Insertion Of Intramedullary Nail Research Articles

Surgical management of proximal femoral unicameral bone cyst in children.

The aim of this study is to evaluate the surgical treatment with the best healing rate for patients with proximal femoral unicameral bone cysts (UBCs) after initial surgery, and to determine which procedure has the lowest adverse event burden during follow-up. This multicentre retrospective study was conducted in 20 tertiary paediatric hospitals in France, Belgium, and Switzerland, and included patients aged < 16 years admitted for UBC treatment in the proximal femur from January 1995 to December 2017. UBCs were divided into seven groups based on the index treatment, which included elastic stable intramedullary nail (ESIN) insertion with or without percutaneous injection or grafting, percutaneous injection alone, curettage and grafting alone, and insertion of other orthopaedic hardware with or without curettage. A total of 201 patients were included in the study. The mean age at diagnosis was 8.7 years (SD 3.9); 77% (n = 156) were male. The mean follow-up was 9.4 years (SD 3.9). ESIN insertion without complementary procedure had a 67% UBC healing rate after the first operation (vs 30% with percutaneous injection alone (p = 0.027), 43% with curettage and grafting (p = 0.064), and 21% with insertion of other hardware combined with curettage (p < 0.001) or 36% alone (p = 0.014)). ESIN insertion with percutaneous injection presented a 79% healing rate, higher than percutaneous injection alone (p = 0.017), curettage and grafting (p = 0.028), and insertion of other hardware combined with curettage (p < 0.001) or alone (p = 0.014). Patients who underwent ESIN insertion with curettage had a 53% healing rate, higher than insertion of other hardware combined with curettage (p = 0.009). The overall rate of postoperative complications was 25% and did not differ between groups (p = 0.228). A total of 32 limb length discrepancies were identified. ESIN insertion, either alone or combined with percutaneous injection or curettage and grafting, may offer higher healing rates than other operative procedures. Limb length discrepancy remains a major concern, and might be partly explained by the cyst's location and the consequence of surgery. Therefore, providing information about this risk is crucial.

THE MODIFIED BALANCED CABLE TRANSPORT SYSTEM: A CASE SERIES UTILIZING A NOVEL TECHNIQUE FOR BONE TRANSPORT IN THE TIBIA

IntroductionBone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique.MethodolgyPatients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union.Results4/8 bone defects were due to severely comminuted open fractures requiring extensive debridement. All other cases had previously undergone fixation of tibial fractures which had failed due to infection, soft tissue defects or mal-reduction. The mean tibial defect treated with bone transport was 41mm (range 37–78mm). From the start of cable transport to removal of external fixator our patients spent an average of 201 days in frame. 7/8 patients underwent a 2-week pin-site holiday and subsequent insertion of intramedullary nail 2 weeks later. One patient had sufficient bony union to not require further internal fixation after frame removal. 10 problems were identified during treatment. These included 4 superficial infections treated with antibiotics alone and 5 issues with hardware, which could be resolved in the outpatient clinic. 1 patient had their rate of transport slowed due to poor skin quality over the site of the regenerate. 4 obstacles resulted in a return to theatre for additional procedures. 1 patient had a re-do corticotomy and 3 had revision of their internal cable transport constructs due to decoupling or screw pull out. 1 patient had residual ankle joint equinus following treatment which required an Achilles tendon lengthening procedure. Another patient underwent treatment for DVT. There were no deep infections identified and no significant limb length discrepancies or deformities.ConclusionsOverall, we have found that our modified balanced cable transport technique has allowed for successful bone transport for significant defects of the tibia. We have learned from the obstacles encountered during this case series to avoid unnecessary return trips to theatre for our future transport patients. The internal cable system allowed all patients to complete their planned transport without excessive pin tract scarring or pain. Early conversion to intramedullary nail allowed for a shorter time in frame with continued full weight bearing as the regenerate consolidated. No metalwork failure or deformity has occurred in relation to docking site union. All patients have made a good return to pre-operative function during their follow-up period with no evidence of late complications such as deep infection.

An Antibiotic-Loaded Hydrogel Demonstrates Efficacy as Prophylaxis and Treatment in a Large Animal Model of Orthopaedic Device-Related Infection.

