IM Nailing Research Articles

Reamed Versus Unreamed Intramedullary Nailing of the Femur: Comparison of the Rate of ARDS in Multiple Injured Patients

To compare the rate of Acute Respiratory Distress Syndrome (ARDS) in multiply injured patients with femoral shaft fractures, treated with intramedullary femoral nails inserted with or without reaming. Prospective, randomized, multicenter, clinical trial. Seven Level 1 trauma centers. Three hundred fifteen patients with 322 femoral shaft fractures were stratified into 2 groups according to their estimated injury severity scores (ISS > or =18 vs. ISS<18) and then randomized to receive an IM nail with either reamed or unreamed insertion for primary stabilization of their femoral shaft fracture. One hundred forty seven patients with 151 fractures received an unreamed nail whereas 168 patients with 171 fractures, received a reamed nail. All fractures were nailed within 24 hours after their trauma. Closed intramedullary nailing for femoral shaft fractures. Determination of the rate of ARDS in patients undergoing intramedullary nailing of femoral shaft fractures. Three of the 63 multiply injured patients who received a reamed nail developed ARDS as compared with 2 out of 46 patients in the unreamed group. This difference was not statistically significant (P=0.42). (The power for this difference is only 5%. 39,817 patients are needed in each group to detect a difference that small.) This difference was not statistically significant. There were a total of 4 deaths, 2 each in both the reamed and unreamed group. No death resulted from ARDS. The overall incidence of ARDS was found to be low with primary stabilization of femoral shaft fractures with intramedullary nailing. There was no difference in the incidence of ARDS between the reamed and unreamed groups, given the sample size.

Pathologic Fracture of Proximal Femur with Benign Bone Tumor

Purpose : The treatment results for a proximal femur fracture caused by a benign bone lesion were evaluated. Materials and Methods : Nineteen patients (23 cases) who had been treated for proximal femur pathologic fracture from 1987 to 2002 were enrolled in this study. The mean follow-up duration was 40 months. The causes and treatments of the pathologic fractures and complications such as nonunion, deformity and recurrence were evaluated. Results : The benign bone lesions treated were fibrous dysplasia (15), simple bone cyst (3), aneurysmal bone cyst (2), giant cell tumor (2) and eosinophilic granuloma (1). An autograft (3), allograft (2), and both autograft and allograft (3) was performed after adjuvant curettage with a high-speed burr. There was no recurrence in these 8 cases. At the final course, internal fixation was performed in 18 cases (intramedullary nail (10), compressive hip screw (6), plate (1), screw (1)), a hip spica cast 3 cases and a THR 2 cases. Three cases where a hip spica cast had been performed showed a varus deformity. A refracture and deformity were prevented in 10 cases who underwent intramedullary nailing. Conclusion : The IM nail is very effective in preventing complications such as a deformity, refracture after a treatment for polyostotic fibrous dysplasia. However, in a solitary benign bone lesion, bone graft and internal fixation is effective after thorough curettage.

Avascular necrosis of femoral head after IM nailing for fracture shaft -A case report

Avascular necrosis of femoral head after IM nailing for fracture shaft -<i>A case report</i>

Delayed onset tibial nerve axonotmesis and posterior tibial artery pseudoaneurysm caused by tibial diaphysis fracture

Duringafootballgame,a20-year-oldmansustainedaclosed rightoblique fractureatthejunctionofthemiddle and distal third of the tibia and fibula shaftswith no neurovascular deficit (Fig. 1a and b). Heunderwent intramedullary nailing of his right tibia(Trigen IM nail, Smith & Nephew Orthopaedics).Closed reduction and instrumentation was achievedwithout penetrating the surrounding soft tissues(Fig. 2).Routine subcutaneous Dalteparin 2500 units wasadministered daily as thromboprophylaxis, andthere were no signs of any neurovascular compro-miseintheimmediatepostoperativeperiod.Hewasdischarged from hospital after 3 days.On day 11, his right calf was 3 cm more swollenthan the left. A venous Doppler was performedrevealing no evidence of deep vein thrombosis(DVT).On day 19, the swelling worsened and he devel-oped movement induced neuralgic pain and anaes-thesia along the medial aspect and sole of his rightfoot. A repeat venous Doppler examination wasperformed to the level of the venous trifurcation,revealing no evidence of DVT.On day 29, he was admitted complaining ofsevere pain and paraesthesia of his right foot andankle. He had loss of sensation over the distributionof his right medial plantar nerve and was referred

Ankle distraction device in IM nailing of tibial fracture

Ankle distraction device in IM nailing of tibial fracture

Infection resistance of unreamed solid, hollow slotted and cannulated intramedullary nails: an in-vivo experimental comparison

