Intramedullary Nailing Group Research Articles

LOCKING INTRAMEDULLARY NAIL VERSUS PLATE AND SCREWS FOR FIXATION IN TIBIAL DIAPHYSEAL FRACTURE

Diaphyseal tibial fracture is the most common fractured long bone because of it is subcutaneous position anteromedially and thinner diaphysis distally. Tibial diaphysis has poor blood supply and poor soft tissue envelope around it so it is more susceptible to infection, delay union, and non-union. For these reasons many modalities including cast and brace, external fixation, plate and screws, and locking intramedullary nail were used for treating diaphyseal tibial fracture. The aim of this study is to compare the outcome of locking intramedullary nail(LIMN) fixation versus plate and screws fixation in treating diaphyseal tibial fracture in term of operation time, early weight bearing, time to union, and complications. The study was carried out in Sulaimaniyah Teaching Hospital, Department of Orthopedics prospectively from May 2010 to July 2014 on 74 patients, 40 of them underwent surgical fixation by locking intramedullary nail (26 close method and 14 by open method), and 34 of them underwent open reduction and internal fixation by plate and screws. The outcome was assessed by clinical and radiological evaluation. The results show that young male are more affected by trauma, and the main mechanism of injury was Road Traffic Accident. Operation time was shorter among plate and screws group with a mean of 51.4±4.9 minutes, than locking intramedullary nail group with a mean of 88.5±12.5 minutes. Weight bearing(WB) time achieved earlier in the locking intramedullary nail group with a mean of 2.6±0.8 weeks than the plate and screws group with a mean of 4.2±1.4 weeks. There were no significant difference between the two groups regarding time to full weight bearing(FWB), time to union, and complications. In conclusion, Locking intramedullary nail and plate fixation are ideal option for treatment of diaphyseal tibial fractures since there were no significant differences between them in time of union and the post-operative complications.

Case-control study on InterTan intramedullary nail in treating coronal femoral intertrochanteric fracture in elderly

To compare clinical effect of closed reduction and limited open reduction and internal fixation with InterTan intramedullary nail in treating elderly patients with coronal femoral intertrochanteric fracture. From January 2013 to December 2015, 23 elderly patients with coronal femoral intertrochanteric fracture were divided into two groups according to different ways of reduction to be retrospectively analyzed. There were 12 cases with closed reduction and internal fixation with InterTan intramedullary nail group (closed reduction group), including 7 males and 5 females with an average age of(63.6±12.1) years old; while 11 cases with limited open reduction and internal fixation with InterTan intramedullary nail group(limited reduction group), including 6 males and 5 females with an average of (60.8±12.5) years old. Intraoperative blood loss, fluoroscopy, operative time, postoperative complications, hospital stays and bone healing time were observed and compared. Harris score of hip joint at 1 year after operation was compared between two groups. The incisions between two groups were healed well at stage I, and no complications occurred. One case was died during following-up, and 22 cases were obtained following-up from 12 to 23 months with an average of 13.6 months. There were significant difference in operative time, intraoperative blood loss and fluoroscopy(P<0.05); while no difference in hospital stays, postoperative complications(P>0.05). Harris score at 1 year after operation in open reduction group was(83.9±8.9), and(83.4±9.1) in closed reduction group without significant difference between two groups(P>0.05). Closed reduction and limited open reduction with InterTan intramedullary nail internal fixation for the treatment of intertrochanteric femoral coronal fractures could achieve good clinical effects, the former to receive more radiation dose, with less trauma;while the latter has disadvantages of long blood bleeding and operative time, but could obtain high quality of reduction.

Comparison of intramedullary nailing and minimal invasive plate osteosynthesis in the treatment of simple intra-articular fractures of the distal tibia (AO-OTA type 43 C1-C2)

