Intramedullary Nailing Technique Research Articles

Proximal tibia fractures and intramedullary nailing: The impact of nail trajectory to varus/valgus deformity

Although intramedullary nailing has been the treatment of choice for diaphyseal tibial fractures, its role in the management of fractures occurring at the proximal tibial metaphysis remains controversial, as high complication rates that mostly refer to unsuccessful reduction and malalignment have been reported. To overcome these problems and improve outcomes, certain modifications to the standard operative technique have been proposed, such as the use of blocking screws, additional buttress plate, different patient positioning, and extended parapatellar or retropatellar approaches. Remarkably, the role of location of the entry portal for the nail in the coronal plane in achieving and maintaining fracture reduction has not been thoroughly investigated. In the present study, we evaluated the hypothesis that, in the management of extra-articular proximal tibial fractures with intramedullary nailing, proper selection of the nail-entry portal that determines the trajectory of the nail could contribute towards fracture reduction, simplify the procedure and reduce complications. This hypothesis was investigated with careful observation of past X-rays (Figs. 1 and 2) that enabled us to propose a specific guideline about the proper site of the entry portal of the nail for the avoidance of varus/valgus deformity. According to this guideline, the entry portal of the nail on the coronal level must be lateral or medial, depending on the side where the fracture approximates most the articular surface of the proximal tibia on the anteroposterior (AP) view. Validation of the hypothesis could result in simplifying the operative procedure and, thus, less operating time and morbidity by reducing the need for additional implants or other relevant modifications of the standard intramedullary nailing technique. 10,12,18–24 A R T I C L E I N F O

Comparison Of Two Biological Internal Fixation Techniques In The Treatment Of Adult Femur Shaft Fractures (Plate - Screws and Locked Intramedullar Nail)

We aimed to compare two (plate-screws and locked intramedullary nail) biological internal fixation techniques in the treatment of adult femur shaft fractures. Group I included 28 patients operated with biological internal fixation with plate and screws. Group II consisted of 31 patients operated with locked intramedullary nailing technique. During the follow-up period in Group I, 1 patient died and 3 patients dropped out of the study, so the results of 24 patients were evaluated. During the follow-up period in Group II, 2 patients died and 3 patients dropped out of the study, so the results of 26 patients were evaluated in this group. Age, sex, injury mechanism, fracture type, time to operation, duration of operation, amount of bleeding, fluoroscopy usage time, early and late complications, duration of hospitalization, fracture union time, and functional results of all patients were comparatively evaluated. According to our results, no superiority of either technique was demonstrated with respect to fracture union time, complication rate and functional results. Biological internal fixation with plate and screws is an alternative technique to locked intramedullary nailing in patients with multi-trauma or compromised pulmonary or cardiac function, or in complex comminuted or segmented diaphyseal or metaphyseal fractures.

The invisible nail: A technique report of treatment of a pathological humerus fracture with a radiolucent intramedullary nail

The goal in the treatment of pathological fractures of long bones is to gain functional stability of the limb, improve quality of life and relieve the pain of the broken bone. Metastatic bone disease presents a challenge for orthopaedic surgeons because of the potential for local tumour recurrence and the susceptibility for nonunion of fractures. The carbon-fibre nail possesses special qualities not present in traditionalmetal nails. The use of a radiolucent intramedullary nail has the potential to enhance clinical follow-up of bone healing postoperatively, and improve overall clinical outcomes. We present the technique of intramedullary nailing of a pathological humerus fracture with a radiolucent carbon-fibre nail.

Cardiopulmonary Response to Reamed Intramedullary Nailing of the Femur Comparing Traditional Reaming With a One-Step Reamer-Irrigator-Aspirator Reaming System: An Experimental Study in Pigs