Infection continues to be a problematic complication of fracture treatment, particularly in severe open fractures. The implant design and material as well as implantation technique play an important role in the pathogenesis of local infection. The aim of our study was to determine if the local resistance to infection of a cannulated IM nail is less than that of a solid nail and more similar to that of a hollow nail. In 65 female White Zealand rabbits, the intramedullary cavity was inoculated with matching concentrations of Staphylococcus aureus, and one of the three nails was inserted. The solid nail had a greater than twofold higher resistance to infection (23%) compared to that of the other two nails (hollow, 65%; cannulated, 61%) which was statistically significant ( p < 0.02). No difference in infection resistance was detected between the hollow slotted and cannulated nail designs ( p = 1). Although these experimental results may be clinically considered, direct extrapolation to clinical infection rates is ill advised.

Operative Treatment of Traumatic Humeral Shaft Fracture: Comparision of Interlocking IM Nailing and Plate Fixation by Posterior Approach

Operative Treatment of Traumatic Humeral Shaft Fracture: Comparision of Interlocking IM Nailing and Plate Fixation by Posterior Approach

The Incidence of Infection in Interlocking Intramedullary Nailing after Skeletal Traction of Distal Femur

Purpose: The insertion site of K-wire for skeletal traction is proximal part of tibia or distal part of femur. However, people prefer proximal tibia over distal femur due to lower risk of infection rate when change to interlocking IM nailing is needed. We evaluated the infection rate of interlocking IM nailing. Materials and Methods: Fourty-seven patients were included in this study who underwent interlocking IM nailing due to femur shaft fracture. Traction was applied at the distal femur in 19 cases and proximal tibia in 10 cases before interlocking IM nailing. No skeletal traction was applied to the remaining 18 cases. Thirty-eight patients were male and 9 were female. The average age at the time of surgery was 36.7 years old (range, 15~17 years). The average traction period was 9.5 days (range, 3~33 days) and the average followed-up period was 17.2 months. Results: In the distal femoral traction group, 8 cases of superficial pin tract infection developed, but no case of deep infection such as osteomyelitis occurred. In the proximal tibia traction group, 2 cases of superficial pin tract infection developed, but no case of deep infection occurred. In the group that received no skeletal traction before interlocking IM nailing, no case of infection developed. Conclusion: In femur shaft fracture, the distal femoral skeletal traction followed by interlocking IM nailing of femur, compared to proximal tibia skeletal traction, did not increase the risk of deep infection such as osteomyelitis.

The Effect of Fibular Malreduction on Ankle Joint after Tibial Interlocking IM Nailing of Tibial and Fibular Fractures

목 적: 편측 경골 및 비골 간부 골절 환자 중, 경골만 교합성 골수내 금속정 삽입술을 시행한 자로, 술 전 비골의 골절 형태가 분쇄골절, 분절골절 또는 나선상골절로, 1년 이상 추시 관찰 시, 비골 간부 골절의 불량 정복으로 인한 족관절의 방사선적 변화와 임상결과를 비교 분석하기 위함이다. 대상 및 방법: 1995년부터 2002년까지 편측 경골 및 비골 간부 골절 환자 중 비골 간부의 골절 형태가 분쇄골절 또는 분절골절이며, 편측 경골 및 비골 간부 골절에서 대해 경골만 교합성 골수내 금속정 삽입술 시행 후 비골 불량 정복된 최종 추시 관찰이 가능한 39명을 대상으로, 후향적으 로, 기립 상태에서 양측 족관절 전 · 후면 방사선 사진을 촬영하여 거골-하퇴각 (talocrural angle)과 원위 경골 관절면부터 외과 끝까지의 길이를 측정하여 paired t-test로 분석하였고, 거골 하퇴각과 외과 끝까지의 길이 차이와 AOFAS score와의 관계를 Spearman 상관 분석 하였다. 결 과: 건측 및 환측의 거골-하퇴각은 각각 13.3±3.72도, 11.27±3.63도로 통계적으로 의의 있는 차이를 보였고 (p 0.05). 결 론: 경골 및 비골 간부 골절에 대해 경골만 교합성 골수내 금속정 삽입술 시, 술 전 비골 간부의 골절 형태가 단순 횡골절을 제외한, 분쇄골 절, 분절골절 및 나선상골절에대해, 추시 관찰 시 비골 간부 골절의 불량 정복으로 인해 족관절의 변화를 초래할 수 있다고 사료된다.

