Intramedullary Nailing Procedures Research Articles

Short-term complication rates of open reduction and plate fixation and intramedullary nailing in the treatment of humeral shaft fractures: a propensity score matched analysis.

This is a retrospective cohort study designed to compare short-term postoperative complication rates between closed humeral shaft fractures treated by open reduction and internal fixation (ORIF) versus intramedullary nailing (IMN), as well as secondary independent risk factors for adverse outcomes. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using CPT codes to identify patients that underwent an open reduction and plate fixation or intramedullary nailing procedure for a closed humeral shaft fracture from 2010 to 2021. Cohorts were matched using propensity scores to account for demographic differences and rates of complications were compared between the two groups. From the database, a total of 4,222 patients were identified who met inclusion criteria, with 3,326 and 896 undergoing ORIF and IMN respectively. After propensity score matching, 866 of the nearest-neighbor matches were included in each cohort for a total of 1,732 patients in the final analysis. The rate of any adverse event (AAE) was significantly higher in the ORIF cohort (16.3%) than the IMN cohort (12.1%, p = 0.01). The ORIF group had higher rates of postoperative transfusion (p = 0.002), return to OR (p = 0.005), and surgical site infection (SSI, p = 0.03). After multivariate analysis, ASA class 4, increasing age, increasing operative time, and history of bleeding disorder were found to increase the risk of AAE in both ORIF and IMN patients. While prior studies have claimed higher complication rates in IMN patients, this study found a significantly higher short-term risk of AAE in ORIF patients when compared in matched cohorts. However, individual 30-day complication rates do not differ significantly between procedures, and both have been shown to be safe and effective tools in the management of humeral shaft fractures.

Risk Factors for Intraoperative Hypotension in Elderly Patients Undergoing Fast Track Hip Fracture Surgery under Spinal Anesthesia: A Retrospective Observational Study

Objective: Fast-track hip fracture surgery is urgent. Time-limited preoperative optimization increase the risk of perioperative cardiovascular issues, affecting postoperative outcomes. This study aimed to identify risk factors for intraoperative hypotension in elderly patients undergoing fast-track hip fracture surgery with spinal anesthesia. Materials and Methods: This retrospective observational analysis was conducted at a university-based hospital. Medical records from 2018 to 2022 were examined to compare variables associated with intraoperative hypotension. Multivariate logistic regression analysis was used to determine the risk variables for intraoperative hypotension. Results: The incidence of intraoperative hypotension was 50.1%. Significant factors associated with intraoperative hypotension included a history of previous stroke (adjusted odds ratio [OR]: 2.41; 95% confidence interval [CI]: 1.38–4.21, P = 0.002), a preoperative baseline SBP below 100 mmHg (adjusted OR: 2.34; 95% CI: 1.34–4.08, P = 0.003), a preoperative urine output less than 0.5 ml/kg/h (adjusted OR: 2.74; 95% CI: 1.07–6.96, P = 0.034), undergoing an intramedullary nail procedure (adjusted OR: 2.64; 95% CI: 1.85–3.77, P < 0.001). Conversely, protective factors included receiving preoperative blood transfusions (adjusted OR: 0.43; 95% CI: 0.24–0.77, P = 0.004) and receiving a spinal bupivacaine dose of 7.5 mg or above (adjusted OR: 0.59; 95% CI: 0.36–0.95, P = 0.033). Conclusion: Modifiable factors include ensuring adequate preoperative intravascular volume to optimize urine output and blood pressure, and correcting anemia. Prioritizing these measures for at-risk patients can help prevent complicated hospital stays.

Comparative Study of Intramedullary Interlocking Nailing and Minimally Invasive Percutaneous Plate Osteosynthesis for Distal Tibia Extra-Articular Fractures