Local antibiotic therapy is increasingly being recognised for its role in preventing and treating orthopaedic device-related infection (ODRI). A bioresorbable, injectable gentamicin-loaded hydrogel has been developed to deliver local antibiotics at the time of surgery with potential for both prevention and treatment of ODRI. In a prophylaxis model, the antibiotic hydrogel was compared with systemic perioperative antibiotic prophylaxis alone in twelve sheep (six per group) at the time of intramedullary (IM) nail insertion to the tibia, which was inoculated with methicillin-sensitive Staphylococcus aureus (MSSA). In a treatment model of single-stage revision surgery, adjunctive antibiotic-loaded hydrogel was compared with systemic antibiotics alone in a single stage revision of MSSA infection associated with a tibia intramedullary nail in eleven sheep (five/six per group). The primary endpoint was quantitative microbiological results of soft tissue, bone and sonicate fluid from explanted hardware at the time of euthanasia. At euthanasia, the control sheep that received no local antibiotics in the prophylaxis model were all culture-positive (median 1x108, range 7x106-3x108 colony forming units, CFU) while only two of six sheep receiving local gentamicin had any culture positive biopsies (median 1x101, range 0 - 1x105 CFU). For the treatment model, sheep receiving only systemic antibiotics were all culture-positive (median 8x105, range 2x103- 9x106 CFU) while only two of six sheep treated with gentamicin-loaded hydrogel had any culture positive biopsies (median 3x102, range 0 - 7x104 CFU). Local gentamicin concentrations measured in extracellular fluid in the tibial canal show a burst release of gentamicin from the hydrogel. Serum gentamicin concentrations peaked in both models at one day post application and were below detection limit thereafter. This study has demonstrated the effective use of a locally delivered antibiotic hydrogel for both the prevention and treatment of ODRI that is superior to that of systemic antibiotics alone. Future studies will endeavour to translate from preclinical to clinical research trials.

Acute Correction of Multiplanar Proximal Tibial Deformity Utilizing Fixator-Assisted Intramedullary Nailing.

The patient is positioned supine on a radiolucent table. The locations of the proximal tibial osteotomy, fibular osteotomy, external fixator pin sites, and intramedullary nail insertion site are marked with use of a surgical marker and fluoroscopic imaging. Large external fixator half-pins are placed proximal and distal to the planned tibial osteotomy in both the anterior-posterior and sagittal planes, avoiding the path of the planned tibial intramedullary nail. A fibular osteotomy and then a low-energy tibial osteotomy are performed with use of multiple drill holes and an osteotome. Next, the bone deformity is fully corrected and held in the corrected alignment with the external fixators. Then, the opening drill for the intramedullary nail is introduced into the proximal aspect of the tibia over a guidewire, and blocking screws are placed in the coronal and sagittal planes of the proximal fragment next to the opening reamer. The intramedullary canal is then reamed over a ball-tipped guidewire to the desired diameter and the selected intramedullary nail is placed and secured with proximal and distal interlocking screws. Finally, the external fixators are removed. Alternative operative treatments include external fixation and gradual or acute deformity correction as well as fixator-assisted acute deformity correction and plate fixation13-16. Typically, a tibial osteotomy with gradual deformity correction with use of a circular fixator is employed for the treatment of these deformities3,17. The literature shows this to be an effective technique for accurate correction of these complex proximal tibial deformities. With the advent of internal motorized lengthening nails, however, there have been increasing efforts to develop safe and accurate techniques for acutely correcting bone deformity so that these nails can be utilized to treat both angular deformities and bone-length differences simultaneously. Deformity at the proximal aspect of the tibia is often multiplanar, and complete correction of these deformities requires translation, angulation, and rotation through the osteotomy. An osteotomy performed at the proximal aspect of the tibia results in the equivalent of a proximal-third tibial fracture, which is more challenging and more demanding to fix than a diaphyseal tibial fracture because of the wide medullary canal and the strong deforming muscular forces at the proximal tibia. Fixator-assisted intramedullary nailing with blocking screws allows for the accurate correction of the mechanical and anatomic axes while avoiding external fixation. The expected outcome is complete bone deformity correction and healing of the osteotomy site(s)2. Careful preoperative planning is essential to accurately correct the anatomic and mechanical axes in all planes.In cases of acute correction of severe bone deformities, consider prophylactic nerve decompression.When possible, avoid the use of a tourniquet in order to minimize tissue trauma, postoperative swelling, and the need for prophylactic fasciotomies.Obtain and hold perfect osseous alignment with use of temporary uniplanar external fixators prior to placing any definitive hardware. AP = anteroposteriorIM = intramedullaryPACS = picture archiving and communication systemK-wire = Kirschner wireCORA = center of rotation and angulationDVT = deep venous thrombosisPE = pulmonary embolism.

