Intramedullary Fixation Device Research Articles

Extramedullary versus intramedullary fixation of stable trochanteric femoral fractures: a systematic review and meta-analysis.

This systematic review and meta-analysis compared extramedullary fixation and intramedullary fixation for stable two-part trochanteric femoral fractures (AO type 31-A1) with regards to functional outcomes, complications, and surgical outcomes. Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results were presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). Five RCTs (397 patients) and 14 observational studies (21,396 patients) were included. No significant differences in functional outcomes, complications, or surgical outcomes were found between extramedullary and intramedullary fixation devices, except for a difference in duration of surgery (MD 14.1min, CI 5.76-22.33, p < 0.001) and intra-operative blood loss (MD 92.30mL, CI 13.49-171.12, p = 0.02), favoring intramedullary fixation. Current literature shows no meaningful differences in complications, surgical, or functional outcomes between extramedullary and intramedullary fixation of stable two-part trochanteric femoral fractures. Both treatment options result in good outcomes. This study implicates that, costs should be taken into account when considering implants or comparing fixation methods in future research.

Biomechanical comparison of different implants for PIP arthrodesis

BackgroundSurgical correction of hammertoe deformities with arthrodesis of the proximal interphalangeal joint (PIP) is one of the most frequent forefoot procedures. Recently, new intramedullary fixation devices for PIP arthrodesis have been introduced. The aim of this study was to compare a newly developed absorbable intramedullary implant made of magnesium (mm.PIP), an already available intramedullary implant made of titanium (PipTree), and the classical Kirschner-wire (K-wire). MethodsThe three intramedullary devices (mm.PIP, PipTree, and K-wire) for PIP arthrodesis were compared. A classical arthrodesis of the PIP joint was performed on fifty-four composite synthetic bone pairs. After arthrodesis, torsional load, weight-bearing and cyclic load tests were performed, and stability of the synthetic bone pairs was analyzed. ResultsThe mm.PIP was the most torsion resistant (mm.PIP vs. PipTree and K-wire, p < 0.001). The PipTree showed the best overall stability during cyclic weight-bearing simulation (PipTree vs. mm.PIP and K-wire, p < 0.001). K-wire demonstrated the highest breaking loads during bending tests (K-wire vs. mm-PIP and PipTree, p < 0.001). ConclusionBiomechanical properties of two new intramedullar implants, the bioresorbable mm.PIP made of magnesium and the PipTree made of titanium, were found to be comparable to the biomechanical properties of a K-wire which is commonly used for this procedure. Future work should be directed towards a clinical assessment of the bioabsorbable fixation devices for hammertoe procedures.

The mechanical testing of a novel interlocking forearm nail

BACKGROUND: Mechanical testing of newly designed implants provides valuable insight into their mechanical properties. This provides surgeons with information about implant choice for the treatment of fractures and the effect of the implant's mechanical properties on fracture healing METHODS: A novel interlocking forearm nail was subjected to standardised mechanical testing according to the Standard Specification and Test Methods for Intramedullary Fixation Devices (ATSM 126416), using static and dynamic four-point bending and static torsion (ASTM STP 588). Three nails were used for the static bending and torsion and nine for the dynamic bending tests. All nails were catalogued, numbered and photographed before testing RESULTS: The mechanical testing results showed a mean force yield (Fy) of 566 ± 20 N, a moment of yield (My) 10.75 ± 0.37 Nm, a stiffness of 67.10 ± 2 N/mm and structural stiffness of 1.53 ± 0.50 m2. The torsional stiffness of the nail was 0.088 ± 0.002 Nm/°. The four-point dynamic bending test showed a fatigue strength of 5.23 Nm. This value was determined using the semi-log moment/ number of cycles (M-N) diagram and showed a 50% failure at a million cycles. If the moment were reduced to 4.4 Nm, mathematically, the survival rate would improve to 90% CONCLUSION: The results from this mechanical testing show that this novel intramedullary forearm nail can resist mechanical forces experienced during fracture healing and could potentially be used in future clinical studies Level of evidence: Level 4

Early Results of a Novel Intramedullary Fixation Device for Proximal Fifth Metatarsal Fractures