Management of distal tibial extra-articular fractures presents a significant challenge in orthopedic practice due to their complex anatomical features and variable fracture patterns. Surgical intervention plays a crucial role in achieving stable fixation and optimal functional outcomes. This study aimed to compare the effectiveness between minimally invasive percutaneous plate osteosynthesis and intramedullary nailing for the management of distal tibial extra-articular fractures. This was a prospective observational study that was conducted in the Department of Orthopedics, Bangabandhu Sheikh Mujib Medical College, Hospital (BSMMCH), Faridpur, Bangladesh from January 2021 to December 2022. Total 24 patients having a fracture of the distal third of the tibia were enrolled in this study as the study subjects. Total patients were divided into two groups. In group A, 12 patients underwent minimally invasive percutaneous plate osteosynthesis (MIPPO) and in group B, 12 patients underwent intramedullary nailing (IMN). A random selection method was used in sample selection. According to Olerud Molander’s score, Excellent, Good and Fair results were found in 50%, 50%, and 0% of the group A patients respectively. On the other hand, those results were found in 42%, 50% and 8% of group B patients respectively. Although both minimally invasive percutaneous plate osteosynthesis and intramedullary nailing procedures are effective in managing distal tibial extra-articular fractures, considering excellent union rate, low blood loss and remarkable Olerud Molander’s score, MIPPO may be considered as the better option. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(2):92-96.

Acute minimally invasive bone grafting of long bone fractures to reduce the incidence of fracture non-union

Diaphyseal fractures of the femur and tibia are a frequent consequence of trauma and are most often managed with intramedullary nailing. Although outcomes from these fractures are generally perceived as good, it is estimated that 7 to 14% of people with tibial and femoral shaft fractures progress to non-union and an even greater proportion suffer delayed union, which causes substantial health and economic burdens both for patients and health services. Compared to those whose fractures unite within the normal timeframe, patients suffering delayed union or non-union suffer more pain, worse functional outcomes, greater psychological disability and longer amounts of time off work. In response to non-union, invasive and costly secondary procedures such as exchange nailing, supplementary fixation and/or bone grafting are commonly required. We hypothesise that performing acute autologous bone grafting at the time of the primary intramedullary nailing procedure would reduce the incidence of fracture delayed union and non-union for tibial and femoral shaft fractures. The autologous cancellous bone retrieved during reaming with intramedullary nailing is usually discarded. We propose a minimally invasive surgical technique to transplant the retrieved intramedullary reamings to the fracture site during the primary fracture fixation. Autologous cancellous bone grafting is the gold standard for management of fracture non-union, and works by providing osteoprogenitor cells, an osteoconductive scaffold, and growth factors to the fracture site, where they are crucial for fracture healing. Proprietary biological products have also been developed that aim to replicate the results from bone grafting. Although autologous cancellous bone grafting is a proven and robust technique for the treatment of atrophic fracture non-union, it has not been widely studied in the acute management of femoral and tibial shaft fractures. The proposed hypothesis is amenable to testing in randomized clinical trials. If found to be effective in reducing rates of delayed union and non-union with minimal adverse events, this method could be adopted on a large scale, potentially transforming acute management of long bone fractures, and improving patient outcomes from these injuries.

Medullary cavity application of tranexamic acid to reduce blood loss in tibial intramedullary nailing procedures—a randomized controlled trial

PurposeStudies have shown an average postoperative hidden blood loss (HBL) of 473.29 ml and an average Hb loss of 16.71 g/l after intramedullary nailing. Reducing HBL has become a primary consideration for orthopaedic surgeons.MethodsPatients with only tibial stem fractures who visited the study clinic between December 2019 and February 2022 were randomized into two groups using a computer-generated form. Two grams of tranexamic acid (TXA) (20 ml) or 20 ml of saline was injected into the medullary cavity before implantation of the intramedullary nail. On the morning of the surgery, as well as on days one, three and five after surgery, routine blood tests and analyses of CRP and interleukin-6 were completed. The primary outcomes were total blood loss (TBL), HBL, and blood transfusion, in which the TBL and HBL were calculated according to the Gross equation and the Nadler equation. Three months after surgery, the incidence of wound complications and thrombotic events, including deep vein thrombosis and pulmonary embolism, was recorded.ResultsNinety-seven patients (47 in the TXA group and 50 in the NS group) were analyzed; the TBL (252.10 ± 10.05 ml) and HBL (202.67 ± 11.86 ml) in the TXA group were significantly lower than the TBL (417.03 ± 14.60 ml) and HBL (373.85 ± 23.70 ml) in the NS group (p < 0.05). At the three month postoperative follow-up, two patients (4.25%) in the TXA group and three patients (6.00%) in the NS group developed deep vein thrombosis, with no significant difference in the incidence of thrombotic complications (p = 0.944). No postoperative deaths or wound complications occurred in either group.ConclusionsThe combination of intravenous and topical TXA reduces blood loss after intramedullary nailing of tibial fractures without increasing the incidence of thrombotic events.