Treatment of Periprosthetic Joint Infection in Total Knee Arthroplasty with a Temporary Intramedullary Nail: Is a Long or Short Nail Better?

To our knowledge, no studies have compared postoperative outcomes between patients who received a temporary short or long intramedullary (IM) nail in the setting of infected total knee arthroplasty (TKA). Therefore, the aim of this study was to compare short-term outcomes for patients who underwent long or short IM nail insertion for treatment of periprosthetic knee infection. Specifically, we compared: (1) success rates; (2) patient reported/functional outcomes; and (3) complications between patients implanted with a short or a long IM nail following PJI of the knee. A retrospective chart review was performed for patients who underwent two-stage exchange arthroplasty with a temporary long or short IM nail between November 2010 and June 2018 at our institution (n = 67). Continuous and categorical variables were assessed using t-test/Mann-Whitney U test and chi-squared test, respectively. Logistic regression analyses were conducted to assess the effect of IM nail length on success rate while adjusting for age, sex, body mass index, and race. A total of 36 patients underwent temporary treatment with a long IM nail, while 31 patients received a short IM nail. There were no differences in success rate for reimplanted patients treated with long and short IM nails (odds ratio 0.992; p = 0.847). Fewer patients with a long IM nail went on to reimplantation (52.8 vs. 83.9%; p = 0.007). There was no difference in satisfaction (7.86 vs. 7.68; p = 0.515), pain scores (3.39 vs. 4.45 points; p = 0.126), or Knee Society score outcome scores (150.61 vs. 166.26 points; p = 0.117) between long or short IM nail patients. Following reimplantation, there was no difference in the number of patients who became reinfected (15.8 vs. 11.5%; p = 0.679) or went on to amputation (0 vs. 7.7%; p = 0.210). Periprosthetic joint infection (PJI) is a rare but serious postoperative complication following TKA. Our findings suggest that the use of long and short IM nails during two-stage exchange can have equal utility in PJI patients with severe bone defects.

Does Retrograde Femoral Nailing through a Normal Physis Impair Growth? An Experimental Porcine Model.

Materials and methodsThe study was carried out using an experimental porcine model. Eleven juvenile female porcines were randomized for insertion of a retrograde femoral nail in one limb. The other limb acted as a control. The animals were housed for 8 weeks before the nail was removed and housed for 8 additional weeks, that is, 16 weeks in total. Growth was assessed by interphyseal distance on 3D magnetic resonance imaging (MRI) after 16 weeks and the operated limb was compared to the non-operated limb. Histomorphometric analysis of the physeal canal was performed.ResultsNo difference in longitudinal growth was observed when comparing the operated femur to the non-operated femur using MRI after 16 weeks. No osseous tissue crossing the physis was observed on MRI or histology. The empty canal in the physis after nail removal was filled with fibrous tissue 16 weeks after primary surgery.ConclusionGrowth was not impaired and no bone bridges were seen on MRI or histology 16 weeks after insertion and later removal of the retrograde femoral nail.Clinical significanceThe insertion of a retrograde intramedullary femoral nail centrally through the physis and later removal might be safe, however, long-term follow-up is needed.Aim and objectiveThe insertion of an intramedullary nail may be beneficial in certain cases of leg length discrepancy (LLD) in children. However, it is unknown if the physeal injury due to the surgery may cause bone bridge formation and thereby growth arrest after removal. This study aimed to assess longitudinal interphyseal growth 16 weeks after insertion and later removal of a retrograde femoral nail passing through the physis. Moreover, to analyse the tissue forming in the empty physeal canal after removal of the nail.How to cite this articleAbood AA, Rahbek O, Olesen ML, et al. Does Retrograde Femoral Nailing through a Normal Physis Impair Growth? An Experimental Porcine Model. Strategies Trauma Limb Reconstr 2021;16(1):8–13.