ObjectiveThe aim of this study was to compare midterm functional and radiographic results of minimal invasive plate osteosynthesis (MIPO) with intramedullary nailing (IMN) of simple intra-articular distal tibial fractures (AO-OTA type 43 C1-C2). MethodsSeventy-three simple intra-articular distal tibial fracture patients were evaluated retrospectively. All were treated between 2009 and 2014. The average age of the patients was 40.3 years. Thirty-seven patients were treated with IMN and 36 patients were treated with MIPO. Fibular plate osteosynthesis was applied in 5 cases (13.5%) in the IMN group and in 23 patients (63.9%) in the MIPO group. ResultsFunctional results and complications of IMN and MIPO methods were assessed in 73 patients. The average union time was 16.4 ± 2.7 weeks in the IMN group and 15.2 ± 1.8 weeks in the MIPO group (p = 0.079). The average Olerud-Molander Ankle Score was 87.8 ± 8.1 in the IMN group and 81.5 ± 11.8 in the MIPO group (p = 0.013). Four patients in the IMN group experienced valgus malunion, while it was not observed in any patients in the MIPO group (p = 0.042). Recurvatum malunion was detected in 10 patients in the MIPO group and not seen in the IMN group (p = 0.001). Ankle dorsiflexion angle was 25.8 ± 4.5° in the IMN group and 33.3 ± 8.9° in the MIPO group (p = 0.000). ConclusionSimple intra-articular distal tibial fractures are successfully treated with IMN and MIPO. Prevalence of valgus malunion was higher in the IMN group and recurvatum was more prevalent in the MIPO group. MIPO is the first preference according to the literature; however, successful results have been obtained with IMN in this fracture pattern. Level of EvidenceLevel III, Therapeutic Study.

A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures

BackgroundThe purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting.Materials and methodsWe performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento’s criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months.ResultsAt 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months.ConclusionsPatients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion. Level of evidence Level-II prognostic.

Comparison of 2 Methods of Percutaneous Fixation of Proximal Phalanx Fractures

Purpose: Short oblique or transverse extra-articular fractures at the proximal phalanx are very common. Stabilization and early motion are critical to support good results. No single operative method has been shown to be superior in clinical studies. Traditionally, these fractures were treated with percutaneous pinning. Latter intramedullary nailing (IMN) became popular. During the past years, a new technique using intramedullary placed Herbert screws (HSs) showed satisfactory outcome. The aim of this study is to assess the complications and outcomes of these last 2 techniques performing postoperative early digital motion. Our hypothesis is that HSs have less complications rates and better outcomes than IMN. Methods: Over a 2-year period, a prospective study was conducted at our service. Radiological (reduction, consolidation time, secondary displacement) and clinical (Visual Analogue Scale [VAS]-Total Active Motion [TAM]-Quick Disabilities of Arm, Shoulder and Hand [QuickDASH]) results of 20 patients having 25 displaced extra-articular fractures of the proximal phalanges were recorded through a minimum follow-up of 3 months. Short oblique or transverse types were included. Intra-articular fractures, thumb fractures, and concomitant injuries of the tendons or collateral ligaments were excluded from this study. All fractures were reduced closed and fixed. Aggressive active full range of motion was encouraged 48 hours after surgery. Surgical Techniques: We performed percutaneous IMN with 2 crossed 1-mm rods in Eiffel tower configuration using 2 portals at the base of the phalange in 12 fractures; we left the rods outside the skin, and they were removed at consolidation time. We placed percutaneous 3-mm HSs, 1 in each fracture inserted in antegrade fashion in 13 cases. For statistical analysis, the quantitative variables were reported as mean values. The Student t test was used for continuous data. For all analyses, P &lt; .05 was considered statistically significant. Results: Radiographically there was a statistically significance ( P = .01) in the average consolidation time between the 2 groups—IMN: 107 (±60) days; HS: 63 (±10) days. We got anatomical reduction and no secondary displacement in both groups. The mean TAM for the IMN and HS groups was 161 (±36) and 218 (±27), respectively ( P = .001). Average VAS was similar at discharge in both groups, but during the first postoperative month, patients with HS referred less pain. Mean final QuickDASH was 18 (±12) for IMN group and 15 (±14) for HS group. Regarding complications, we recorded a mild superficial infection at the entrance of the wires in 1 patient that healed with oral antibiotics (ATB). The volar cortex in shaft fractures treated with IMN showed a delayed union in 48% of cases. No complications were recorded in HS group. Conclusions: It is generally agreed that closed fixation minimizes additional soft tissue injury and allows for early motion. Percutaneous intramedullary placed HS was a superior method compared with IMN in terms of the measured parameters.