Surgical Management of Metastatic Pathologic Subtrochanteric Fractures

Subtrochanteric pathological fractures (PFs) occur in approximately one-third of femur bone metastases. We seek to analyze surgical treatment strategies for subtrochanteric metastatic PFs and their revision rates. A systematic review was performed using the PubMed and Ovid databases. Reoperations as a result of complications were analyzed according to initial treatment modality, primary tumor site, and type of revision procedure. We identified a total of 544 patients, 405 with PFs and 139 with impending fractures. The study population's mean age was 65.85 years with a male/female ratio of 0.9. Patients with subtrochanteric PFs who underwent an intramedullary nail (IMN) procedure (75%) presented a noninfectious revision rate of 7.2%. Patients treated with prosthesis reconstruction (21%) presented a noninfectious revision rate of 8.9% for standard endoprostheses and 2.5% for tumoral endoprostheses (p < 0.001). Revision rates because of infection were 2.2% for standard and 7.5% for tumoral endoprostheses. There were no infections within the IMN and plate/screws group (p = 0.407). Breast was the most common primary tumor site (41%) and had the highest revision rate (14.81%). Prosthetic reconstructions were the most common type of revision procedure. No consensus exists regarding the optimal surgical approach in patients with subtrochanteric PFs. IMN is a simpler, less invasive procedure, ideal for patients with a shorter survival. Tumoral prostheses may be better suited for patients with longer life expectancies. Treatment should be tailored considering revision rates, patient's life expectancy, and surgeon's expertise. Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibiotalocalcaneal Arthrodesis: A Retrospective Comparison Between Nails and Lateral Locking Plate Complications.

Tibiotalocalcaneal arthrodesis is a well-established procedure to treat some hindfoot diseases. Currently, the most used implants are retrograde intramedullary nails and locking plates combined with lag screws, but there are few articles comparing differences regarding the complications. We have retrospectively analyzed the medical records and the radiographs of patients older than 18 years who underwent this procedure in our service between 2005 and 2019 through retrograde intramedullary nails or lateral locking plates and compression screws with at least 12 months of follow-up and with no history of osteomyelitis in these bones. We evaluated a total of 67 patients; of these, 48 received retrograde intramedullary nail implants and 19 received locking plates and compression screws. The overall mean age was 48 years; the median follow-up time was 64.3 months. The complication rate was 60.4% for the intramedullary nail procedure and 52.6% for the locking plate combined with compression screws procedure. No significant differences were found in the complication rates between the 2 implants. Level V, Case series.

The semi-extended infrapatellar intramedullary nailing of distal tibia fractures: a randomized clinical trial

BackgroundMalalignment is a common event during the intramedullary nailing (IMN) of distal tibia fractures (DTFs). Although it is reported that the semi-extended IMN techniques such as suprapatellar (SP) and parapatellar (PP) approaches may be superior in preventing malalignment, the application of these techniques is concerning owing to the intra-articular involvement. We thus developed an extra-articular semi-extended infrapatellar (SEIP) approach which utilizes the infrapatellar (IP) space while maintaining the knee in a semi-extended position. However, there are no studies on the safety and efficacy of SEIP in treating DTFs. Therefore, in this study, the SEIP technique was examined, particularly in terms of the potential alignment improvement of DTFs, and this technique was compared with the traditional hyperflexed infrapatellar (HFIP) procedure.Materials and methodsThis randomized clinical trial (RCT) compared IMN malalignment while correcting extraarticular and nondisplaced intra-articular DTFs between April 2018 and June 2021 using the HFIP and SEIP techniques at a level I trauma center in China. The study participants were clinically and radiographically examined for at least 12 months of follow-ups. Intraoperative fluoroscopy time, operation time, blood loss, hospitalization duration, functional ankle score, and complications were assessed as well.ResultsAmong the 88 recruited participants, 45 (51%) underwent traditional HFIP IMN and 43 (49%) underwent SEIP IMN. Malalignment occurred in 9 patients (20.0%) from the HFIP cohort and in 2 patients (4.7%) from the SEIP cohort (P value = 0.030). In addition, the SEIP IMN technique significantly reduced the intraoperative fluoroscopy time, operation time, and improved the postoperative ankle function compared to the HFIP IMN technique. However, the intraoperative blood loss, hospitalization duration, infection, delay union, and nonunion remained the same between the two cohorts.ConclusionsIn summary, we demonstrated that the SEIP IMN provides markedly enhanced alignment of extraarticular and nondisplaced intra-articular DTFs compared to the traditional HFIP IMN procedure. The described technique represents an effective option for IMN of DTFs.Level of evidenceLevel 2.Trial registration The Chinese Clinical Trial Registry, ChiCTR2100043673. Registered 26 February 2021, retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=122263