DETERMINATION OF THE EFFICACY OF SUPRAPATELLAR APPROACH FOR INTRAMEDULLARY NAILING OF PROXIMAL TIBIAL FRACTURES

Summary. The topicality of the research is predetermined by the high frequency of adverse functional results after PTF (proximal tibial fractures) treatment, like deforming osteoarthritis, contractures, knee joint instability developing fairly often in the distant period and occurring in 5.8% to 28% of cases; disability rate up to 5.9-9.1%. The mater of a traditional approach to an intramedullary nail insertion point versus the suprapatellar one for FPRTB intramedullary nailing is still under discussion. Objective: To specify the efficacy of suprapatellar approach for IM nailing in patients with PTF. Materials and methods: prospective and retrospective analysis of the efficiency of 30 PTF patients’ treatment at the clinic of the State Institution “ITO NAMN of Ukraine” and at the traumatology department of KNMP “Globinskaya CRН” within 2016-2017, using both suprapatellar and traditional accesses. Their outcomes have been evaluated after their fractures consolidation (1 year after the start of the treatment) according to the Neer-Grantham-Shelton scale. Results. The IM nailing from the suprapatellar access has shown itself to be the most efficient method for proximal tibial fractures management. The share of excellent results reached 60%, demonstrating statistically significant difference (p ≤ 0.01) from those of patients cured from a traditional access; there were only 20% of satisfactory results. No poor results were reported. Practical importance: the study proves the expediency of suprapatellar access in IM nailing of PTF and the need for wider implementation of the method within the territory of Ukraine. Conclusions. Considering the low injury rate and ensuring potentially better bone fragments reposition, the suprapatellar access in IM nailing is the most efficient method for PTF management.

Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications.

Antegrade insertion of third-generation intramedullary nail (IMN) has been shown to provide excellent results in young patients for treatment of displaced two-part surgical neck fracture. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. The purpose of this study was to report the health-related quality of life (HRQoL), functional results, and postoperative complications obtained with straight third-generation antegrade nailing of proximal humerus fractures (PHFs) in elderly patients. A retrospective review of 32 patients aged 80 y.o. or older presenting a two-part or three-part PHFs treated with a straight IMN with a minimum follow-up of 12months. Results assessed included 1) radiographic measures 2) clinical data: Charlson Comorbidity Index (CCI), VAS, range of motion (ROM), Individual Relative Constant score (IRC), Simple Shoulder Test (SST) and 3) Health-related Quality of life (HRQoL) with the EQ-5D index/EQ-VAS. Mean age was 82.1 (range 80-90) and mean follow-up was 45.6months (range 16-53months) with 91% of female patients and a mean CCI 4.6. 81% were two-part surgical neck fractures and 19% were three-part greater tuberosity fractures. The mean neck-shaft angle (NSA) at final follow-up was 132º ± 17.9º. 15.6% underwent hardware removal because of subacromial impingement and one patient (3%) was revised to RSA because of severe secondary fracture displacement. Mean IRC was 67,7 ± 30, the mean SST and VAS-Pain were 8.1 ± 3.1 and 3.2 ± 3.2, respectively, and the mean EQ-5D/EQ-VAS were 0.40 ± 0.33/64.2 ± 8.9. At last review, mean active forward flexion, abduction, and external rotation were 115º ± 35º, 100º ± 35º, and 20º ± 15º, respectively. Appropriate selection of fracture and proper operative technique with a third-generation nail result in good functional results and good HRQol with a low complication rate in elderly population.

Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60

IntroductionIntramedullary nailing is an acceptable treatment option for femoral shaft fracture in young patients but not extensively studied in the elderly with osteoporotic fractures. Plate fixation for osteoporotic femoral shaft fractures have a high rate of complications and delayed healing time, and the most acceptable treatment is intramedullary nailing. This study evaluated the healing time and incidence of complications in osteoporotic femoral shaft fractures after intramedullary nailing. Patients &MethodsThis was a retrospective study that included 16 patients above 60 years old with osteoporotic femoral shaft fractures operated between January 2015 and December 2018. Patients with metastatic fractures or with atypical fractures were excluded. Thirteen patients had low-energy injuries such as a simple fall from standing height or lower and twisting injuries. The remaining 3 patients sustained high-energy-mechanism of injury. No patient received bisphosphonate except 2 patients received oral bisphosphonate for a period of 6 and 8 months, respectively. ResultsSixteen patients (12 females and 4 males) with mean age 69.5 ± 3.7 presented with femoral shaft fracture were operated with intramedullary nail, 10 patients were fixed with trochanteric entry nails with proximal neck screws, and 6 patients were fixed with piriformis entry nails. In 9 patients, closed reduction of fracture was achieved while 7 patients required open reduction, of which 5 fracture required cerclage wire addition. The mean bone healing time was 5.35±1.2 months. Intraoperative extension of femoral fractures during intramedullary nail insertion was observed in two cases that required open reduction and addition of cerclage wires around the fracture. The overall incidence of complications was 18.7%. ConclusionsIntramedullary nailing for osteoporotic femoral shaft fracture is a good acceptable option in elderly patients with reasonable healing time with no major complications.

