Intramedullary Procedures Research Articles

Surgical load in major fractures — results of a survey on the optimal quantification and timing of surgery in polytraumatized patients

PurposeIt is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions.MethodsA standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between “1,” defined as the surgical load equivalent to external (monolateral) fixator application, and “5,” defined as the maximal surgical load possible in that specific anatomic region.ResultsThis questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load.ConclusionThis study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient’s physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.

Implant failure after externally magnetic-controlled nail lengthening

The number of intramedullary procedures to treat leg length discrepancy (LLD) has risen in the past decade and this has led to increased complications such as nail breakage. The aim of this study was to reveal our experience with implant failure after externally magnetic-controlled telescopic bone lengthening. We observed nail-breakage in 4 out of 24 patients (16.7%) after 6 to 15 months (median 13.5 months) following lower limb lengthening for LLD due to non-union or insufficient bone healing. Three femora and one tibia were treated in one posttraumatic and three congenital cases. Three out of the four patients had an elevated Charleston Comorbidity Index (CCI). Revision surgery involved removal of the broken nail and implantation of a trauma nail. At final follow-up all patients showed subjective satisfaction, achievement of desired lengthening with complete bone healing. Based on our results no unequivocal risk factor including number of previous surgeries, comorbidities and age was identified. In cases of delayed bone formation, early revision surgery with an exchange to a trauma nail has to be considered to prevent breakage of the intramedullary telescopic device.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis

IntroductionThe humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17–31%), kidney (13–15%) or lung (11–24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HypothesisWe hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients’ function. Materials and methodsBetween 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30–94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. ResultsSeven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. ConclusionsOur initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso–epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. Level of evidenceIV, retrospective study.

Patient dose reference levels in surgery: a multicenter study.

To assess diagnostic reference levels (DRLs) in surgery for the most frequent procedures as required by the European Directive 2013/59/Euratom. A survey was conducted in six centers. Eight orthopedic, urology and gastrointestinal surgical procedures were analyzed. Kerma area product (KAP) and fluoroscopy time (FT) were recorded for 50 patients (except for elbow: 30 patients) per procedure and per center from September 2016 to September 2017. DRLs were calculated as the 3rd quartiles of the distributions. For shoulder surgery, DRLs were defined according to the complexity of the procedure. For hand/wrist and foot/ankle surgery, DRLs were defined according to the technology (conventional C-arm vs. mini-C-arm). Results of 1870 procedures were retrieved. DRLs were calculated for the two dosimetric indicators and the eight procedures. DRLs were 2130 mGy.cm2 and 1.4 min for proximal femoral intramedullary nail, 1185 mGy.cm2 and 0.9 min for laparoscopic cholecystectomy and 2195 mGy.cm2 and 1.0 min for double-J (pigtail) ureteral catheter insertion. For shoulder surgery, KAP and FT were significantly higher (p < 0.05) for intramedullary procedures compared to extramedullary procedures. For hand/wrist and foot/ankle surgery, the KAPs were significantly higher (p < 0.05) with conventional C-arm compared to mini-C-arm, but FTs were not significantly different (p: not significant). This study reports DRLs in surgery based on a multicentric survey. • Delivered dose in surgery depends on procedure, practice and patient. • Diagnostic reference levels (DRLs) are proposed for eight surgical procedures. • DRLs are useful to benchmark practices and optimize protocols.