Discrimination, reliability, sensitivity, and specificity of metric-based assessment of an unstable pertrochanteric 31A2 intramedullary nailing procedure performed by experienced and novice surgeons

IntroductionIdentifying objective performance metrics for surgical training in orthopedic surgery is imperative for effective training and patient safety. The objective of this study was to determine if an internationally agreed, metric-based objective assessment of video recordings of an unstable pertrochanteric 31A2 intramedullary nailing procedure distinguished between the performance of experienced and novice orthopedic surgeons. Materials and methodsPreviously agreed procedure metrics (i.e., 15 phases of the procedure, 75 steps, 88 errors, and 28 sentinel errors) for a closed reduction and standard cephalomedullary nail fixation with a single cephalic element of an unstable pertrochanteric 31A2 fracture. Experienced surgeons trained to assess the performance metrics with an interrater reliability (IRR) > 0.8 assessed 14 videos from 10 novice surgeons (orthopaedic residents/trainees) and 20 videos from 14 experienced surgeons (orthopaedic surgeons) blinded to group and procedure order. ResultsThe mean IRR of procedure assessments was 0.97. No statistically significant differences were observed between the two groups for Procedure Steps, Errors, Sentinel Errors, and Total Errors. A small number of Experienced surgeons made a similar number of Total Errors as the weakest performing Novices. When the scores of each group were divided at the median Total Error score, large differences were observed between the Experienced surgeons who made the fewest errors and the Novices making the most errors (p < 0.001). Experienced surgeons who made the most errors made significantly more than their Experienced peers (p < 0.003) and the best performing Novices (p < 0.001). Error metrics assessed with Area Under the Curve demonstrated good to excellent Sensitivity and Specificity (0.807–0.907). DiscussionBinary performance metrics previously agreed by an international Delphi meeting discriminated between the objectively assessed video-recorded performance of Experienced and Novice orthopedic surgeons when group scores were sub-divided at the median for Total Errors. Error metrics discriminated best and also demonstrated good to excellent Sensitivity and Specificity. Some very experienced surgeons performed similar to the Novice group surgeons that made most errors. ConclusionsThe procedure metrics used in this study reliably distinguish Novice and Experienced orthopaedic surgeons' performance and will underpin quality-assured novice training.

An Overview of Rate of Infection and Mortality in Femur Fracture Patients and its Fixation during Covid-19 Pandemic

Aim: To observe the workload of fractures of the femur (shaft and distal femur) and their fixations along with complications in terms of infection and mortality at our hospital during COVID 19 pandemic. Study design: Prospective study. Place and duration of study: Dept of Orthopaedic, Ghurki Trust Teaching Hospital, Lahore from 01-03-2020 to 31-07-2020 Methodology: One hundred and thirty-one diagnosed patients with femur fracture (shaft and distal) during pandemic period of COVID were enrolled. Demographic data included (age, sex, implant type, surgical site infection (SSI) and mortality).Since study was done during COVID-19 pandemic, positivity of COVID symptoms was noted as yes/ no on data collection proforma. Results: There were 105 (80.15%) males while 26 (19.84%) were females with mean age was 39.20±13.02 years. Majority of the surgical interventions were done based on Intramedullary nailing 74.05%, the second prevalent surgeries were done on AO external fixation 8.4%. Infection rate was observed in 7(5.32%) patients. No mortality was seen in any of the cases. Four infected cases were observed after intramedullary nailing procedure, two from AO external fixation and one after locking plate. Conclusion: There is no significant higher complication rate due to COVID-19 pandemic to patients whom femur fracture fixation was done. None of admitted patient suffered COVID-19 symptoms during hospitalization. It was only pointless fear about orthopaedic intervention during this interval. Key words: COVID-19, Femur, Infection