Reamed versus unreamed intramedullary nailing for the treatment of closed tibial fractures-A comparative study

Tibial fractures were the most common long bone fracture. These were treated by intramedullary nailing. Treatment of reamed versus unreamed intramedullary nailing was still controversial. This comparative study was conducted in the department of orthopaedic surgery in Mahatma Gandhi Memorial Hospital, Warangal, Telangana state, India with an aim to know the efficacy of both treatments. In this study the average duration of surgery was 72±12 min, the average time to full weight-bearing was 9.2 weeks and the average time to union of the fracture was 14 weeks. The unreamed intramedullary nailing group demonstrated a significantly higher rate of fracture non-union (R 3%, U 6%) and malunion (R 6%, U 9%). The significantly higher incidences of implant exchange, a higher risk of screw failure and dynamization were noticed in the unreamed intramedullary nailing group. Regarding the adverse effects like infection, compartment syndrome and knee pain there was no significant difference between two groups.

Plate fixation versus intramedullary nailing for midshaft clavicular fractures: a prospective rndomized controlled trial

Objective To compare the clinical effects of closed reduction and intramedullary nailing versus open reduction and plate fixation in the treatment of displaced midshaft clavicular fractures. Methods A prospective, randomized, controlled trial was performed between July 2012 and May 2014 in 194 patients with acute displaced midshaft clavicular fracture. They were 136 males and 58 females, from 16 to 65 years of age. They were randomly divided into 2 groups to received either closed reduction and intramedullary nailing(n= 98)or open reduction and plate fixation(n= 96). We recorded operation time, intraoperative blood loss, hospitalization expenses, fracture healing time and complication rate. Functional assessments were conducted at 3, 6 and 12 months using the Disabilities of the Arm, Shoulder and Hand(DASH)and Constant-Murley scores. The preoperative general data showed no statistical significance between the 2 groups(P> 0. 05). Results All the 194 patients were followed up for 12 to 27 months(average, 15. 6 ±3. 1 months). The operation time(27. 7 ±16. 3 min), intraoperative blood loss(18. 6 ±14. 4 mL), hospitalization expenses(12, 462. 0 ±3, 263. 4 yuan), and fracture healing time(12. 1 ±3. 0 weeks)in the intramedullary nailing group were significantly better than those(62. 3 ±19. 4 min, 40. 3 ±17. 4 mL, 24, 760. 0 ±3, 320. 4 yuan, and 16. 9 ±2. 8 weeks)in the plate fixation group(P 0. 05). The complication rate in the intramedullary nailing group(25.5%, 25/98)was significantly higher than in the plate fixation group(9.4%, 9/96)(P<0. 05). Conclusions In the treatment of displaced midshaft clavicular fractures, compared with open reduction and plate fixation, closed reduction and intramedullary nailing has advantages of less invasion, lower cost and faster fracture healing, but a disadvantage of higher complication rate. The 2 treatments may lead to similar functional recovery of the shoulder. Key words: Clavicle; Fracture fixation, internal; Bone plates; Bone nails

Metaphyseal Distal Tibia Fractures

The purpose of this study was to compare clinical and functional outcomes of patients with distal tibia fractures treated with minimally invasive plating (MIPO) or intramedullary nailing (IMN). Cohort study. Level II regional trauma center. Overall, 86 patients with metaphyseal distal fractures (within 5 cm of joint) with simple or no articular involvement treated by a single, fellowship trained, orthopedic trauma surgeon from 2002 to 2013. Intramedullary nailing or minimally invasive plate osteosynthesis. Clinical and radiographic results were evaluated at a minimum of 1-year follow-up. Limb-specific outcomes (American Orthopedic Foot and Ankle Surgeons' ankle-hindfoot instrument) and whole-person measures [Short Form 36 (SF-36) instrument] were assessed at the final follow-up. We studied 86 patients with distal tibia fractures treated with MIPO (43 patients) and IMN (43 patients). Thirty-seven patients in the MIPO group and 27 in the IMN group met inclusion criteria. All patients ultimately healed, with the average time to union of 23 weeks in both the groups. Complications were similar between the 2 groups (MIPO vs. IMN, respectively), including nonunion (8% vs. 7%), malalignment (3.6% vs. 3%), wound complications (3.6% vs. 3%), and infection (0% vs. 3.6%). The need for secondary procedures for the removal of implants was 25.9% in the IMN group (distal locking screws only in 6/7) versus 8.3% in the MIPO group (P = 0.05). Additionally, the American Orthopedic Foot and Ankle Surgeons and all SF-36 version 2 domain scores were quantitatively higher for the IMN group, although only Role Emotional reached a level of statistical superiority between the groups. Similar clinical results and marginally enhanced functional outcomes were seen when treating nonarticular or minimally articular metaphyseal distal tibia fractures with IMN compared with MIPO. However, patients treated with IMN required more frequent secondary surgeries for the removal of painful distal locking screws. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To compare the outcome of intramedullary nailing and locking compression plate fixation in treatment of proximal one third tibia fracture: A randomized control trial