Intramedullary reaming and nailing increases intramedullary pressure. This may cause intravasation of bone marrow contents, leading to bone marrow embolization and altered cardiopulmonary function. Possible beneficial effects of attenuation of the intramedullary pressure increase by the use of a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would cause lower numbers of pulmonary embolisms (PEs) and lesser cardiopulmonary affection than traditional reaming (TR). Intramedullary reaming and nailing was performed in intact femora of young Norwegian landrace pigs using either a standard intramedullary nailing technique (n = 8) or a RIA technique (n = 7). The hemodynamic and pulmonary effects were investigated during the reaming and nailing procedure and for 2 hours postoperatively. The animals were killed after 72 hours, and the lung/carcass weight ratio and the numbers of PEs were investigated. The pattern of the procedure-related hemodynamic and pulmonary effects did not differ significantly between the RIA and the TR groups. The RIA group had lower numbers (ns) of embolisms per square centimeter lung area than the TR group. After reaming with the TR device, two animals died of PEs, the first postoperative day. The patients with femoral shaft fracture and additional cardiopulmonary injury or preexisting reduced cardiopulmonary function, however, need special attention, and the use of RIA may, in these cases, represent a better operative alternative with a lesser operative burden.

Pulmonary fat embolism after reamed and unreamed nailing of femoral fractures

BackgroundTo determine whether reamed or unreamed intramedullary nailing of femoral fractures results in higher incidence of pulmonary fat embolism, three different methods of intramedullary nailing were compared in sheep. To analyze the presence of bone marrow fat embolism in pulmonary arteries, histological evaluation was undertaken using a quantitative computer-assisted measurement system. MethodsIn this experimental model of 27 female Swiss alpine sheep, an osteotomy of the proximal femur was conducted in each animal. Then, the animals were divided into three groups according to the method of treatment: two different reamed intramedullary nailing techniques and an unreamed nailing technique were used.In the first group “ER” (experimental reamer; n=9), the nail was inserted after reaming with an experimental reamer; in the second group “CR” (conventional reamer; n=7), the intramedullary nail was inserted after reaming with the conventional AO-reamer. In the third group “UN” (unreamed; n=8) unreamed nailing was performed. During the operation procedure intramedullary pressure was measured in the distal fragment.After sacrificing the animals, quantitative histological analyses of bone marrow fat embolism in pulmonary arteries were done using osmium tetroxide fixation and staining of the fat. ResultsThe measurement of intramedullary pressure showed significantly lower values for reamed nailing than for the unreamed technique. The quantitative histological evaluation of lung vessels concerning bone marrow fat embolism revealed a statistically significant difference between reamed and unreamed insertion of the nail: 7.77%±6.93 (ER) and 6.66%±5.61 (CR) vs. 16.25%±10.05 (UN) (p<0.05) of the assessed lung vessels were filled with fat emboli. However, no difference was found between the traditional and experimental reamer. ConclusionsIntramedullary nailing after reaming is a safe procedure with low systemic embolisation when compared to the unreamed insertion of the nail.

Management of non-union of humeral fractures with the Stryker T2™ compression nail

Fractures of the humeral shaft are relatively common injuries and the majority achieve union uneventfully; however, non-union rates of up to 13% are reported when managed either conservatively or operatively. Despite the many surgical techniques described for the management of non-unions, including plate fixation, intramedullary nailing or external fixation, some cases remain resistant to treatment with ongoing problems achieving union. We describe a technique using the Stryker T2 humeral nail which incorporates a compression system allowing closure of the non-union fracture gap. Twelve patients underwent compression nailing for established humeral fracture non-union. All achieved radiological union at an average of 4.5 months (range 3-12 months). All patients reported a return to their normal pre-injury level of activities. We conclude that this technique of intramedullary nailing with a novel compression technique is effective in the treatment of humeral shaft fracture non-union.

Fraturas da extremidade distal da tíbia tratadas pela haste intramedular e placa em ponte: comparação do tempo de exposição à radiação nos dois métodos

OBJECTIVE: To compare the exposure time to radiation in patients with distal third fractures of the tibia treated with intramedullary nail and bridge plate. METHODS: In 33 fractures intramedullary nails were used, and in 41 fractures plates were used. In the intramedullary nail group, according to the AO classification, 14 patients had type A fractures, 15 patients had type B fractures and four had type C fractures. Twelve patients had closed fractures and 21 had open fractures. In the plate group, 10 patients had type A fractures, 22 patients had type B fractures and nine had type C fractures. 27 patients had closed fractures and 14 had open fractures. RESULTS: A significant difference was observed in exposure time to radiation between the patients treated with the intramedullary nail and the plate (p = 0.0001). The group treated with the intramedullary nail had a significantly higher exposure time to the radiation than the group treated with the plate. Comparing the type of fracture (A, B and C), it was observed that there is no considerable difference in exposure time to radiation between the intramedullary nail technique (p = 0.19) and the plate technique (p = 0.80). CONCLUSION: Fractures of distal third of the tibia treated with intramedullary nail show considerably higher exposure time to radiation than fractures treated with the bridge plate, independent of fracture type.