Variability of human femoral geometry and its implications on nail design

ObjectivesThe objectives of this study are to present a new method of quantifying variability in human femoral geometry and to use this data to optimize intramedullary nail geometry for a better fit within the femoral canal. MethodsComputed tomography (CT) scans of forty intact adult human femora were divided according to race, sex, and age, and were reconstructed digitally into three-dimensional solid models. Geometric features were then measured and compared among groups using ANOVA. An average geometric model was generated, from which an optimal intramedullary (IM) nail curvature function was derived. Insertion of the derived optimal nail and of two currently-available commercial nails into the femur having the highest degree of curvature was then simulated via finite element methods. ResultsSubstantial variability in femoral curvature was observed among the population sample. Sex was found to correlate most strongly with femoral size; males tend to have larger femora than females. Although the average femoral radius of curvature for African Americans was slightly higher than for Caucasians, the difference was not statistically significant. Curvature did not vary across the sample by age, sex or race. Finite element analysis results simulating IM nail insertion using the geometrically-optimized nail showed a substantial decrease in von Mises stress when compared to tested commercially-available IM nails. Fracture was predicted within the posterior canal wall for commercially available nails, as the generated stresses exceeded the allowable stress of cortical bone, but not for the geometrically-optimized nail. ConclusionsConsidering variation in femoral geometry among patients when designing implantable fixation devices may be important. Femoral size differs between adults by sex, with males being larger than females. Pattern of curvature, however, did not differ, although there may be slight differences between European and African Americans. As such, the proposed average femoral curvature function calculated here may be sufficient for the entire population. According to finite element analysis, insertion-induced stresses in the femur were within the allowable range for the geometrically-optimized nail and appear more desirable than in other common nail designs.

Analysis of Computed Tomography-Based Technique for Measuring Femoral Anteversion: Implications for Measuring Rotation After Femoral Intramedullary Nail Insertion.

To assess the reliability of the current computed tomography (CT)-based technique for determining femoral anteversion and quantify the prevalence and magnitude of side-to-side differences. Cross-sectional cohort study. Academic trauma center. We reviewed CT scans from 120 patients with bilateral full-length axial cuts of both femurs. Two hundred forty femurs with no fractures or other identifying features in their femora were included. Ten unique data sets were created to measure anteversion of the left and right sides. Intraobserver and interobserver reliability were calculated using intraclass correlation coefficients (ICCs) and pooled absolute differences. The mean absolute difference between the sides was determined using a fixed-effects model. Interobserver reliability was high (ICC: 0.85, 95% confidence interval [CI]: 0.83-0.88). The pooled mean absolute magnitude of variation between reviewers was small at 1.6 degrees (95% CI: 1.4-1.8 degrees) per scan. The intraobserver reproducibility was high (ICC: 0.91, 95% CI: 0.88-0.93) with a mean error of 2.7 degrees (95% CI: 2.2-3.1 degrees) per repeat viewing of the same scan by the same person. The magnitude of side-to-side variation was 2.0 degrees (95% CI: 1.5-2.6 degrees). Twenty-one subjects (18%, 95% CI: 12%-25%) had a mean side-to-side calculated femoral anteversion difference of ≥10 degrees, whereas 6 (5%, 95% CI: 2-10) subjects had a calculated mean side-to-side difference of ≥15 degrees. CT based femoral anteversion measurement techniques demonstrate good precision. Only 1 in 20 patients had side-to-side differences of 15 degrees or more.