Ein ungewöhnlicher Fall eines chirurgischen Hitzeschadens

We report on an unusual case of an extensive heat necrosis of the tibia and its surrounding tissues including the skin after closed IM nailing. The first clinical sign appeared shortly after the procedure as circular skin necrosis over the tibial crest. The severe necrosis of a bone segment, the surrounding soft parts as well as the skin was probably the sequella of reaming of a pathologically altered bone with the tourniquet inflated. Only after a free latissimus dorsi transfer and the resection of the dead bone that was then bridged by a segmental bone transport according to the Ilizarov technique the situation could be salvaged. We concluded that reaming with the tourniquet inflated should never be done, as it can cause severe damage due to abnormal heat generation.

Rotational malalignment after fractures of the femur

Rotational malalignment is an important complication of intramedullary nailing for femoral shaft fractures. The deformity is established during the operation, indicating inadequate reduction of the fracture. Little was known about the incidence and clinical implications of femoral malrotation. In a series of 76 patients we found 28% to have rotational malalignment ( 15 ). Patients complain about problems with more demanding activities, like practicing sports. The incidence of malrotation was independent of the type of femoral nail (GK or AO) used or the location of the fracture. External rotational deformities cause significantly more symptoms than internal rotational deformities. Rotational malalignment is usually measured clinically or by computed tomography (CT). CT is currently the method of choice. Our study reveals that the accuracy of the clinical measurements is very poor ( 20 ). Also the accuracy of CT determined rotational malalignment of the femur is questionable. Differences between two measurements of one observer can be 10.8 and between two measurements of different observers 15.6 . The inaccuracy in measuring a CT image is mostly determined by the inaccuracy in drawing the line through the femoral neck. All patients with femoral malrotation tend to compensate towards a normal value of foot rotation, relative to the femoral torsion present. The major part of this compensation takes place at hip level. Patients with an external malrotation experience more difficulties compensating, than patients with an internal malrotation. In vitro, rotational malalignment is completely avoided by using the profile of the contralateral lesser trochanter as a reference. Rotations only up to 4 (2.2 1.5 ) were measured. The American Medical Association's Guide to the Evaluation of permanent Impairment does not differ between external and internal malrotation of the femur when evaluating whole person impairment. This is incorrect and the American Medical Association should consider changing this in their guidelines.

Intramedullary Nailing for the Treatment of Femoral Non-Unions Following Multiple Failed Plate Fixations

Goal: The evaluation of the clinical outcome of IM nailing for the treatment of femoral shaft pseudarthrosis in patients who had multiple failed plate osteosyntheses. Method: From January 2000 till March 2002, 18 (17 male and 1 female, mean age 37 years) patients were treated because of femoral shaft non-union in our institution. All patients had two or more failed plate osteosyntheses. There were no septic non-unions in this group. There was no segmental bone loss. In all 18 patients the implants were removed and intramedullary nailing was performed. There was extensive periosteal stripping and areas of osteonecrosis in the majority of the patients. The quality of the surrounding soft tissues was poor due to scaring. Eight femurs were grafted with autologous iliac crest bone graft. All patients were followed by serial X-rays until union. Results: There were no postoperative complications. All pseudarthroses were healed within an average of 10.7 months (6 -14). Non-unions which received bone graft (8 out of 18) in day one, were healed faster than those which didn't. There was no re-operations among these patients. Among the remaining 10 patients 6 were grafted five to six months postoperatively and three had had nail dynamization. Conclusions: Intramedullary nailing for femoral shaft non-unions after multiple failed plate osteosyntheses is a safe and effective method of treatment. It seems that autologous bone graft reduces healing time and re-operation rate.

Correlation of the Postoperative Mechanical Properties of Femoral IM Nails to the Fracture Management Process

A biomechanical study of twenty-six Grosse-Kempf interlocking intramedullary nails was carried out aiming to assess the effect of the femoral fracture characteristics and the fracture management process on the postoperative mechanical properties of the nails. The nails were retrieved from recovered patients. Full medical records were maintained. They included fracture topology, fracture type, locking type, patient mobilization time, callus formation time, time until the nail has been retrieved, patient's gender and age. The nails have been tested on a specially built four point bending jig on a 10 kN loading testing machine after establishing a specific testing protocol. The ultimate load was recorded and the nail bending stiffness was calculated. Additionally, three intact nails have been tested for comparative purposes. Two nails exhibited visible angle deformation beyond their designed curvature before testing, in the order of 1° to 3°. Only four nails exhibited ultimate load and bending stiffness values below the 90 % of the average and nominal values. Two of them were the pre-distorted specimens and one corresponded to a case of a non-union where a revision took place. There was no evident explanation for the fourth nail. Finally, the mechanical testing results were correlated to the medical records data. It was shown that the mechanical properties of the nails had hardly been affected by any of the parameters included in the medical records. This indicates that more flexible nails could be employed in the future for the treatment of femoral fractures, especially if it facilitates insertion technique.