Category:Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Proximal fifth metatarsal fractures are commonly treated surgically due to their poor healing capacity. While intramedullary screws may be the most popular operative treatment choice, newer fixation methods continue to develop that offer fracture compression in addition to maintenance of length, alignment and rotation. We present a case-series utilizing a novel intramedullary fixation device for proximal fifth metatarsal fractures. To our knowledge, no other study in the literature has assessed the safety and efficacy of this novel fixation methodMethods:A retrospective analysis was performed for 16 patients with proximal fifth metatarsal fractures who underwent fixation with the same novel intramedullary device. Patient charts were reviewed for fracture union, plantar fracture gapping, time to weightbearing, refracture, perioperative complications, and secondary surgeries.Results:Sixteen patients with an average age of 43.3 years old underwent fixation with this novel device from 2015 to 2020. Mean follow-up was 32.4 weeks. Fifteen of the 16 patients achieved radiographic union at a mean of 8.9 weeks. One patient suffered a non-union. Mean time to full weight-bearing in, and out of, a walking boot was 6.4 and 9.8 weeks, respectively, for healed fractures. Mean plantar fracture gap improved from 1.22 mm to 0.88 mm following surgery. There were zero infections, refractures or hardware complications. Three patients suffered iatrogenic distal diaphyseal fracture during implant insertion, however postoperative progression to weightbearing was not altered in these patients relative to the remainder of the cohort.Conclusion:To our knowledge, this is the first report of early results for this novel intramedullary device. Excellent union rates, acceptable time to weight bearing, and a low complication profile can be achieved. Additionally, plantar fracture gapping, which has been shown to delay time to union, was improved using this novel implant. Based on our early findings, we propose a viable treatment option that is safe and effective for proximal fifth metatarsal fracture stabilization.

Invivo evaluation of a new intramedullary distal biceps tendon fixation device.

Intramedullary fixation in distal biceps tendon repair may be a solution to address specific shortcomings of current fixation techniques. Most investigations are limited to biomechanical evaluation. The purpose of this study was to report the short-term outcomes of an intramedullary fixation device. We evaluated functional and radiographic outcomes at up to 6 months of follow-up. Patients with an acute distal biceps tendon rupture eligible for surgical repair were invited to take part in the study. Ten patients were included in the final analysis. All patients were evaluated both clinically and radiographically at 2 weeks, 6 weeks, 3 months, and 6 months. Outcomes were recorded using a visual analog scale score for pain, the Mayo Elbow Performance Score, and the Disabilities of the Arm, Shoulder and Hand score. Radiographic evaluation comprised radiographic and computed tomography evaluation. There were no failures of fixation in the patient group examined. Elbow mobility was symmetrical for all patients from 3 months onward. Supination strength was 86% of the uninjured side at final follow-up. The mean Disabilities of the Arm, Shoulder and Hand score and Mayo Elbow Performance Score at final follow-up were 0 and 100, respectively. Computed tomography images showed no signs of button migration, cortical thinning due to button pressure, or button breakout. The tendon could be followed to the button in all cases. The intramedullary fixation button technique to repair the distal biceps tendon has excellent functional outcomes at 6 months. No adverse reactions of the button on the bone were seen. As this technique minimizes the risk of posterior interosseous nerve injury and has a sufficient bone tunnel to avoid gap formation, this may be a promising new technique for distal biceps tendon rupture refixation.

Relative Strengths of Intramedullary K-Wire Techniques for Digital Deformities

Hammertoe deformity correction surgery is one of the most common procedures performed by foot and ankle surgeons. Recent foot and ankle medical literature presents conflicting opinions regarding the optimal intramedullary fixation device and techniques for use in digital deformity correction. There are a number of varying fixation constructs of intramedullary Kirschner wire fixation reported for proximal interphalangeal joint arthrodesis; however, there are no reports of relative loading strength of the fixations. In this study, 90 sawbone models were divided equally into 3 groups of different intramedullary Kirschner wire fixation techniques: Group A- single straight, Group B- single bent, Group C- double bent. Each fixation construct underwent controlled axial loading and failure points were observed. Results showed no significant difference in load failure from all 3 groups with mean maximum force of Group A = 20N, Group B = 19.1N, and Group C =17.5N. We conclude that all Kirschner wire fixation options for digital deformity correction, will provide similar resistance to sagittal plane axial loads.