Does Virtual Reality Improve Procedural Completion and Accuracy in an Intramedullary Tibial Nail Procedure? A Randomized Control Trial

Artificial reality technologies are currently being explored as potential options to improve surgical education. Previous studies have primarily examined the efficacy of artificial reality in laparoscopic procedures, but to our knowledge, none have been performed in orthopaedically relevant procedures such as intramedullary tibial nailing, which calls for more versatile large-scale movements. Does a virtual reality simulator with or without a standard technique guide result in (1) a higher proportion of participants who completed the insertion of an intramedullary tibial nail in a synthetic bones model and (2) greater procedural accuracy than does training with a technique guide alone? Twenty-five first- and second-year medical students without prior exposure to intramedullary tibial nail insertion were recruited. Participants were randomly assigned to the technique guide control group (n = 8), the virtual reality group (n = 8), or the virtual reality and technique guide group (n = 9). The technique guide was adapted from a commercially available technique guide, which participants in the assigned groups could use to prepare as much as desired. The virtual reality simulation was based on the same procedure, and we used a commercially available virtual reality simulator that we purchased for this task. Participants in the virtual reality experimental groups completed the simulation on three separate sessions, at a set interval of 3 to 4 days apart. After 10 to 14 days of preparation, all participants attempted to insert an intramedullary nail into an intact, compact bone-model tibia that lacked surrounding soft tissue. Participants were given written hints if requested, but no other assistance was given. A procedure was considered complete if the nail and screw were properly placed. Procedural accuracy was defined as the number of incorrect steps normalized out of the 16 possible performed. After the procedure, one orthopaedic surgeon assessed a blinded video of the participant performing it so the assessor could not recognize the individual or that individual's gender. Additionally, the assessor was unaware of which group each participant had been randomized to during the evaluation. A higher proportion of participants in the virtual reality group (6 of 8) and the virtual reality and technique guide group (7 of 9) completed the intramedullary nail than did participants in the technique guide group (2 of 8; p = 0.01). There was no difference in completion between the virtual reality groups (p = 0.89). Participants in the virtual reality and virtual reality and technique guide had fewer normalized incorrect steps than did participants in the technique guide group (3.2 ± 0.1 of 16 and 3.1 ± 0.1 of 16 versus 5.7 ± 0.2 of 16, respectively; p = 0.02 for comparisons of virtual reality groups to technique guide, p = 0.63 between the virtual reality group). Virtual reality increased both procedural accuracy and the completion proportion compared with a technique guide in medical students. Based on our findings, virtual reality may help residents learn the procedural workflow and movements required to perform surgical procedures. Future studies should examine how and when exactly the technology can be applied to residencies and its impact on residents. Level I, therapeutic study.

Association Between Femoral “Spike” Size After Intramedullary Nailing and Subsequent Knee Motion Surgery

To determine the association between displaced femoral shaft bone fragments ("spikes") seen on radiographs after intramedullary nail insertion and the need for future motion surgery. Retrospective case-control study. Academic trauma center. We included patients with femoral shaft fractures treated with intramedullary nail insertion. Case patients (n = 22) had developed knee stiffness treated with motion surgery. The control group was a randomly selected sample (1:3 ratio). Motion surgery to address knee stiffness. We defined a "spike distance ratio" and "spike area ratio" from initial postoperative anteroposterior and lateral radiographs. Multivariable logistic regression determined the effect of spike distance and area ratios on the likelihood of need for motion surgery, controlling for polytraumatic injuries and bilateral fractures. The case group had a median femoral spike distance ratio of 1.9 [interquartile range (IQR), 1.6-2.5] compared with 1.5 (IQR, 1.2-1.8) in the control group. An increased femoral spike distance ratio was associated with increased odds of motion surgery (P < 0.01). A femoral spike distance >2 times the femoral radius had 32 times the odds (95% confidence interval, 2-752) of motion surgery compared with patients with distance ratios <1.25. Median femoral spike area ratios were similar between the case (0.2; IQR, 0.1-0.5) and control (0.2; IQR, 0.0-0.5) groups and were not associated with increased odds of motion surgery (P = 0.34). A larger spike distance ratio is associated with increased odds of subsequent motion surgery. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Faceoff: Suprapatellar Tibial Nailing for Tibia Fractures.

Clinical Faceoff: Suprapatellar Tibial Nailing for Tibia Fractures.

Semiextended Tibial Nail Insertion Using an Extraarticular Lateral Parapatellar Approach: A 24-Month Follow-up Prospective Cohort Study.