Background: Fractures of tibia shaft are most common of long bone fractures. Proximal tibia fractures account for approximately 5% to 11% of all tibial injuries and affect knee function and stability in most of the cases. Higher rates of malunion and increased incidence of associated complications have made these fractures particularly problematic. In recent years due to advancement in technique, proximal tibia plating and multidirectional locked intramedullary nailing, both have become widely used treatment modalities for proximal tibial metaphyseal fractures. This study was performed to compare plating and nailing options in proximal tibia extra-articular fractures. Materials and methods: This randomized prospective clinical study was conducted on 62 skeletally mature patients with closed extra-articular fracture of the proximal tibia treated with proximal tibial locking compression plating (PTLCP) or intramedullary nailing (IMN) by expert surgeons at a tertiary trauma center. Results: Postoperative hospital stay (p = 0.043), postoperative infection rate (p = 0.036) were significantly high in the PTLCP group than in the IMN group, while rate of malunion (p=0.041) and nonunion(0.037) were significantly high in IMN group than in PTLCP group. However there was no clear advantage of either technique in terms of functional recovery of knee. Conclusion: Present comparison of IMN and PTLCP for the treatment of proximal one third tibia fracture showed no clear advantage of either technique. Present study concluded that both forms of treatment (IMN and PTLCP) provide adequate fracture stability. Level of evidence: Level 2, randomized controlled trial.

Clinical and functional comparison of endoprosthetic replacement with intramedullary nailing for treating proximal femur metastasis.

Objective:To evaluate the clinical and functional outcomes of modular endoprosthetic replacement (EPR) compared to proximal femur intramedullary nailing (IMN) for the treatment of proximal femur metastases.Methods:We retrospectively studied the records of patients with proximal femur metastatic lesions treated with surgical stabilization between January 2007 and December 2014 in terms of operation time, blood loss, postoperative score, soreness, Karnofsky performance score (KPS) and survival time.Results:There were 34 patients treated with surgical stabilization. The mean follow-up period was 12.1?.6 months (range: 10-47 months). Thirteen were treated with EPR and 21 were stabilized with IMN (20 males, 14 females; mean age: 68.7 years). The median survival time was 11.0 months for both groups (P=0.147). The operation time, blood loss and Harris score of IMN group were lower than those of EPR group (P=0.001, P=0.001, P=0.002, respectively).Conclusions:Both EPR and IMN for treating proximal femur metastasis achieved effective clinical outcomes. Therefore, the suitable surgical methods depended on the general conditions and medical requirements of patients, as well as the technical advantages of the doctor.

A comparative study of the therapeutic effect between long and short intramedullary nails in the treatment of intertrochanteric femur fractures in the elderly

PurposeTo compare the clinical effects of long vs. short intramedullary nails in the treatment of intertrochanteric fractures in old patients more than 65 years old. MethodsA retrospective analysis of 178 cases of intertrochanteric fractures of the femur (AO type A1 and A2) in the elderly was conducted from January 2008 to December 2013. There were 85 males (47.8%) and 93 females (52.2%) with the age of 65–89 (70.2 ± 10.8) years. The patients were treated by closed reduction and long or short intramedullary nail (Gamma 3) fixation. The length of short nail was 180 mm and that for long nail was 320–360 mm. The general data of patients, operation time, intraoperative blood loss, length of hospital stay, preoperative hemoglobin level, blood transfusion rate, postoperative periprosthetic fractures, infections, complications, etc were carefully recorded. ResultsThere were 76 cases (42.7%) in the long intramedullary nail group and 102 cases (57.3%) in the short nail group. All the cases were followed up for 12–48 (21.3 ± 6.8) months, during which there were 21 deaths (11.8%), mean (13.8 ± 6.9) months after operation. The intraoperative blood loss was (90.7 ± 50.6) ml in short nail group, greatly less than that in long nail group (127.8 ± 85.9) ml (p = 0.004). The short nail group also had a significantly shorter operation time (43.5 min ± 12.3 min vs. 58.5 min ± 20.3 min, p = 0.002) and lower rate of postoperative transfusion (42.3% vs. 56.7%, p = 0.041). But the length of hospital stay showed no big differences. After operation, in each group there was 1 case of periprosthetic fracture with a total incidence of 1.1%, 1.3% in long nail group and 0.9% in short nail group. At the end of the follow-up, all patients achieved bony union. The average healing time of the long nail group was (6.5 ± 3.1) months, and the short nail group was (6.8 ± 3.7) months, revealing no significant differences (p = 0.09). Postoperative complications showed no great differences either. ConclusionBoth the intramedullary long and short nail fixation has a good clinical effect in treating intertrochanteric femur fractures in the elderly. They showed no significant difference in terms of therapeutic effect, hospital stay and postoperative complications. The incidence of periprosthetic fractures treated by either length of nails was low. But short intramedullary nailing can obviously decrease the intraoperative blood loss, operation time and postoperative blood transfusion.