Intramedullary spread of tumour cells during im nailing: a histological diagnosis

Metastatic lesions with some exceptions of long bones with impending or pathological fractures are treated by intramedullary nailing as the standard of care. Spread of tumour emboli into the systemic circulation during such procedures has been well documented in the literature, but to our knowledge there have been no reports documenting intramedullary tumour spread during intramedullary nail insertion. We describe four cases where the reamings collected from a venting hole at the metaphyseal/diaphyseal junction during intramedullary fixation of long bone lesions were sent for histological examinations. All samples were reported as containing large amounts of tumour cells consistent with the primary diagnosis.

Minimal Open Reduction and Interlocking IM Nailing of Comminuted Humeral Shaft Fracture: Comparison between Plate Internal Fixation.

Minimal Open Reduction and Interlocking IM Nailing of Comminuted Humeral Shaft Fracture: Comparison between Plate Internal Fixation.

Simultaneous ipsilateral diaphyseal fractures of the femur and tibia: treatment and complications

We present our experience of intramedullary nailing (IM) and external fixation in the treatment of 54 patients with ipsilateral diaphyseal fractures of the femur and tibia. Eight femoral and 24 tibial fractures were open. They were classified into three groups: IM nailing of both fractures (group A, 19 patients); IM nailing of the femoral and external fixation of the tibial fracture (group B, eight patients); and external fixation of both fractures (group C, 27 patients). In group C (which included all but one grade III open fracture), two patients died and four underwent amputation. Femoral fractures treated with external fixation had significantly more complications and reoperations than those treated with IM nailing. In tibial fractures this difference was also present but not statistically significant. We believe that IM nailing is the method of choice for femoral fractures and is preferable for tibial fractures, with the exception probably of grade III B and C open injuries.

IM nailing of contaminated fractures: An experimental study

IM nailing of contaminated fractures: An experimental study

The Comparative Study of Treatment between the IM nailing and the Plate fuation of the Humerus Shaft Fracture

The Comparative Study of Treatment between the IM nailing and the Plate fuation of the Humerus Shaft Fracture

Leg lengthening and correction of deformity using the femoral Albizzia nail

The albizzia femoral nail allows for lengthenings up to 10 cm. It can be used in achondroplastic patients. Multiplane corrections can be addressed with a special nail (3D-Albizzia) if multiple osteotomies are performed (e.g. for proximal and distal femoral varus). A derotation and a flexion/extension osteotomy can also be associated. IM nailing is suitable for patient with previous external fixators. Surgical planning should be careful. The operation is currently performed percutaneously, with a 1 to 2 cm skin incision for nail insertion, and a 6 mm incision for distal femoral dome osteotomies. CPM machine is applied in recovery room and rehabilitation resumes on day 1, allowing more than 120 degrees of knee flexion by day 1. Ratcheting for gradual lengthening is begun on day 5 at a rate of 1 mm/day. Muscle stretching and strengthening are maintained for one year. In bilateral cases, a preoperative strengthening program is set. A 120 degrees knee range of motion can be maintained all during lengthening. Intramedullary lengthening allows for maintaining muscle and soft tissue suppleness which protects from hyperpressure over joints and from long-term muscle waisting. The Albizzia is currently a good tool once the surgeon get used to its physiotherapy aspect. Previously reported general anaeshtesia for getting the ratcheting is barely needed, when the technique has been done percutaneously and when the full range of knee motion is recovered on day 1 and maintained thereafter.

Sonographic imaging of leg geometry

Posttraumatic malalignments are a frequent sequlae of IM nailing of lower extremity fractures. Conventional US has proven to be inferior to CT determinations of tibial or femural length and torsion. A new 3-D US method is presented that allows for accurate single step determination of lower extremity length and torsion without ionizing radiation. A regular US machine with a 5 Mhz linear probe is combined with an US localizer. Reference markers affixed to the lower extremity eliminate errors associated with patient position or motion. The 3-D US method was compared against CT (Ulm's method) in the measurement of torsion and length of the tibia and femur in 50 adults and 50 children. In both methods, the maximum difference of the intraindividual torsional angles and length measurements was 7 degrees and 7 mm. The maximum standard deviation for reproducibility in length measurement was 1.6 mm and 1.5 degrees for angular torsion. The new 3-D US technique was superior to CT in terms of reliability and reproducibility. Clinical advantages of the 3-D US technique include rapidity, independence from patient motion or positioning and the avoidance of ionizing radiation. Indications for 3-D torsional and length determinations include follow-up evaluation of adult and pediatric tibial and femoral fractures, pediatric limb and gait evaluations, and osteotomy planning.