The Early Effects of Intramedullary Reaming of the Femur on Bone Mineral Density; an Experimental Study in Pigs

Both fracture and fracture treatment affect bone mineral density (BMD). BMD after standard intramedullary reaming of the femoral cavity and after reaming with a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would lead to lower BMD levels. Dual-energy X-ray absorptiometry (DXA) was performed on the third day after operation with standard intramedullary nailing technique (n = 6) or RIA technique (n = 7) in intact femora of young Norwegian landrace pigs. Significantly lower BMD were found in the mid-shaft and total femur after reaming with the RIA technique compared to the non-operated femur. Traditional reaming technique resulted in significantly higher BMD in the distal -femur. The results of this study indicate that standard reaming increased BMD in the distal femur, suggesting compressive effects on trabecular bone. The RIA technique decreased BMD in the femoral diaphysis and total femur, suggesting removal of trabecular bone. A possible clinical impact of the findings remains to be investigated.

Robot-assisted Long Bone Fracture Reduction

The preferred treatment of femoral (thigh bone) shaft fractures nowadays is the minimally invasive technique of intramedullary nailing. However, in addition to its advantages, this technique also has a number of disadvantages, such as the frequent occurrence of malaligned fracture reductions and high X-ray exposure, especially to the operating team. The aim of our research is to overcome these shortcomings by utilizing modern techniques such as three-dimensional (3D) imaging, navigation, and robotics. In this paper we present the current state of our interdisciplinary research project. We first introduce a telemanipulated fracture reduction procedure, which is based on 3D imaging data. This set-up is improved one step further towards an automated fracture reduction procedure. Finally, two drilling tasks, namely the opening of the medullar cavity and the distal locking of the intramedullary nail, are presented, which are supported by automated X-ray-based image analysis and robot-assisted drill guidance. We show that high reduction accuracies can be achieved with our robotic system. Furthermore, the robot-assisted drill guidance achieves superior results with respect to increased precision and decreased X-ray exposure compared with the conventional procedure. We conclude that this surgical procedure benefits conspicuously from the support of robotic assistance systems and that further research and development in this field is worthwhile.

Intramedullary Nailing and Clavicle Fractures

Nonoperative treatment has long been the norm for clavicle fractures. However, more recent evidence indicates that shortening or poorly healed fractures lead to considerable loss of arm function. A logical treatment algorithm for clavicle fractures based on up-to-date scientific data was developed, and the operative technique of intramedullary nailing of the clavicle is here described and demonstrated with instructive diagrams. Along with surgical indications, the preoperative, perioperative, and postoperative management is detailed. Operative hints and tricks are explained, the known complications and pitfalls of the procedure are analyzed, and avoidance strategies are offered.

A Comparison of Compressive Force Generation by Plating and Intramedullary Nailing Techniques in a Transverse Diaphyseal Humerus Fracture Model

The null hypothesis to be tested in this study is that the compression forces generated with a novel compressible intramedullary nail are not different from compression plating techniques. A custom sensor was used to measure the compressive force at a transverse midshaft humeral sawbone osteotomy (OTA 12-A3.2) in four groups. The groups included: standard compression plating using a limited contact dynamic compression plate (LCDC) with eccentric screw placement (ED-LCDC), compression plating using an LCDC plate with an articulated tensioner and eccentric compression screw (AT-LCDC), locked humeral nail compressed using the manufacturer's long stainless steel screwdriver (T2-IMN), and locked humeral nail compressed using a short stainless steel AO screwdriver (SF-IMN). From continuous measurements recorded during osteotomy compression, the maximum force (CMax) and force at 60 seconds after the peak measurement (CMax +60) were analyzed. The mean CMax was 2043 N for SF-IMN, 1109 N for AT-LCDC, 799 N for T2-IMN, and 365 N for ED-LCDC. Mean CMax +60 was 1648 N for SF-IMN, 944 N for AT-LCDC, 650 N for T2-IMN, and 319 N for ED-LCDC. The difference in both CMax and CMax +60 was statistically significant between all groups (p < 0.002). A new humeral nail can generate higher compression than plating using eccentric drill holes or the articulated tensioner when used with a short stainless steel screwdriver shaft. Clinical studies are needed to analyze whether this compression could improve the union rate of humeral fractures and nonunions beyond those of standard nails.