Benefit of lag screw placement by a single- or two-screw nailing system in elderly patients with AO/OTA 31-A2 trochanteric fractures.

ObjectiveTo retrospectively analyze the clinical outcomes of two intramedullary fixation devices, the INTERTAN nail and Gamma3 nail, for treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients.MethodsIn total, 165 elderly patients underwent treatment for AO/OTA 31-A2 trochanteric fractures in our hospital from June 2017 to June 2018 (INTERTAN group, n = 79; Gamma3 group, n = 86). All patients underwent radiological and clinical investigations and were followed up for an average of 12 months. Age, sex, fracture type, surgical time, intraoperative blood loss, fracture healing time, and complications were compared between the two groups.ResultsThe surgical time was significantly shorter and the intraoperative blood loss volume was significantly lower in the Gamma3 than INTERTAN group (58.2 ± 2.5 vs. 81.7 ± 14.2 minutes and 170 ± 29 vs. 220 ± 16 mL, respectively). However, there were no significant differences in the reduction quality, hospital stay, fracture healing time, Harris hip score, postoperative complications, or 1-year postoperative mortality.ConclusionBoth INTERTAN and Gamma3 nails may be effective for surgical treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients. However, the Gamma3 nail was superior to the INTERTAN nail in terms of surgical time and intraoperative blood loss.

Spontaneous non-traumatic dislocation of the hip as a complication of screw-plate fixation of a femoral neck fracture

Femoral neck fractures are commonly seen in elderly population as a cause of a trivial fall. In younger patients it usually occurs following high energy trauma. Dynamic hip screw (DHS) is one of the most common type of internal fixation although intramedullary fixation devices have been introduced in the treatment in the last decade not without controversy [1,2]. Described complications are failure of fixation, cut-out, malunion, non-union, disengagement of lag screw and side plate, cut-in, intrapelvic migration, vascular injuries, etc.

Functional outcomes and complications of intramedullary fixation devices for Midshaft clavicle fractures: a systematic review and meta-analysis

BackgroundAn alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics and an evaluation of their clinical results is warranted. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device.MethodsA systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group.ResultsSixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12 months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93–95) and 94.0 (95%CI 92–95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14–26) and 12% (95%CI 8–18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13–35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2–17) of cases (GRADE Very low).ConclusionAlthough most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient.Level of EvidenceIV

Results of an innovative method of intramedullary fixation for displaced 4-part fractures of the proximal humerus in patients younger than 70 years

Background The management of displaced 4-part fractures of proximal humerus is a challenge, as it is difficult to produce consistently good results with the current methods of fixation. Varus collapse of the head and eventual failure of plate fixation have been reported in up to 45% of cases. We present an innovative method of intramedullary fixation for displaced 4-part proximal humeral fractures. The aim of this study was to present the results of an intramedullary fixation device used for displaced 4-part proximal humeral fractures in patients younger than 70 years. Materials and methods Fixation was performed with an intramedullary device in 30 patients with an average age of 56 years who had displaced 4-part proximal humeral fractures. The device consists of a circular staple that is impacted in the head and engages into the neck of an intramedullary uncemented stem. The stem has a sleeve that provides the ability to adjust the height and thereby facilitates accurate reduction of the tuberosity with ease. Fracture union was assessed with plain radiographs, and clinical outcomes were assessed using American Shoulder and Elbow Surgeons and Constant scores. Results Union was achieved in 93.33% of patients and the mean American Shoulder and Elbow Surgeons and Constant scores were 75.2 and 73.97, respectively, at an average follow-up of 25.83 months. None of the patients had tuberosity avulsion, tuberosity nonunion, or resorption. However, 2 patients had humeral head nonunion and 2 had avascular necrosis. Revision surgery was performed in 2 patients (6.67%), because of avascular necrosis in 1 and nonunion in 1. Conclusion In patients younger than 70 years with displaced 4-part proximal humeral fractures, the described intramedullary device provides a simple and reproducible method of internal fixation with predictable tuberosity union and shoulder function.

