follow-up was 17 months. Twenty-one percent had a previous history of fragility fracture; 34% had prodromal pain. Most (88%) lived independently before injury. Thirty-one percent had radiographic changes suggesting stress reaction. Surgical fixation was with cephalomedullary nail (51%), IM nail (48%), or plate (1%). Complications included death (4), PE (3), and wound infection (6). Twenty (12%) patients underwent revision at an average of 11 months. Excluding revisions, average union time was 5.2 months. For revisions, union occurred at an average of 10.2 months after intervention. No association was identified between discontinuation of bisphosphonates and union time (P = 0.5) or need for revision (P = 0.7). Twenty-one percent sustained contralateral femur fractures; 32% of these had pain and 59% had stress reaction before contralateral fracture. In this series, surgery had a 12% failure rate and delayed average time to union. Twenty-one percent developed contralateral femur fractures within 2 years, underscoring the need to evaluate the contralateral extremity. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical properties of a structurally optimized carbon-fibre/epoxy intramedullary nail for femoral shaft fracture fixation

Intramedullary nails are the golden treatment option for diaphyseal fractures. However, their high stiffness can shield the surrounding bone from the natural physiologic load resulting in subsequent bone loss. Their stiff structure can also delay union by reducing compressive loads at the fracture site, thereby inhibiting secondary bone healing. Composite intramedullary nails have recently been introduced to address these drawbacks. The purpose of this study is to evaluate the mechanical properties of a previously developed composite IM nail made of carbon-fibre/epoxy whose structure was optimized based on fracture healing requirements using the selective stress shielding approach. Following manufacturing, the cross-section of the composite nail was examined under an optical microscope to find the porosity of the structure. Mechanical properties of the proposed composite intramedullary nail were determined using standard tension, compression, bending, and torsion tests. The failed specimens were then examined to obtain the modes of failure. The material showed high strength in tension (403.9±7.8MPa), compression (316.9±10.9MPa), bending (405.3±8.1MPa), and torsion (328.5±7.3MPa). Comparing the flexural modulus (41.1±0.9GPa) with the compressive modulus (10.0±0.2GPa) yielded that the material was significantly more flexible in compression than in bending. This customized flexibility along with the high torsional stiffness of the nail (70.7±2.0Nm2) has made it ideal as a fracture fixation device since this unique structure can stabilize the fracture while allowing for compression of fracture ends. Negligible moisture absorption (~0.5%) and low porosity of the laminate structure (< 3%) are other advantages of the proposed structure. The findings suggested that the carbon-fibre/epoxy intramedullary nail is flexible axially while being relatively rigid in bending and torsion and is strong enough in all types of physiologic loading, making it a potential candidate for use as an alternative to the conventional titanium-alloy intramedullary nails.

Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications.

Distal tibial or pilon fractures are usually the result of combined compressive and shear forces, and may result in instability of the metaphysis, with or without articular depression, and injury to the soft tissue. The complexity of injury, lack of muscle cover and poor vascularity make these fractures difficult to treat. Surgical treatment of distal tibial fractures includes several options: external fixation, IM nailing, ORIF and minimally-invasive plate osteosynthesis (MIPO). Management of distal tibial fractures with MIPO enables preservation of soft tissue and remaining blood supply. This is a report of a series of prospectively studied closed distal tibial and pilon fractures treated with MIPO. A total of 21 patients with closed distal tibial or pilon fractures were enrolled in the study between March 2008 and November 2013 and completed follow-up. Demographic characteristics, mechanism of injury, time required for union, ankle range of motion and complications were recorded. Fractures were classified according to the AO/OTA classification. Nineteen patients were initially managed with an ankle-spanning external fixator. When the status of the soft tissue had improved and swelling had subsided enough, a definitive internal fixation with MIPO was performed. Patients were invited for follow-up examinations at 3 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months. Mean age of the patients was 40.1 years (range 19-67 years). Eighteen cases were the result of high-energy trauma and three were the result of low-energy trauma. According to the AO/OTA classification there were extraarticular and intraarticular fractures, but only simple articular patterns without depression or comminution. The average time for fracture union was 19.7 weeks (range 12-38 weeks). Mean range of motion was 10° of dorsiflexion (range 5-15°) and 28.3° of plantar flexion (range 20-35°). Three cases were metalwork-related complications. Two patients underwent plate removal at 24 weeks because of plate impingement. There was one case of wound breakdown at 11 weeks. One patient had fracture union with tibial recurvatum of approximately 10°, without functional impairment. Two patients had delayed union. MIPO is a reliable method of treatment for distal tibial fractures; it provides a high union rate and good functional outcome with minimal soft tissue complications. Skin impingement remains a common complication with MIPO, but this can be solved by timely plate removal.