Postsurgical Dance Rehabilitation for Tibial Stress Fracture: 2 Case Reports

Background Tibial stress fractures (TSFs) develop in dancers due to a complex interplay of biopsychosocial influences, occasionally resulting in delayed union and surgery. This Case Report illustrates 2 rehabilitation approaches for TSF with differing complexity in 2 professional dancers. Case Presentation The same surgeon performed intramedullary nailing procedures with screw fixation on both dancers' tibias. In Case 1, the postsurgical physiotherapy included orthopaedic postsurgical care and multimodal physiotherapy involving manual and exercise therapies with patient education and dance-specific retraining. In Case 2, the postsurgical physiotherapy included a psychologically informed approach combined with postsurgical rehabilitation to address both psychosocial comorbidities and orthopaedic deficits. Outcome and Follow-up Both dancers returned to full-time dancing within 7 months post-surgery and reported high recovery rates in long-term follow-up. Discussion The study highlights the importance of physiotherapists' role in identifying and managing psychosocial comorbidities for proper case management, optimum outcomes, and reinjury prevention. JOSPT Cases 2022;2(2):93–100. doi:10.2519/josptcases.2022.10738

Time to entry point and distal locking of intramedullary nails: a methodological phantom study comparing biplanar and uniplanar surgical imaging

BackgroundIntramedullary nailing is the method of choice for diaphyseal fractures of the femur and tibia and is also commonly used to treat trochanteric hip fractures. Perioperative imaging is essential for visualising adequate reduction, achieving an optimal entry point (EP) and performing distal locking (DL) of intramedullary nails. This methodological study aims to compare biplanar and uniplanar imaging in some steps of intramedullary nailing.MethodsWe used a biplanar preassembled imaging device (Biplanar™ 600s, Swemac Imaging) and a uniplanar imaging device (Ziehm Solo FD, Ziehm Imaging) to measure procedural and radiation times for antegrade and retrograde femoral and antegrade tibial nailing in fully soft flexible tissue encased legs with radiopaque sawbones (SKU:1515–7-11, Sawbones Europe, Malmö, Sweden). Four orthopaedic surgeons with different levels of experience performed all procedures in all three phantoms with both image techniques in random order, producing in total 12 EPs and nailings with DL with each imaging device. Time to EP, radiation times, time to DL for both devices and the number of swings of the uniplanar device for the two procedures were measured. Comparisons between the biplanar and uniplanar systems with a paired-samples t-test were conducted.ResultsUsing the biplanar device, time to optimal EP was shorter for retrograde femoral (26 s (SD15) vs 35 s (SD13), p = 0.01) and for antegrade tibial nailing (23 s (SD13) vs 49 s (SD24), p = 0.001). No statistically significant differences in time to EP, radiation time or time to DL were found for antegrade femoral nailing. A median of two swings of the uniplanar device was needed to obtain optimal EP for all procedures.ConclusionsBiplanar imaging slightly but statistically significantly reduced time to EP for retrograde femoral and antegrade tibial nailing in this methodological study comparing biplanar and uniplanar imaging techniques. Biplanar imaging can reduce time and radiation exposure when defining the EP around the knee in intramedullary nailing procedures, but the clinical relevance of these time savings remain to be defined. For antegrade femoral nailing we found no clear benefit with biplanar imaging in the investigated steps of nailing.

Gluteal Contractions as a Gateway to Sacral Plexus.