A new intramedullary fixation method for distal biceps tendon ruptures: a biomechanical study

Various techniques have been described for distal biceps tendon reinsertion. Although high success rates have been reported, all current techniques have specific shortcomings, with complications such as heterotopic ossification, nerve damage, and gap formation. The purpose of the present study was to biomechanically evaluate a new intramedullary fixation device that might reduce the risk of posterior interosseous nerve lesions. We therefore compared the fixation strength of this new intramedullary button with an extramedullary placed classic extracortical button. A standard bicortical button was compared to the new intramedullary fixation device using fresh-frozen cadaveric specimens. The fixation strengths were tested both cyclically and statically. Load to failure and method of failure were also recorded. There were no failures during the cyclic load testing. The mean tendon-bone displacement was 0.87 ± 0.13 mm for the bicortical group and 0.83 ± 0.13 mm for the new button. During static loading, the mean load to failure for the bicortical group was 296 ± 97 N, whereas the new button group showed a higher mean load to failure of 356 ± 37 N. Breakout through the anterior cortex was recorded in 2 of 6 bicortically placed buttons and 1 of 6 in the new device. The new intramedullary fixation device yields comparable loads to failure compared with currently used techniques in a biomechanical setup. These findings together with the theoretical advantages suggest that this technique may be a valuable solution for the repair of distal biceps tendon rupture.

Evaluation of proximal femoral plate in peritrochanteric fractures

Background Peritrochanteric fracture is one of the leading causes of mortality and morbidity of the elderly, in whom the fracture can occur from just a simple fall. In younger individuals, it occurs owing to severe trauma such as motor car accident or fall from a height. These type can occur in any age but got a higher incidence in the fifth and seventh decade of life. Multiple intramedullary and surface fixation implants have been designed to fix such a fracture, such as the dynamic hip screw, the anatomic proximal femoral plate, and the proximal femoral nail, but there is no single design that got the best results in all types of proximal femoral fracture. Aim To evaluate the outcomes of using proximal femoral plate in peritrochanteric fractures. Patients and methods A prospective study was conducted on 20 patients with proximal femoral fracture fixed by proximal femoral plate presented to the Cairo University Hospital from August 2014 to June 2016. The study included 14 male and six females. Their age ranged from 29 to 71 years old (mean 57 years old). The mode of trauma was three patients (15%) with motor car accident, three patients (15%) with motor bike accidents, 12 patients (60%) with fall on the ground, and two patients (10%) with fall from height. According to orthopeadic trauma association (OTA) classification, eight patients (40%) had 31-A2.1 pattern, six patients (30%) had 31-A2.2 pattern, and 2 patients (10%) had 31-A2 pattern. Results Radiological outcome was anatomical in eight patients (40%), satisfactory in nine patients (45%), and poor in three patients (15%). The follow-up was from 7 to 20 months (average 11 months). Fracture healing time ranged from 7 to 29 week (average 14 weeks). The modified Harris hip score was used to evaluate patients at 3 and 6 months postoperatively, which ranged from 60 to 74 (mean was 66.5±3.5) at 3 months and 68 to 93 (84.4±9.5) at 6 months. Conclusion Proximal femoral plate is an easy, safe, and dependable alternative for fixation proximal femoral fracture, giving satisfactory results comparable to other surface and intramedullary fixation devices, when applied in the accurate recommended position.

Recent advances in rib fracture fixation.

As a means of treating rib fractures, surgical stabilization of rib fractures (SSRF) has been carried out sporadically for nearly 100 years. However, with the recent advent of new materials and technologies suitable for SSRF, the developmental rate and data concerning SSRF have increased greatly. The main manifestations of these advancements include the improvement of the preoperative localization method by combining CT scanning with three-dimensional reconstruction technology and ultrasound application to accurately locate fractures. The bone fracture plate is specifically used for rib fixation, and the intramedullary fixation devices and special SSRF tools make SSRF relatively simple. The application of 3D printing technology can accurately reproduce the anatomical shape of the fracture site under in vitro conditions before operation and combine with the internal fixation of chest wall, especially the thoracoscopy-assisted internal fixation of the chest wall, to achieve the minimally invasive internal fixation of the rib fracture. Absorbable internal fixation materials and thoracoscopic SSRF are considered the primary future research directions.