Perioperative adverse events in distal femur fractures treated with intramedullary nail versus plate and screw fixation

BackgroundTo compare 30-day outcomes in patients treated for a distal femur (DF) fracture with plate fixation (PF) or intramedullary nail (IMN). MethodsDifferences in rates of any adverse events (AAE), serious adverse events (SAE), infectious complications, and mortality were explored between groups in the ACS-NSQIP database. ResultsThere were 511 PF and 44 IMN patients. The PF group and IMN groups had similar rates of AAEs (p=0.35), SAEs (p=0.46), infectious complications (p=1.00), and mortality (p=0.39). ConclusionsDF fractures treated with IMN have equivalent short-term outcomes compared to those treated with PF.

A biomechanical comparison of proximal femoral nails and locking proximal anatomic femoral plates in femoral fracture fixation: A study on synthetic bones.

Background:The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly people with osteoporosis. Although dynamic hip screw fixation is the gold standard for the treatment of stable intertrochanteric femur fractures, treatment of unstable intertrochanteric femur fractures still remains controversial. Intramedullary devices such as Gamma nail or proximal femoral nail and proximal anatomic femur plates are in use for the treatment of intertrochanteric femur fractures. There are still many investigations to find the optimal implant to treat these fractures with minimum complications. For this reason, we aimed to perform a biomechanical comparison of the proximal femoral nail and the locking proximal anatomic femoral plate in the treatment of unstable intertrochanteric fractures.Materials and Methods:Twenty synthetic, third generation human femur models, obtained for this purpose, were divided into two groups of 10 bones each. Femurs were provided as a standard representation of AO/Orthopedic Trauma Associationtype 31-A2 unstable fractures. Two types of implantations were inserted: the proximal femoral intramedullary nail in the first group and the locking anatomic femoral plate in the second group. Axial load was applied to the fracture models through the femoral head using a material testing machine, and the biomechanical properties of the implant types were compared.Result:Nail and plate models were locked distally at the same level. Axial steady load with a 5 mm/m velocity was applied through the mechanical axis of femur bone models. Axial loading in the proximal femoral intramedullary nail group was 1.78-fold greater compared to the plate group. All bones that had the plate applied were fractured in the portion containing the distal locking screw.Conclusion:The proximal femoral intramedullary nail provides more stability and allows for earlier weight bearing than the locking plate when used for the treatment of unstable intertrochanteric fractures of the femur. Clinicians should be cautious for early weight bearing with locking plate for unstable intertrochanteric femur fractures.

Trends in the management of intertrochanteric femur fractures in the United States 2005-2011.

In the last 2 decades, surgical treatment of intertrochanteric (IT) femur fractures has shown a continuing trend towards the increased use of intramedullary nails (IMN) and decreased use of sliding hip screws (SHS). Recent trends in the United States regarding the use of these implants, including charges and reimbursement, have not been investigated. A national database of Medicare patients (PearlDiver, Inc.) was queried using Current Procedural Terminology (CPT) codes for patients with surgical dates from 2005-2011. A total of 34,759 SHS or IMN procedures for intertrochanteric femur fractures were identified from 2005-2011. There was a significant increase in the percentage of IMN compared to SHS, from 46.9% IMN in 2005 to 79.1% in 2011. The average charges for IMN and SHS increased. Statistically higher rates of PE (p&lt;0.001), DVT (p&lt;0.001), MI (p&lt;0.001), respiratory failure (p&lt;0.001), UTI (p&lt;0.001), pneumonia (p&lt;0.001), CVA (p&lt;0.001) and blood transfusion (p&lt;0.001) were noted in the IMN group. The SHS group had higher 1 year (4.3% vs 3.8%, p = 0.012) and 2 year (5.8% vs 5.0%, p = 0.002) mortality rates. The previously recognised trend of increasing use of IMN for IT femur fractures has continued. The overall incidence of operative IT femur fractures is not increasing at this time. The cost of IMN remains higher than SHS.