To analyze the outcomes of tibial shaft fractures treated with a lateral parapatellar approach in the semiextended position for intramedullary nail insertion. Prospective cohort study. Level I trauma center. Seventy patients treated from March 2012 to July 2015 with intramedullary nailing (IMN) using an extraarticular lateral parapatellar approach in the semiextended position were reviewed. Patients were clinically and radiographically checked at a minimum follow-up of 24 months, and the following data were recorded: fracture healing, any residual deformity, nail-apex distance, range of motion of the treated knee together with the contralateral side, knee functional outcome, and residual knee pain. Twenty-four months after surgery, all patients were clinically and radiographically healed, with 2 cases of malalignment (angular deformity <10 degrees). The average range of motion of the treated knee was 0-130.6 degrees (±8.6 degrees) compared with 0-131.1 degree (±7.9 degrees) of the contralateral. Lysholm knee score was excellent for 57 patients, good for 11, and fair for 2. The mean residual pain was 0.6 (±1.1) according to the visual analogue scale. The described technique represents an effective option for IMN of tibial fractures. It is suitable for all tibial fractures, including proximal and distal. The results of our series demonstrate the effectiveness of this technique with nearly complete recovery of knee function and negligible incidence of anterior knee pain at a minimum follow-up of 24 months. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Application of fracture-sustaining reduction frame in closed reduction of femoral shaft fracture

ObjectivesThis study aims to explore the clinical efficacy of applying a new reduction brace in the closed reduction of femoral shaft fracture.MethodsA total of 18 patients with femoral shaft fracture, who were admitted to the Bone Trauma Surgery, Second Hospital of Shanxi Medical University, from September 2015 to January 2017, were chosen. A novel reduction brace combined with closed reduction intramedullary nail insertion on the traction table adopted for the orthopedic surgery was taken for the fixation. Then, surgical time, bleeding amount, and postoperational fracture healing time were recorded.ResultsAll 18 patients with femoral shaft fracture successfully received closed reduction femoral nail with the application of the novel reduction brace. The follow-up period was 3–18 months, with an average of 12 months, and the femoral shaft fracture was well healed with good recovery of function.ConclusionsThe design of the closed reduction brace of the femoral shaft fracture was reasonable, simple, and convenient to use and has a short learning curve. Furthermore, it led to little trauma to these patients and fully played the advantages of minimally invasive therapy for femoral fractures.

Intra-medullary nail insertion accuracy: A comparison of the infra-patellar and supra-patellar approach

AimsThe anatomical safe zone for intra-medullary nail insertion through the tibial plateau is small, insertion outside of this area risks damage to intra-articular structures and poor fracture reduction. The purpose of this retrospective study was to determine if the new supra-patella (SP) approach confers improved nail insertion accuracy, when compared with the standard infra-patella (IP) technique. Patients and MethodsTwo hundred cases were included in the study (SP 95, IP 105). Insertion accuracy was assessed on AP and lateral radiographic imaging, and measured as the distances between the central axis of the proximal nail and the ideal entry point. ResultsThe median distance from the ideal entry point was 4.4 mm (SP) and 5.1 mm (IP) (p = 0.046) in the coronal plane, and 4.0 mm (SP) and 3.7 mm (IP) (p = 0.527) in the sagittal plane. A narrower range in measurements was observed in the SP technique in both sagittal and coronal planes, 17.8 mm vs 28.6 mm, and 19.7 mm vs 30.3 mm respectively. ConclusionWe found that the SP technique achieved significantly improved nail insertion accuracy in the coronal plane. Insertion accuracy was equivocal between the two techniques in the sagittal plane. A narrower range in entry points was observed in the SP cohort in both planes suggesting improved control in nail insertion using this technique.

Minimally invasive retrograde insertion of elastic intramedullary nails for displaced clavicle fractures in children