The Use of Modern Intramedullary Nailing in Distal Fibula Fracture Fixation.

Background. Lateral malleolus (LM) fixation is necessary for unstable ankle fractures. Traditional fixation relies on the use of plates through a lateral incision, wound healing can be an issue for such incisions. A novel intramedullary (IM) fixation device has been developed that can be placed through a minimal incision. The purpose of this study was to demonstrate the clinical efficacy of this device. Methods. A retrospective analysis was performed on patients who received IM fixation for isolated fibula, bimalleolar (BM), and trimalleolar (TM) fractures. Pertinent demographic information, operative factors, complications, and clinical outcomes were recorded. Results. Sixteen patients were included in the study with an average age of 59 years (range 35-86 years). Six patients presented with isolated LM fractures, four patients had a BM fracture with a syndesmotic injury, 2 patients sustained a LM fracture with an associated syndesmotic injury, 2 patients had a BM fracture, and 2 patients had a TM fracture with a syndesmotic injury. There was a 100% healing rate of the lateral malleolus without any cases of malunion or shortening. There were no cases of sural nerve or peroneal tendon injuries, nor any wound complications found. Conclusion. These findings demonstrate the safe and efficacious use of a novel intramedullary fixation device for fibula fractures with lower wound complications compared with published outcomes found with lateral fibular plating. The features of this device allow for reliable fixation of the fibula, maintaining length and minimizing wound issues. Levels of Evidence: Level IV: Case series.

Intramedullary Fixation of Distal Radius Fractures Using CAGE-DR Implant.

Purpose CAGE-DR implant is a novel Food and Drug Administration approved intramedullary fracture fixation device used for distal radius fractures. We examine a series of 22 patients and report the outcomes with this device. Materials and Methods A total of 24 patients with distal radius fractures (8 articular AO type C1/C2; 16 extra-articular AO type A2/A3) underwent open reduction and internal fixation (ORIF) using CAGE-DR implant by a single surgeon. Data including fracture type, angle of displacement, radiographic consolidation, grip strength, wrist range of motion (ROM), patient-rated wrist evaluation (PRWE), and Visual Analog Scale (VAS) pain scores were recorded at time of surgery and at standard follow-up. Results All 24 patients underwent uneventful ORIF. At first follow-up visit (9 days), all patients had full digital ROM (measured as 0 cm tip-to-palm distance). Two patients were lost to follow-up. Eighteen of the remaining 22 patients had sufficient radiographic follow-up and all 18 demonstrated healing. At latest follow-up (mean 9.7 months, range, 3-20), VAS pain scores averaged 0.6 (range, 0-8) and PRWE averaged 12.1 (range, 0-53.5). Grip strength of the operated hand averaged 58 lbs (range, 20-130). ROM included: wrist flexion 73° (50-95), wrist extension 78° (60-110), pronation 77° (60-90), supination 79° (60-90), ulnar deviation 31° (5-45), and radial deviation 17° (10-30). Three patients underwent screw removal to prevent tendon irritation. One patient underwent hardware removal due to prominence on imaging but was asymptomatic. There were otherwise no major complications, including complex regional pain syndrome, in the series to date. Conclusion The CAGE-DR fracture fixation system is a promising alternative to established methods of distal radius internal fixation. This series has a low reported pain score starting immediately postoperatively and a low complication rate. This novel device is a promising option for internal fixation of displaced distal radius fractures with a low complication profile. Level of Evidence This is a level IV, therapeutic study.