Elastic Stable Intramedullary Nailing (ESIN) in Children

This book has been written by a distinguished group of international authors and editors. It is a manual on the operative technique for elastic stable intramedullary nailing on long bone fractures in children. This is a modern textbook, being well set out and illustrated using up-to-date technology with an accompanying DVD showing workshops and clinical details. There is an introduction on the biomechanics of the technique, which explains factors leading to failure. Each chapter has an excellent section at the end on ‘Pearls and Pitfalls’ and these are helpfully illustrated with radiographic pictures. It is a very practical text, subdividing long bones into anatomical areas with the pre-operative limb position. surgical approach and postoperative care and rehabilitation clearly described. It is up to the usual high standards of AO publishing. Any user who undertakes the demanding ESIN technique should have access to it via the operating theatre or library, although of course surgeons undertaking this technique should be trained properly and merely use it for reference. In summary, this is likely to become the standard textbook for ESIN nailing technique, which has recently gained popularity in the paediatric population. It is a demanding technique with many potential complications and this textbook should help surgeons to avoid most of these.

Multiple intramedullary nailing of proximal phalangeal fractures of hand

Background:Proximal phalangeal fractures are commonly encountered fractures in the hand. Majority of them are stable and can be treated by non-operative means. However, unstable fractures i.e. those with shortening, displacement, angulation, rotational deformity or segmental fractures need surgical intervention. This prospective study was undertaken to evaluate the functional outcome after surgical stabilization of these fractures with joint-sparing multiple intramedullary nailing technique.Materials and Methods:Thirty-five patients with 35 isolated unstable proximal phalangeal shaft fractures of hand were managed by surgical stabilization with multiple intramedullary nailing technique. Fractures of the thumb were excluded. All the patients were followed up for a minimum of six months. They were assessed radiologically and clinically. The clinical evaluation was based on two criteria. 1. total active range of motion for digital functional assessment as suggested by the American Society for Surgery of Hand and 2. grip strength.Results:All the patients showed radiological union at six weeks. The overall results were excellent in all the patients. Adventitious bursitis was observed at the point of insertion of nails in one patient.Conclusion:Joint-sparing multiple intramedullary nailing of unstable proximal phalangeal fractures of hand provides satisfactory results with good functional outcome and fewer complications.

A Novel Technique Of Interlocking Nailing In Compound Fractures Of The Tibia Without Image Intensifier By Nail Overlapping Technique