Functional and radiological outcome of pertrochanteric fractures treated with proximal femoral nailing in post-menopausal women, age &gt;60 years

Pertrochanteric fractures (intertrochanteric and subtrochanteric) are one of the common fractures encountered in general population especially with post-menopausal women following a fall due to high energy trauma requiring immediate and active intervention. The main benefit of Proximal Femoral Nailing is being a closed technique offering an excellent reduction at the fracture site and adequate strength for weight bearing even in unstable hip fractures. This intramedullary device is proven to be biomechanically superior to DHS which is an extra medullary device in the treatment of Pertrochanteric fractures. The objective of this study is to analyse and evaluate the functional and radiological outcome of Pertrochanteric fracture treated with proximal femoral nail. A study population was selected and was carried out with a total of 30 patients (post-menopausal) treated with proximal femoral nail from the year 2015-2017. All the patients were selected based on inclusion criteria such as closed fractures of less than 3 weeks and age above 60 years. The appropriate selected patients were assessed both clinically and radiologically at regular intervals of 4wks, 8wks, 12wks, 16wks and 20wks. The functional outcome was assessed using Harris Hip score. From our selected study sample we found majority of the patients were unstable fractures (70%) and others were stable fractures (30%). Based on the union, 50 % of patients showed full union by 12 to 15 weeks and 35 % showed full union by 17 to 20 weeks. We had 85% of the patients with good anatomical results and 50% of the patients with excellent functional results. PFN is a quite safe, well tolerated and effective instrumentation useful in the treatment of all Pertrochanteric fractures. Being a closed intramedullary procedure early mobilization and rehabilitation is possible with early restoration of premorbid functions.

Functional and radiological outcome of intramedullary interlocking nail in the treatment of fracture shaft of humerus

Fracture shaft of Humerus are one of the most common injuries of the arm caused by high velocity injury. Both direct and indirect forces act on it resulting in different fracture patterns. Based on the pattern humeral shaft fractures have been treated both by operative and nonoperative methods. Closed intramedullary nailing of these fractures has been the modality of choice for both segmental and communited fractures compared to plate and screw fixation. By this closed nailing procedure fracture complication, operative and post operative complications are reduced with good functional outcome and early restoration of pre morbid functions. The main purpose of the study was to evaluate the functional outcome and the role of locked intramedullary nailing in fracture shaft of humerus with respect to bone union, shoulder function and related complications. A study population was selected and was carried out with a total of 25 patients (male: 20, female: 5) treated with with intramedullary interlocking nail. The inclusion criteria were patients with closed humerus fracture less than 2 weeks and age more than 20 years. The selected patients were assessed both clinically and radiologically at regular intervals of 6 wks, 12 wks, 24 wks and 6 months thereafter till union. The functional outcome was accessed using Constant murley's scoring system. From our selected study sample we found majority of the patients had segmental fractures (70%) and others had communited fractures (30%). Based on the union, 80 % of patients showed full union by 12 weeks and 20 % showed full union by 16 to 20 weeks. We had 20 patients with excellent functional outcome at final follow-up while 5 patients had good outcome. Intramedullary interlocking nail is a quite safe, effective procedure associated with fast healing, good shoulder movements and reduced infection rates in humeral shaft fractures. Being a closed intramedullary procedure early mobilization and rehabilitation is possible with early restoration of premorbid functions.

Functional and radiological outcome of subtrochanteric fracture treated with proximal femoral nail

Subtrochanteric fractures are one of the common fractures encountered in general population following a fall due to high velocity injury warranting immediate and active intervention. The main benefit of Proximal Femoral Nailing is being a closed technique offering an excellent reduction at the fracture site and adequate strength for weight bearing even in unstable hip fractures. This intramedullary device is proven to be biomechanically superior to DHS which is an extramedullary device in the treatment of subtrochanteric fractures. The objective of this study is to analyse and evaluate the functional and radiological outcome of subtrochanteric fracture treated with proximal femoral nail. A study population was selected and was carried out with a total of 25 patients (male: 20, female: 5) treated with proximal femoral nail from the year 2015-2016. All the patients were selected based on inclusion criteria such as closed fractures of less than 3 weeks and age above 25. The appropriate selected patients were assessed both clinically and radiologically at regular intervals of 4wks, 8wks, 12wks, 16wks and 20wks. The functional outcome was assessed using Harris Hip score. From our selected study sample we found majority of the patients were unstable fractures (70%) and others were stable fractures (30%). Based on the union, 50% of patients showed full union by 10 to 15 weeks and 35% showed full union by 16 to 20 weeks. We had 95% of the patients with good anatomical results and 50% of the patients with excellent functional results. PFN is a quite safe, well tolerated and effective instrumentation useful in the treatment of all subtrochanteric fractures. Being a closed intramedullary procedure early mobilization and rehabilitation is possible with early restoration of premorbid functions.