Biomechanics of common fixation devices for first tarsometatarsal joint fusion\u2014a comparative study with synthetic bones

BackgroundHallux valgus disease is a common deformity of the forefoot. There are currently more than 100 surgical approaches for operative treatment. Because hypermobility of the first tarsometatarsal joint is considered to be causal for hallux valgus disease, fusion of the tarsometatarsal joint is an upcoming surgical procedure. Despite the development of new and increasingly stable fixation devices like different locking plates, malunion rates have been reported in 5 to 15% of cases.MethodsBiomechanical comparison of three commonly used fixation devices (a dorsal locking plate, a plantar locking plate, and an intramedullary fixation device) was performed by weight-bearing simulation tests on synthetic bones. Initial compression force and stiffness during simulation of postoperative weight-bearing were analysed.ResultsFixation of the first tarsometatarsal joint with the plantar plate combination demonstrated a higher stiffness compared to fixation with the intramedullary implant or the medial locking plate. The intramedullary device provided the highest initial compression force. Failure was detected in the following ranking: (1) the angle-stable intramedullary fixation device, (2) the medial located plate, and (3) the plantar locking plate.ConclusionThe intramedullary device demonstrated the highest initial compression force of the three tested implants. The plantar locking plate showed the best overall stability during weight-bearing simulation. Further clinical research is necessary to analyse if the intramedullary fixation device needs a longer period of non-weight-bearing to reach a better non-union rate compared to the plantar locking plate.

The Use of Modern Intramedullary Nailing in Distal Fibula Fracture Fixation

Category: Trauma Introduction/Purpose: Lateral malleolus (LM) fixation is necessary for unstable ankle fractures. Traditional fixation relies on the use of plates through a lateral incision, wound healing can be an issue for such incisions. A novel intramedullary (IM) fixation device has been developed that can be placed through a minimal incision. The purpose of this study was to demonstrate the clinical efficacy of this device. Methods: A retrospective analysis was performed on patients who received IM fixation for isolated fibula, bimalleolar (BM), and trimalleolar (TM) fractures. Pertinent demographic information, operative factors, complications, and clinical outcomes were recorded. Results: Sixteen patients were included in the study with an average age of 59 (Range of 35 to 86). Six patients presented with isolated LM fractures, four patients had a BM fracture with a syndesmotic injury, two patients sustained a LM fracture with an associated syndesmotic injury, two patients had a BM fracture, and two patients had a TM fracture with a syndesmotic injury. There was a 100% healing rate of the lateral malleolus without any cases of malunion or shortening. There were no cases of sural nerve or peroneal tendon injuries, nor any wound complications found. Conclusion: These findings demonstrate the safe and efficacious use of a novel intramedullary fixation device for fibula fractures with a lower wound complication and infection rates compared to published outcomes found with lateral fibular plating. The features of this device allow for reliable fixation of the fibula, maintaining length and minimizing wound issues.

Intramedullary Screw Fixation and Relevant Diameter of the Proximal Phalanges of the Foot

Category: Midfoot/Forefoot Introduction/Purpose: The average intramedullary diameter of the proximal phalanges of the foot has not been well documented in the literature. This dimension has important implications for surgical fixation devices, such as intramedullary screws. By design, intramedullary fixation devices rely on endosteal fit to provide stability. The precise intramedullary diameter is not readily identifiable on plain radiographs. A better understanding of the average diameter of the proximal phalanges of the foot can assist surgeons in surgical planning and appropriate screw diameter selection to provide more satisfactory patient outcomes. Methods: Twenty below-knee cadaveric specimens were dissected to expose each proximal phalanx. A sagittal saw was used to transect the diaphysis at its narrowest portion. The dorsal to plantar and medial to lateral diameters were measured using a digital manometer. Results: The average diameter dorsal to plantar for each digit was 6.25 ± 2.24 mm, 3.61 ± 1.25 mm, 2.94 ± 0.70 mm, 2.72 ± 0.77 mm, and 2.48 ± 0.80 mm, respectively. The average diameter medial to lateral for each digit was 7.83 ± 2.13 mm, 3.08 ± 0.93 mm, 2.47 ± 0.74 mm, 2.33 ± 0.73 mm, and 2.62 ± 0.69 mm, respectively. The overall average diameter for toes one through five was 7.04 ± 1.95 mm, 3.35 ± 1.04 mm, 2.71 ± 0.66 mm, 2.52 ± 0.71 mm, and 2.55 ± 0.63 mm, respectively. Conclusion: Understanding the intramedullary diameters of the proximal phalanges of the foot is a valuable tool when utilizing intramedullary surgical stabilization. The hallux proximal phalanx demonstrated the largest, and most variable, diameter, which could make selection intramedullary fixation difficult. In addition, the hallux proximal phalanx may lend itself better to 2 smaller fixation devices rather than one larger one. The lesser phalanges demonstrated smaller diameters more consistently, which is more amenable to a single smaller (2.5 mm) intramedullary device. This data can provide surgeons with an expected intramedullary diameter during surgical planning.