BackgroundNeurostimulation-guided sacral plexus blocks (SPBs) are primarily indicated for surgeries of the foot and ankle and secondarily for supplementing a lumbar plexus block for hip surgeries. Although ultrasound has largely replaced neurostimulation-guided SPB, it may not be available at all facilities. Hence, it is prudent to understand the intricacies of neurostimulation-guided SPB.MethodologyIn this study, 10 American Society of Anesthesiologists-physical status I and II patients undergoing an intramedullary femoral nail procedure for femoral fractures of the shaft femur received a combined lumbar and sacral plexus block for operative surgery and postoperative pain relief. Neurostimulation-guided SPB was administered in all patients after the lumbar plexus block.ResultsIn all patients, gluteal contractions were observed as the stimulating needle advanced during neurostimulation-guided SPB, which was either a dorsal or plantar flexion. The end-point of neurostimulation-guided SPB was obtained at 1-1.5 mm beyond the gluteal contractions.ConclusionsIt is important to understand that gluteal contractions are evident as the needle is advanced and can be considered a gateway during a neurostimulation-guided SPB.

Overview of research work of Prof. Chu on two medical devices

Surgical procedures are relatively common and procedures for broken bones often involve intramedullary nailing to repair the bone and keep it stable. However, there are challenges associated with the process and Professor Woeichyn Chu, who is a distinguished professor based within the Department of Biomedical Engineering at the National Yang Ming Chiao Tung University in Taiwan, is developing a medical device to help surgeons overcome these challenges, benefiting patients and clinicians. The device is called iMET (intra-medullary endo-transilluminating) and came about after Woeichyn Chu spoke with his brother, Dr William Chu, General Orthopedic Department, Cheng Hsin General Hospital, Taiwan, about some of the challenges relating to intramedullary nailing which led the brothers to begin working together to develop a medical device to help target distal locking holes in intramedullary nailing procedures. The iMET device that the brothers are developing is designed to improve target aiming accuracy and reduce dose absorption concerns. In the process, it will save significant time, effort and money. As well as benefiting patients and clinicians, iMET also reduces X-ray fluoroscopy time, which has health benefits for all involved. Woeichyn Chu and his brother are also developing a device called iKypho, which applies negative pressure during bone cement injection in percutaneous vertebroplasty surgeries. iKypho reduces bone cment leakage risks when using low viscosity cement and reducing the costs associated with high viscosity bone cement.

Management of Pediatric both-bone Forearm Fractures by Titanium Elastic Nailing System: A Prospective Study of 60 Cases

Intramedullary nailing procedure is highly appreciated by many phsyicians for treating pediatrics forearm fractures. Minimum operating time, fewer chances of incisions, faster bone healing, and accuracy in bone alignment less rigid fixation made this technique more popular and preferable. This study was specially designed to observed the management of pediatric both forearm fracture by using the titanium elastic nail technique.&#x0D; Methodology: Our prospective descriptive study was conducted in King Abdul Aziz Hospital Makkah Saudi Arabia from march 2018 to march 2021. Total 60 patients were enrolled which were treated with titanium elastic nail system (TENS). In this study patients with close displaced and open type 1 fractures with age range of 4 to 14 years were included.&#x0D; Results: Total 42.5% of participants were under the age of 10, and 57.5% of patients were above 10 years or equal to 10 years age. We reported 58.9% prevelance of injury among male patients. Along with these, we reported 53.4% cases with left side fractures and 60.3% had middle bone fractures. In our study, we reported that the overall average union time was 9.10±1.8.&#x0D; Conclusion: Titanium elastic nailing is the most effective technique for managing unstable fractures among pediatrics. The male population was more prone to forearm fracture, especially at the middle third shaft. Overall meantime 9 weeks were reported for bone unification. Titanium elastic nailing is more effective technique for patients less than 10 years old. Mean unification time of bone was less among them with little compliactions.

Development and Validation of a Virtual Reality Haptic Femoral Nailing Simulator

To create a virtual reality (VR) femoral nailing simulator combining haptics and image intensifier functionality and then carry out validation studies to assess its educational value. The simulator consisted of a 3D virtual environment, a haptic device and 3D printed drill handle and a VR headset. The environment was created using a video game development engine, interfaced with plugins to allow haptic feedback and image intensifier functionality. Two tasks were created within the simulator as part of an antegrade femoral intramedullary (IM) nail procedure: proximal guidewire entry and distal locking.For the validation study, participants performed the above tasks on the simulator. Metrics were collected including time taken, number of X-rays and tool distance travelled and used to assess construct validity. A questionnaire was then completed to assess authenticity and content validity. Simulator development in centre for simulation and engagement science laboratory. Validation study in a teaching hospital environment. Orthopedic specialist trainees and consultants. Surgeon experience (number of IM nails performed/postgraduate year) correlated with significantly improved task performance. More experienced surgeons took less time, used fewer X-rays and had greater economy of movement than less experienced surgeons. Authenticity and content validity were well rated, with criticisms primarily due to hardware limitations. To our knowledge this is the first orthopedic simulator to combine immersive VR with haptics and full image intensifier functionality. By combining multiple aspects of surgical practice within a single device, we aimed to improve participant immersion and educational value. Our work so far has focused on technical skills, demonstrating good authenticity, content and construct validity, however our findings show promise in other applications such as nontechnical skill development and assessment.

