Intramedullary Nailing Procedures Research Articles

The fracture table as a distraction mode in ankle arthroscopy.

Adequate distraction can be obtained in ankle arthroscopy by placing a Steinmann pin transversely in the calcaneus and using the fracture table in a hip or tibial nailing mode. A sterile traction bow is attached to the calcaneal pin and then to the traction crank apparatus of the fracture table. Gross traction is first applied through the leg in the usual manner and then fine traction tension may be increased or decreased intraoperatively through the traction crank. This method of using the fracture table is easy to perform and is familiar to the orthopaedist, as it is used in intramedullary nailing procedures. The primary advantage is that it allows for excellent exposure while avoiding the morbidity associated with a distraction pin through the distal tibia.

Compartment Syndrome in the Well Leg Resulting From Fracture-Table Positioning

A variety of patient positioning options exist on modern fracture tables for use during intramedullary nailing procedures. With the advent of interlocking and reconstruction nailing, some of these procedures can be complicated and prolonged. The use of the hemilithotomy position for prolonged intramedullary nailing procedures can result in the development of a compartment syndrome in the uninjured leg, no matter what type of suspension device is used for that leg. The occurrence of this iatrogenic injury in the patient's well leg can be devastating in light of the contralateral fracture. Two patients at this institution have had such a condition in the past two years, and the authors have revised their positioning procedures. Review of the surgical literature shows that this complication has been seen in urologic, gynecologic, and general surgical patients, but has not been widely reported in the orthopaedic population. Recommendations for avoiding this problem include the use of other positions or distraction devices when performing intramedullary nailings, or, when the hemilithotomy position cannot be avoided, early intraoperative repositioning of the leg when possible.

Acute lengthening of shortened lower extremities after malunion or non-union of a fracture.

Forty-nine skeletally mature patients who had either a non-union or a malunion of a fracture of the tibia or the femur had correction of the deformity and acute axial lengthening of the fractured bone. Distraction was provided by the short AO/ASIF fracture distractor applied directly to the site of the osteotomy or non-union. At an average of sixty-three months (range, twenty-six to 105 months), the average increase in the tibial and femoral length was 1.7 and 3.2 centimeters, respectively. There were no compartment syndromes or ischemia secondary to any of the procedures. One patient had a transient sensory-nerve loss. Fatigue fractures were seen in two tibial plates, two femoral plates, and one femoral intramedullary nail used for osteosynthesis. A non-union developed after four other femoral intramedullary nailing procedures. One infection developed after lengthening of a tibia. Restoration of normal length by acute lengthening and internal fixation was achieved in twenty-seven patients. One patient had overlengthening of one centimeter. Fifteen patients had residual shortening of approximately one centimeter, three had shortening of more than one to 2.5 centimeters, and three patients had more than 2.5 centimeters of shortening. The patients in this series had acute restoration of limb length after traumatic shortening with a low prevalence of complications of neurovascular compromise. Three of the thirty tibial lengthenings and seven of the nineteen femoral lengthenings had to be followed by at least one additional procedure to obtain union.

Exposure of the orthopaedic surgeon to radiation.

A prospective study of sixty-five orthopaedic procedures performed with fluoroscopic assistance was undertaken to determine the risk to the primary orthopaedic surgeon with regard to radiation. Radiation was monitored with the use of a universal film badge placed outside the collar of a lead apron, and a gas-sterilized thermoluminescent dosimeter ring worn on each hand. The rings were changed with every operation, but the same film badge was transferred from surgeon to surgeon. The hand dominance of the surgeon, the duration of the operative procedure, the type of operation, and the total time that fluoroscopy had been used were noted. The study was conducted during twenty-one intramedullary nailing procedures (thirteen involving distal locking), forty open reductions with internal fixation (plates and screws), and four external-fixation procedures. All of the badges and rings were submitted for a report regarding radiation exposure. No relationship was found between a ring with a positive reading for exposure to radiation and the duration of the operation. Similarly, there was no correlation between a positive reading and the surgeon's hand dominance. The mean duration of the fluoroscopy was 2.3 minutes for the group for which the rings did not show a positive reading and 4.7 minutes for the group for which the rings did show a positive reading. This was a significant difference (p < 0.0001). There was no positive reading for exposure to radiation from any ring that had been worn during a procedure in which the fluoroscope had been used for less than 1.7 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Intramedullary Nailing of Tibia1 Nonunions