Functional outcome of comminuted unstable subtrochanteric fractures treated by proximal femoral nail [PFN

Background: Subtrochanteric fractures are often difficult to treat and may well be associated with a mortality of more than 20%. The subtrochanteric region is the site of very high mechanical stresses, the medial and posteromedial cortices were subject to high compressive forces whereas the lateral cortex experiences high tensile forces. Operative management is the treatment of choice to achieve the goals of early rehabilitation and optimal functional recovery. The purpose of the present study is to evaluate functional outcome of the subtrochanteric fractures -both high energy and low energy -treated by PFN. Functional as well as anatomical results were evaluated with regard to pain, limping, activities, deformity and range of movements. The present study was done with the hope to find out a solution for the treatment of unstable comminuted subtrochanteric fractures. Materials and Methods: A total of 24 patients with subtrochanteric fractures presenting in the Department of Orthopaedics from August 2015 to August 2016 were treated by closed intramedullary nailing using PFN and the peroperative and postoperative complications and the functional outcome were studied. All the data was arranged in a tabulate form and analyzed using SPSS software. Chi square test was applied as a test of significance. Probability value of less than 0.05 was considered significant. Result: Out of the 24 patients 16 (66.66%) were males and 8 (33.34%) were females. Most of the cases came under. Type IB (62.50%) and Type IA (20.84%). There were 8.3% cases each of Type II A and Type II B. In this study, 14 cases (58.34%) were locked proximally and distally with 2 screws each. In 4 cases (16.66%), 2 proximal screws and 1 distal screw, in 2 cases of intertrochanteric fracture, only 2 proximal screws were used. Average duration taken for union in this study was 4.5 months (Ranges from 3 months to 7.5 months). 22 (90%) united by 6 months. There were no cases of infection. No shortening in 10 cases. Less than 1 cm shortening in 9 cases and 3.2 cm shortening in one case was found. Proximal screw penetration was noted in one case (RT type II A) at the time of 3 months follow up. Conclusion: PFN is a safe, effective and patient friendly device useful for the treatment of all subtrochanteric fractures irrespective of their comminution. Early mobilization and rehabilitation is possible since it is a closed intramedullary procedure.

Deformity correction and extremity lengthening in the lower leg: comparison of clinical outcomes with two external surgical procedures.

Objective Distraction osteogenesis is a method of stimulating the growth of new bone tissue in order to lengthen the extremities or bridge resected bone defects. In addition to the now-established intramedullary procedures, two different fixator systems are in use. The present study investigated the classical Ilizarov ring fixator (IRF) and a hexapod to assess the precision of lower-leg lengthening and complications classified using the Paley criteria for problems, obstacles, and complications. The study also examined the follow-up results in functional tests to assess outcomes in terms of range of motion in adjacent joints, daily activities, and quality of life. Patients and methodsA total of 43 patients (53 segments) who were treated over a period of 16 years were re-assessed. In 33 segments, treatment was carried out with the hexapod Taylor Spatial Frame (TSF); the conventional IRF was used in 20 segments. The patients’ mean age was 13.5 years (range 2–54 years). The follow-up examinations were carried out 2–15 years postoperatively and comprised measurement of a current leg axis view with the patient standing, calculation of a knee score, activity scores, ankle joint scores, and assessment of motor function and sensory function using appropriate scores in the lower leg and foot. The post-treatment health-related quality of life was assessed using the Short-Form Health Survey-36 questionnaire. ResultsUsing the Paley criteria, far fewer problems occurred in the TSF group in comparison with the IRF (TSF 12.1%, IRF 50%). In the problems category, significant differences were observed with regard to axial deviation (TSF 0%, IRF 36.8%) and pin infections (TSF 9.1%, IRF 40%). Comparison of the obstacles and complications did not identify any significant differences between the two groups. Analysis of the scores for the knee, activity, and motor function/sensory function also did not show any marked discrepancies, apart from a major difference in mobility in the upper and lower ankle joints with poorer findings in the TSF group.ConclusionsDuring treatment, the TSF ring fixator leads to fewer problems, fewer secondary axial translations, and fewer pin infections. However, with temporary transfixation of the ankle joints, the TSF system is also associated with postoperative deterioration in mobility in the upper and lower ankle joint.