CORR Insights®: Does Virtual Reality Improve Procedural Completion and Accuracy in an Intramedullary Tibial Nail Procedure? A Randomized Control Trial.

CORR Insights®: Does Virtual Reality Improve Procedural Completion and Accuracy in an Intramedullary Tibial Nail Procedure? A Randomized Control Trial.

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.

A comparison of free-hand method and electromagnetic navigation technique for the distal locking during intramedullary nailing procedures: a meta-analysis.

Some studies have reported that the electromagnetic navigation (EN) technique is better than the free-hand (FH) method. Nevertheless, there are few clinical trials. In recent years, several clinical trials have been conducted, providing sufficient information to compare the two methods. We compared the FH and EN techniques (SURESHOT, Smith and Nephew, Inc., Memphis, TN) in terms of the distal locking time, exposure time, first success rate, healing time and operative time. We comprehensively searched the Medline, Embase, and Cochrane library databases according to predetermined inclusion and exclusion criteria, and then we extracted data for specific variables from these reports. The risk of bias was assessed. Stata 13.0 was used for analysis. Nine studies involving 579 patients were pooled in this study. The meta-analysis showed that EN was associated with a shorter distal locking time (P = 0.001) and exposure time (P = 0.001) than FH performed by surgeons who are not proficient in using the FH technique. No significant differences were found in the first success rate (P = 0.231), healing time (P = 0.09) or operative time (P = 0.510). The EN technique has the advantages of a shorter distal locking time and smaller amount of ionizing radiation exposure compared with the FH technique.

PMD7 ONE-YEAR COMPLICATIONS AND REIMBURSEMENT AFTER INTRAMEDULLARY NAIL FIXATION FOR DISTAL FEMUR FRACTURES AMONG THE MEDICARE POPULATION

Fractures of the distal femur, and their treatment with an intramedullary nail, are becoming increasingly more common. This study evaluated the one-year incidence of complications and their associated costs (reimbursement) for patients treated with an intramedullary nail(IMN) for fixation of distal femur fracture(). This retrospective observational cohort analysis used patient-level data from the Medicare Standard Analytic File(2015Q4 to 2018Q1). Patients were 65 years of age or older with an insurance claim for DFF and an IMN procedure during the episode of care for which Medicare was the primary payor. One-year post-fixation incidence for infection, deep infection, delayed healing, and nonunion were quantified. One-year post index reimbursement related to these complications was calculated when any of these complications were listed as primary on any insurance claim. Subgroup analysis was performed for patients with evidence of a prior total knee arthroplasty(TKA) on the same side as the DFF. A total of 3,070 patients had an IMN procedure for a DFF diagnosis and were included in the analysis; among these patients 8.0%(n=247 ) had a prior TKA. The mean (standard deviation [SD]) age for the cohort was 80(8.8) years. Eighty-three percent of the cohort was female, and most patients had a closed fracture(96.4%). The one-year incidence of complications was 3.3% for delayed healing, 3.0% for nonunion, 1.5% for deep infection, and 1.4% for infection. The respective mean(SD) one-year reimbursement for these complications was as follows: delayed healing $1,794($3,454), nonunion $7,027($11,915), deep infection $6,496($9,793), and infection $18,949($21,858). With the exception of nonunion, all other evaluated complications were similar or lower 1-year reimbursement rates among those with evidence of a prior TKA. Complications following DFF are costly and in the case of nonunion having a prior TKA increases the financial burden. Improved surgical methods and technologies could reduce these complications thereby reducing healthcare system costs.