Fifteen tibial nonunions, ranging nine months to 19 years after original injury, were treated with the Brooker intramedullary nail (IMN). The average number of previous failed surgeries was two. The fracture location ranged from several centimeters below the tubercle to 3 cm above the plafond. Twelve of 15 had bone grafting, and all 15 had fibular osteotomy at the time of the IMN procedure. Thirteen of 15 were reamed, and 11 of 15 were nailed open. Patients required an average of five postoperative days in the hospital, and 14 of 15 tibial nonunions healed uneventfully at an average of eight months after the IMN procedure. Weight bearing in a removable patellar-tendon-bearing (PTB) brace was encouraged in most cases by two to four weeks postoperative. One nonunion patent, traumatically refractured after rod removal, was treated at another hospital with dynamic compression plating and iliac crest bone graft; the fracture healed three months later but was considered an IMN treatment failure. There were no other significant complications. The IMN procedure encourages early return to function and reliably promotes union in even the most challenging and complex of tibial healing problems.

Viability of intramedullary canal bone reamings for continued calcification

The viability of intramedullary canal bone reamings as a potential bone graft material was examined. Intramedullary bone reamings were obtained from the tibia or femur of three patients during intramedullary nailing procedures. Histologic examination showed bone marrow elements with complete disruption of the marrow compartmental organization. Bone trabeculas were present in a randomly scattered fashion with no structural organization. To assess the viability after reaming of the material for continued calcification, implants of the reaming material were placed in a pocket made in the gluteus maximus muscle of 12 rats. After 7 days, the implanted bone spicules showed evidence of tetracycline label uptake, indicating the material obtained after reaming the intramedullary canal was still viable and capable of continued calcification. That the intramedullary canal bone reamings may be a source of bone graft material is interesting. The reamings appear to continue an osteoproductive capacity when used as a graft.

THE USE OF COMMON CARPENTERSʼ TOOLS IN INTRAMEDULLARY NAILING OF FRACTURES OF THE FEMUR

This tool has many desirable attributes. They are: 1. It will not break. 2. It retains the cutting edge after repeated autoclaving. 3. By the use of this tool, the pathway is cut rather than driven. This is advantageous, for cutting is less shocking and minimizes the possibility of shattering the bone. 4. It can be used for either clover-leaf or diamond-shaped nails. 5. The bit is available in many diameters and, therefore, can be used in other intramedullary-nailing procedures. 6. The brace has a rachet and is adaptable where a full turn can not be taken. 7. It may be purchased at any good hardware store at nominal cost.

Fractures of the femoral shaft: A clinical comparison of treatment by traction suspension and intramedullary nailing

1. 1. A clinical comparison has been made of twenty-one femoral shaft fractures treated with traction suspension and twenty-one such fractures treated with open intramedullary nailing. 2. 2. The nailing procedure presents very great advantages over the traction suspension method regarding period of recumbency, duration of hospitalization, time and quality of bone healing and the functional results. 3. 3. In selected cases, in the proper hands and under the proper circumstances the advantages offered by open intramedullary fixation offset the risk of open reduction and the peculiar hazards of the nailing procedure. 4. 4. If the stated appropriate conditions for intramedullary nailing cannot be met, treatment by traction suspension is recommended. 5. 5. The management of selected femoral shaft fractures by the open intramedullary nailing procedure is described. Contraindications to the method are noted. The inherent difficulties and possible complications of the procedure are emphasized. 6. 6. All open intramedullary nailings in fractures of the femoral shaft should be accompanied with iliac bone grafts to the fracture site. This may interfere with a true estimation of the effects of the nailing procedure on the process of bone healing but it will assure a more rapid, effective and secure bone union.