Locked intramedullary nailing is currently considered the treatment of choice for most type I, II and IIIa open and closed tibial shaft fractures. Intramedullary nailing preserves the soft tissue sleeve around the fracture site and allows early motion of adjacent joints. Unreamed medullary nails are used mostly in Gustillo's types II and III. Tibial intramedullary nailing is now regarded as an emergency procedure for stabilisation of compound fractures to allow early return of function and ambulation. It has replaced external fixator which serves as a temporary means to stabilise compound fractures in the present scenario. Interlocking nailing allows early healing of the wound with permanent stabilisation of the fracture thereby preventing the need for secondary procedure. We hereby describe a technique of intramedullary locked nailing for compound fractures of tibia without X-ray image intensifier by nail overlapping technique. We have applied this technique in 30 cases of compound type II and III fractures of tibia and could be very useful procedure in underdeveloped countries and in rural hospitals where facilities of image intensifier are not available in emergency departments where these patients first land up. TECHNIQUE The patient is prepared and draped in a standard manner as for routine interlocking procedure of tibia. Wound is debrided and irrigated. Preoperatively nail length is measured by tibial tubercle medial malleolar distance (TMD) and nail diameter is measured on a lateral radiograph at the level of isthmus. The tibia is approached via patellar tendon splitting approach and entry portal is properly identified (Fig.1). Figure 1 Figure 1: showing site of entry portal in tibial interlocking nail. Once medullary canal is opened, guide wire is put in and fracture is reduced by closed reduction and manipulation. Once fracture is reduced and there is no angulation at the fracture site as assessed clinically, guide wire is progressed distally into the distal fragment and its position in the distal A Novel Technique Of Interlocking Nailing In Compound Fractures Of The Tibia Without Image Intensifier By Nail Overlapping Technique 2 of 3 fragment is confirmed by gritty feel of the guide wire as it proceeds in the medullary canal of the distal fragment. Interlocking nail of proper size and diameter is assembled with proximal jig and inserted into the medullary canal via guide wire. We did not ream the medullary canal fearing further deterioration of endosteal blood supply as most of our cases were compound fractures. Once nail is properly inserted into the medullary canal so that its tip is barely visible at its entry point, we overlap another nail of the same size over the limb externally after putting k-wire through the proximalmost hole of the jig, through the proximal tip of the overlapped nail and then through the skin and proximal aspect of the intramedullary nail at the same site as that of the overlapped nail (Fig.2). Figure 2 Figure 2: showing overlapped nail with k-wire in the poximalmost hole of the jig and distally hand drill in the distal hole of overlapped nail. Distally overlapped nail is put in the alignment of centre of tip of the medial malleolus. We drill the hole in the distal fragment through the hole in the overlapped nail. Once drilling through the bone is complete and drill enters the intramedullary nail we confirm the drill position by guide wire put through the jig in the intramedullary nail. A definite confirmatory feel comes if drill lies within the intramedullary canal (Fig.3). Figure 3 Figure 3: showing how to confirm the intramedullary position of drill without image intensifier. Once drill position is confirmed to be within the intramedullary nail we drill the opposite cortex after removing the overlapped nail. Locking bolts of proper size are then put in the same drill hole and its position may again be confirmed by means of guide wire if you have any doubt. Similarly, another distal locking screw is put in. Proximal locking is done by means of jig attached. Once locking is complete surgical incision is closed in a standard manner and antiseptic dressing is done. This is followed by postoperative radiography. We have performed this technique in 30 cases of type II and IIIA compound fractures of tibia and the results of this technique are satisfactory with us. We have a very limited experience of the same technique in interlocking femur. CONCLUSION The purpose of presentation of this technique is to recommend it for immediate stabilisation of tibial fractures in institutions where X-ray image intensifier is not available in the emergency department. However this technique is blind one and has a definite learning curve.

Die elastisch-stabile Marknagelung als Therapiealternative in der Versorgung kindlicher Monteggia-Frakturen

Forearm fractures are some of the most common injuries in childhood. Monteggia fractures and Monteggia equivalents are rare injuries of the proximal forearm, but they are important because of their special biomechanics. Many authors have reported good results with excellent function if the Monteggia injuries are diagnosed primarily and treated by an axial reposition of the ulna and by an exactly repositioned proximal radioulnar joint. In our investigation, some clinical cases of pediatric Monteggia fractures were operated upon using the technique of elastic stable intramedullary nailing (ESIN). In correct indications, ESIN could be used as a minimally invasive therapeutic alternative to plate osteosynthesis for treating pediatric Monteggia injuries.

Current Concepts: Aseptic Nonunion of Femoral Shaft Diaphysis.

In spite of increased understanding of biomechanics and improvements of implant design, nonunion of femoral shaft fractures continues to hinder the treatment of these injuries. Femoral nonunion presents a difficult treatment challenge for the surgeon and a formidable personal and economic hardship for the patient. In most series of femoral fractures treated with intramedullary nailing techniques, the incidence of this complication is estimated to be 1%. A higher frequency has recently been reported due to advances in trauma care leading to increased survivorship among severely injured patients and expanded indications of intramedullary nailing. Whereas the treatment of femoral shaft fractures has been extensively described in the orthopedic literature, the data regarding treatment of femoral shaft nonunions are sparse and conflicting, as most of the reported series consisted of a small number of cases. However, careful review of the existing literature does provide some answers regarding either conservative or operative management. The gold standard for femoral shaft nonunions invariably includes surgical intervention in the form of closed reamed intramedullary nailing or exchange nailing, but several alternative methods have been reported including electromagnetic fields, low-intensity ultrasound, extracorporeal shock wave therapy, external fixators and exchange or indirect plate osteosynthesis. In this paper, a comprehensive review of the current treatment modalities for aseptic midshaft femoral nonunion is presented, after a concise overview of the incidence, definition, classification and risk factors of this complication.