English

BACKGROUND: Plate osteosynthesis is the most commonly used technique for the treatment of diaphyseal forearm fractures in adults. However, application of a plate can disrupt the periosteal blood supply and necessitates skin incision that may be unsightly, and there is a risk of refracture if the implant is removed. The purpose of this study was to assess the early results of the use of closed intramedullary nail to stabilize displace diaphyseal fractures of both bones forearm. AIMS OF STUDY: 1.To evaluate the results of internal fixation of diaphyseal fractures of both bones forearm treated by plate osteosynthesis and closed intramedullary nailing. 2. To compare the functional results of the two groups treated with plate osteosynthesis and closed intramedullary nailing. 3. To review the literature on the treatment of diaphyseal fractures of forearm bones. METHODS: From September 2006 to October 2008 in the Department of Orthopaedics and Traumatology, Gandhi medical college and associated Hamidia Hospital, Bhopal, total of 38 patients of both bones forearm fractures were treated. Eighteen (18) patients with were treated with plate osteosynthesis and 20 patients with closed intramedullary nailing using the square nails. Total 31 patients were available for the follow up. Average follows up in plate osteosynthesis group was 14.1 months and in closed intramedullary nailing group was 15 months, with range from 12 months to 21 months. Functional results were assessed by Anderson et al criteria (1975). RESULTS: Average surgery time in plate osteosynthesis group was 68 minutes, and in closed nailing group was 43 minutes. In plate osteosynthesis group radius showed union in 14 (93.2%) patients and ulna in 13 (86.8%) of patients, in closed nailing group both radius and ulna resulted in 100% union rate. In plate osteosynthesis group there was 1 deep infection, 1 implant failure, and 3 nonunion. Functional results in plate osteosynthesis group were excellent in 12 (80%) of patient, satisfactory in 1(6.6%), failure in 2(13.2%). There was no unsatisfactory result in this group. In closed nailing group result were excellent in 11(68.7%), satisfactory in 4(24.8%), unsatisfactory in 1(6.2%) and no failure. CONCLUSIONS: Our experience indicates that the advantage of closed intramedullary nailing for fractures of both bones forearm are that it is technically straightforward, it allows high rate of osseous union, and it requires less surgical exposure and operative time, less risk of infection than does plate osteosynthesis for diaphyseal fractures of both bones forearm in adults. The disadvantage of this system is that post-operative immobilization is required until bridging callus is observed at the fracture site and radiation hazard to patient and surgeon. We conclude that closed intramedullary nailing is not superior to plate fixation but can be considered as an alternative to that method for diaphyseal forearm fractures in adults. KEYWORD: forearm nailing, forearm plating.

Surgical management for displaced pediatric proximal humeral fractures: a cost analysis.

PurposeThe purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).MethodsA retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.ResultsA total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.ConclusionsLeaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.

Plate or nail for distal tibia fractures: Is there a clear answer?

Controversy still exists about the relative merits of the fixation devices for distal tibia fractures, and decision making remains difficult. This study aims to answer the question and find out when each implant is preferred. Of the patients treated at our hospitals for distal tibia fractures, 30 patients treated by minimally invasive plate osteosynthesis (MIPO) (group A) were matched to 30 patients treated by static reamed intramedullary nail (SR-IMN) (group B), with regard to age decade, gender, fracture type (open or closed), the AO/OTA classification of the fracture, and occupation category. No significant difference was found between the two groups regarding bone union and complications including angulation of >5°, shortening of >1 cm, implant failure, fixation loss, or deep infection. Group A had a shorter mean operative time and mean radiation exposure time. Group B had a shorter mean time from trauma to surgery and faster full weight-bearing, radiographic union, and return to work. Only three patients lost their previous job, two in group A and one in group B. Both implants are useful and effective. The clear answer is that no best implant and preoperative planning is the cornerstone to determine the patient, fracture, and surgeon factors that give priority for one implant over the other.

Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial

PurposeThe purpose of this randomized clinical trial is to compare intramedullary nailing (IMN) versus minimally invasive plate osteosynthesis (MIPO) for the treatment of extra-articular distal tibial shaft fractures. Materials and methodsTwenty-five consecutive patients with distal extra-articular tibial fractures which were located between 4 and 12cm from the tibial plafond (AO 42A1 and 43A1) were randomly assigned into IMN (n:10) or MIPO (n: 15) treatment groups. All patients were followed for at least 1 year. Foot function index, time to weight bearing, union time, duration of operation, length of incision, intra-operative blood loss, intra-operative fluoroscopy time, rotational and angular malalignment, rate of infection, secondary interventions and complications were compared between groups. ResultsAll patients completed the trial and were followed with a mean of 23.1±9.4 months (range 12–52). Foot function index, weight bearing time, union time, rate of malunion, rate of infection and rate of secondary interventions were all similar between groups (p=0.807, p=0.177, p=0.402, p=0.358, p=0.404, p=0.404, respectively). Intra-operative blood loss, length of surgical incision, radiation time and rotational malalignment were higher in the IMN group (p=0.012, p=0.019, p=0.004 and p=0.027, respectively). ConclusionsResults of our study showed that both treatment methods have similar therapeutic efficacy regarding functional outcomes and can be used safely for extra-articular distal tibial shaft fractures, and none of the techniques had a major advantage over the other.

Operative treatment of dislocated midshaft clavicular fractures: plate or intramedullary nail fixation? A randomized controlled trial.

Over the past decades, the operative treatment of displaced midshaft clavicular fractures has increased. The aim of this study was to compare short and midterm results of open reduction and plate fixation with those of intramedullary nailing for displaced midshaft clavicular fractures. A multicenter, randomized controlled trial was performed in four different hospitals. The study included 120 patients, eighteen to sixty-five years of age, treated with either open reduction and plate fixation (n = 58) or intramedullary nailing (n = 62). Preoperative and postoperative shoulder function scores and complications were documented until one year postoperatively. Significance was set at p < 0.05. No significant differences in the Disabilities of the Arm, Shoulder and Hand (DASH) or Constant-Murley score (3.0 and 96.0 points for the plate group and 5.6 and 95.5 points for the nailing group) were noted between the two surgical interventions at six months postoperatively. Until six months after the surgery, the plate-fixation group experienced less disability than the nailing group as indicated by the area under the curve of the DASH scores for this time period (p = 0.02). The mean numbers of complications per patient, irrespective of their severity, were similar between the plate-fixation (0.67) and nailing (0.74) groups (p = 0.65). The patients in the plate-fixation group recovered faster than the patients in the intramedullary nailing group, but the groups had similar results at six months postoperatively and the time of final follow-up. The rate of complications requiring revision surgery was low. Implant-related complications occurred frequently and could often be treated by implant removal.

Retrospective analysis of AO 42A-B type tibia fractures treated with percutaneus locked plating and intramedullary nailing

In this study, the results of AO 42A and 42B type tibia fractures treated with intramedullary nail (IMN) and percutaneus locking plate (PLP) were evaluated. The complications were examined, and it was questioned whether the type of fixation had an effect on union time and functional results. Forty-two patients with extraarticular distal tibial fractures were enrolled in this retrospective study. Eighteen patients were treated with closed IMN (Group I) and 24 patients were treated with PLP fixation (Group II). Mean age was 41 (range: 16-70) years; thirty-two of the patients were men. Fractures were classified according to the AO classification system. Union time, functional results and complications (malunion, malalignment, infection) were compared. The American Orthopaedic Foot and Ankle Surgery (AOFAS) scoring was used to compare functional results. The average follow-up period was 20 (12-32) months for Group I and 23 (13-36) months for Group II. The average union time was 16 (12-24) weeks in Group I and 19 (range: 16-24) weeks in Group II (p=0.002). The AOFAS scoring was 85 (range: 69-100) points in Group I and 81 (range: 60-95) points in Group II. The difference in AOFAS scoring was not significant (p=0.06). Two patients had nonunion in Group II. Two patients in Group I and three patients in Group II had malalignment. We suggest that IMN can provide early healing time. Although it is not statistically significant, complication rate was lower and functional results were better in patients treated with IMN.