To study the application and effect of retrograde titanium elastic nails fixation for the treatment of displaced clavicle fracture in children under closed reduction. From January 2014 to November 2016, 26 children with displaced fractures of the clavicle were treated by closed reduction and retrograde inserted titanium elastic nails including 14 boys and 12 girls with an average age of 9.2 years old ranging from 7 to 14 years. Time from injury to operation was 2 to 7 days with an average of 2.8 days. Visual analogue score (VAS) was used to evaluate the main complaint pain in all patients before and 2 days after operation. The Neer score of shoulder function between affected side and healthy side at 2 months after operation were compared. All the 26 children were followed up for 6 to 12 months. All cases healed well without infection, broken nails or titanium elastic nails exit complications. All children achieved anatomical reduction, good bony union, and good recovery of shoulder joint activity. The average time of removing nail was 14 to 32(16.25±2.62)weeks. The pain VAS score was significantly relieved 2 days after operation (P<0.05). At 2 months after operation, the Neer score of shoulder joint was 98.46±1.07 in affected side and 98.58±1.10 in healthy side respectively, there was no significant difference between the two groups (P>0.05). Titanium elastic intramedullary nail fixation for the treatment of displaced clavicular fracture in children has the advantages of minimal invasion, no effect on skin beauty, rapid healing of fracture, good recovery of postoperative function, simple nailing and less complications.

Radiographic predictors of symptomatic locking screw removal after treatment of tibial fractures with intramedullary nails

IntroductionThe purpose of this study was to determine the radiographic parameters associated with symptomatic locking screw removal after intramedullary tibial nail insertion. Our hypothesis was that locking screws located closer to joints and those extending longer than the width of the bone result in more symptomatic implant removal. MethodsWe conducted a retrospective cohort study at our Level I trauma center. Seventy-five patients underwent surgical removal of symptomatic locking screws from 2007 to 2014 and were compared with a control group of 122 patients from the same time period who did not undergo symptomatic locking screw removal. Our main outcome measures were radiographic and demographic factors associated with implant removal. ResultsMultivariable regression indicated that a proximal locking screw that started anterolateral and was directed posteromedial was the strongest radiographic predictor of symptomatic removal (odds ratio [OR], 2.83; p = 0.03). An Injury Severity Score <11 (OR, 3.10; p < 0.001) and a body mass index <25 kg/m2 (OR, 2.15; p = 0.02) were also associated with locking screw removal. The final prediction model discriminated patients requiring symptomatic locking screw removal with moderate accuracy (area under the receiver operating characteristic curve = 0.73). ConclusionsThe strongest radiographic predictor for symptomatic locking screw removal after tibial nail insertion was the direction of the most proximal locking screw. In contrast to previous research on retrograde femoral nails, tibial locking screws that were closer to the joints were not associated with an increased likelihood of symptomatic screw removal. Clinicians can use these data to help counsel patients regarding the likelihood of symptomatic screws and perhaps to help guide screw placement in cases with multiple options.

Precise-surgical-opening intramedullary nail insertion in treating unstable femoral intertrochanteric fractures with closed-reposition difficulty

To compare clinical efficacy of repositioning with precise-surgical-opening intramedullary nail insertion and traditional repositioning in treating unstable femoral intertrochanteric fractures with closed-reposition difficulty. Clinical data of 58 patients with unstable femoral intertrochanteric fractures after closed-reposition difficulty (AO 31A2.2-3.3) were retrospective analyzed. Among them, 32 patients were treated with first open intramedullary nail and then reduction operation(modified reductuon group) including 9 males and 23 females with an average age of (80.9±11.1) years old ranging from 46 to 99 years old; and 26 patients were treated by traditional reduction(traditional reduction group) including 7 males and 19 females with an average of(78.1±13.9) years old ranging from 41 to 89 years old. The time of operation, the amount of bleeding, the length of hospital stay, the first weight-bearing time and the time of fracture healing, postoperative complications and Harris hip score were evaluated and compared between the two groups. All patients were followed up for 12 to 24 months with an average of 17.3 months. The operative time(t=3.612, P=0.008 2) nd the blood loss(t=3.389, P=0.007 5) in the modified reduction group were lower than those in the traditional reduction group. There were no significant differences in hospitalization time(t=0.851, P=0.392), fracture healing time(t=0.640, P=0.531), and the first loading time(t=0.845, P=0.411) between two groups. There was no significant difference in the Harris score between two groups(χ²=0.66, P=0.831>0.05). Traditional repositioning requires a repositioning of the fracture bone and a correct opening reaming before the insertion and fixture of the intramedullary nail, which is a complicated operation in unstable femoral intertrochanteric fractures after closed-reposition difficulty. On the other hand, the new method implements the insertion of the intramedullary nail before the repositioning of the fracture bone, greatly simplifying the operation procedure, shortening the total operation time and reducing the amount of intraoperative blood loss.