Femoral Supracondylar Malunions with Varus Medial Condyle and Shortening

Femoral supracondylar malunions associated with varus deformity of the medial femoral condyle and shortening are rare, and all techniques for treatment of this complication reported to date have limitations. A one-stage antegrade locked intramedullary nailing technique to concomitantly treat these combined disorders was performed in 19 consecutive patients. The following procedures were performed: removal of previous implants, supracondylar corrective osteotomy, one-stage lengthening on a fracture table, antegrade static locked intramedullary nail stabilization, and corticocancellous bone grafting. Seventeen patients with malunions received regular followup for a median of 2.4 years (range, 1.1-5.2 years). Sixteen malunions healed with a union rate of 94.1% (16 patients) and a median union period of 4.5 months (range, 3-7 months). Only one nonunion associated with nail breakage occurred (5.9%; one patient) and one deep infection recurred (5.9%; one patient). Both patients recovered after appropriate treatment. All patients had improved knee alignment and function. Antegrade locked intramedullary nailing is an effective technique for one-stage treatment of combined disorders in patients with femoral supracondylar malunions. Complications can be avoided if patients and surgeons are careful during the treatment course. Protected weightbearing until fracture healing is crucial to successful treatment.

Bouquet Pin Intramedullary Nail Technique of the 5th Metacarpal Neck Fractures

Bouquet Pin Intramedullary Nail Technique of the 5th Metacarpal Neck Fractures

Similar Central Hemodynamics but Increased Postoperative Oxygen Consumption in Unreamed Versus Reamed Intramedullary Nailing of Femoral Fractures

Patients undergoing intramedullary nailing of long bone fractures have pathologically altered pulmonary vascular tone, right heart strain, and transient impairment of pulmonary gas exchange. The purpose of this study was to examine the acute differences in cardiopulmonary variables between reamed and unreamed nailing techniques in 18 (9 + 9) healthy patients with unilateral femoral shaft fractures. Intramedullary nailing was performed under general anesthesia within 12 hours after the trauma. For blood sampling, recording, and measurements, the patients were cannulated with radial artery and pulmonary artery catheters. Changes in central hemodynamics and oxygenation were studied pre-, peri-, and postoperatively for 16 to 20 hours. Abnormally high pulmonary shunting (23 +/- 12% in the reamed and 27 +/- 11% in the unreamed group) was observed before the operation. The trends of all variables were very similar in both groups except for the last phase in which the mixed venous oxygen saturation tended to be lower (65 +/- 8 vs. 70 +/- 5%) and the oxygen consumption index was higher (186 +/- 21 vs. 151 +/- 20 mL/min/m) in the unreamed group than in the reamed group (p < 0.05). The timepoints most strenuous to the heart were at the end of operation and in the recovery room. The unreamed intramedullary nailing technique does not offer any advantage in cardiopulmonary variables over the reamed technique. In both groups, there was considerable deviation in over 10 cardiopulmonary variables from normal reference values during the study. We suggest the use of invasive monitoring on patients with a long bone fracture and poor preoperative oxygenation or a history of cardiopulmonary or cardiac disease.

Distale Femurfraktur - optimierte Verriegelungsmöglichkeiten eines retrograden Marknagels durch 3D-Simulation

In addition to the conventional stabilisation procedures, new trends with reduced operation trauma achieve acceptance concerning the treatment of supra- and interkondylar (C-)fractures of the distal femur. Retrograde intramedullary nailing techniques provide advantages in regard to centre line of weight bearing, bone loss of the distal metaphysis and the periosseous blood supply. By the development of a new retrograde nail with diagonal intersecting distal interlocking bolts the indication spectra is extended. Anatomical examinations, implantations in cadaver femora and three-dimensional CT computer simulations were used to optimise the nail features and to reduce implantation failures.