A comparative study of intramedullary and extramedullary fixation devices in type two unstable trochanteric fractures

Background : For many years, the sliding hip screw and plate had been the gold standard in treating pertrochanteric fractures. Nowadays, there is an increasing interest in intramedullary nailing. Intramedullary devices, although technically difficult seems to have a biomechanical advantage over laterally fixed side plates2.Literature is full of articles categorizing DHS in stable Trochanteric fractures, (31-A1.1, A1.2, A1.3 and 31-A2.1) and use of intramedullary devices PFN as implant of choice in unstable trochanteric, sub trochanteric fractures and particularly in reverse oblique (all A 31.3). But there is always a grey zone of decision of implant to be applied in unstable type A2.2 and A2.3 fractures. This study was designed to compare functional outcome and complications of the PFN device with those of a traditional extramedullary device, the Dynamic hip screw (DHS), inpatients with unstable type 2 trochanteric fracture. (AO/ASIF Classification 31-A2.2 & 31-A2.3) Method : In this Randomised control prospectively, designed study 60 consecutive patients having Fracture according to AO/ASIF classification 31-A2.2 and 31-A2.3 are included and randomized to either PFN or DHS group. The functional outcome and clinical results of the patients was evaluated and graded using HARRIS HIP SCORE system. Results : The average blood loss in PFN was 88.3ml while in DHS it was 318.33ml. Hospital stay after surgery in PFN was average days 4.13 DHS was average days 5.63. Harris hip score in PFN 22 (73.33%) were good, 06 (20%) were fair and 02 (6.66%) while with DHS 12 (40%)were good, 12(40%) were fair and 06 (20%).Average time of union in PFN was 13.4 weeks in DHS was 15.1 weeks. Conclusion : In Type 2 unstable trochanteric fractures PFN gives advantage of lesser blood loss, shorter operating time, faster union, better functional outcome with low complication rate as compared to DHS.

Functional Outcome of Unstable Intertrochanteric Femur Fracture Patients Treated with Trochanteric Fixation Nail

Introduction: Intertrochanteric fractures are disabling injuries that most commonly affect the elderly population. These fractures have a tremendous impact on both the health-care system and society in general. These fractures can be managed by conservative methods, but mal-union and complications of prolonged immobilization are the result. Thus, surgery by internal fixation is the ideal choice. Dynamic hip screw was the gold standard treatment for intertrochanteric fractures before intramedullary devices were developed. These devices have the advantage of being an intramedullary fixation device, shorter lever arm of devices causing less tensile strain on the implant, controlled fracture impaction due to the incorporation of sliding hip screw, shorter operative duration, and less soft tissue dissection. In view of these consideration, this study of management of unstable intertrochanteric fractures using trochanteric fixation nail (TFN) is taken up to assess the outcome in terms of adequacy of fixation and results. Methods: In a retrospective controlled study, 40 patients of unstable intertrochanteric fracture were treated by TFN. Mean age group of the patient was 61.78 years. 26 cases showed union at 3 months, 13 cases showed union at 4 months, and 1 case showed union at 5 months duration. Results: Functional results were assessed in the 40 cases available for follow-up. Excellent results were noted in 10 cases, good in 27 cases, fair in 3 cases, and none had poor result. Anatomical results were assessed by presence or absence of shortening and range of movements. 37 cases had good results and 3 had poor result. Conclusion: At present, we consider that the TFN is a good minimally invasive implant for unstable intertrochanteric fracture when closed reduction is possible. Technical and mechanical complications were mostly related to the operative technique and the type of fracture and pre-operative reduction of the fracture. Keywords: Shortening, trochanteric fixation nail, unstable intertrochanteric fractures.