English

BACKGROUNDS AND OBJECTIVES: Sixty cases of fracture both bone forearm in adults were operated and fixed using various instruments in Narayana Medical College and Hospital, Nellore. The study period was June 2009 to June 2013. The case were followed up from four months to ten months. METHODS: Most of the cases were young adult male with age ranging between 17 to 73 years. The functional outcome of different modalities of surgical treatment of diaphyseal fracture of both bone forearm in adults are interpreted. We have fixed 17 patients with Dcp, 13 patients with Lcdcp, 14patients with Semitubular plating and 16 patients with Intramedullary nailing. Most cases were operated within three days of injury. Anaesthesia and Tourniquet was used for all cases. Thompsons approach was used for proximal radial fractures and Henrys approach was used for distal radial fractures. Ulna was exposed along its posterior border. Intramedullary nailing was done along radial syloid process and distal tip of olecranon in radius and ulna respectively. Closed reduction under C-arm in intramedullary procedure and open reduction and internal fixation when plating was done. Above elbow p.o.p slab were applied for all operated case. Sutures were removed at 10 th Post-operative day. Mobilization were started after suture removal in plating cases. In Intramedullary nailing cases mobilization started after clinical and radiological union. RESULTS: By Anderson Scoring System out of 14 cases of Dcp 75 %were excellent, 25% were satisfactory. Out of 11cases of Lcdcp 72.7% were excellent, 18.2% were satisfactory, 9.1% were unsatisfactory. Out of 13cases of Semitubular plating 69.2%were excellent, 23.1% were satisfactory, 7.7% were unsatisfactory. Out of 14 cases of Intramedullary nailing with Talwakar square nails 42.9% were excellent, 21.4% were satisfactory, 21.4% were unsatisfactory, 14.3%had failure results. INTERPRETATION AND CONCLUSION: Open reduction and internal fixation can be considered as the treatment of choice if there were no contraindications for this because it is important to maintain length, opposition, axial alignment and rotation alignment if a good range of movement of forearm is to be restored. This is achieved in the present study.

Osteogenesis imperfecta

Osteogenesis imperfecta (OI) is the most common genetic disease of bone and is characterized by fragile bones and growth disorders of varying severity. Most cases of OI are inherited autosomal dominant and caused by a mutation in the collagen type I gene. Indications for OI are bone fragility, stunted growth, scoliosis, skull deformities, blue sclera, loss of hearing, dentinogenesis imperfecta and increased laxity of ligaments and skin. In most cases it is possible to make a clinical diagnosis but a skin biopsy or genetic testing can be useful; however, negative results for these tests do not exclude OI. Therapy must be carried out in a multidisciplinary team and includes conservative (e.g. physiotherapy, rehabilitation programs and orthopedic aids), operative (e.g. intramedullary stabilization procedures) and pharmaceutical (e.g. biphosphonates and growth hormones) procedures. The prognosis depends on the type of OI and ranges from normal life expectations for type 1 patients up to up to perinatal mortality for type II patients.

Limb lengthening with fully implantable magnetically actuated mechanical nails (PHENIX®)—Preliminary results

Limb lengthening and deformity correction with fully implantable systems is becoming more and more widespread. Different actuation techniques are known and every system has its specific limitations in distraction control and/or stability. A new system with magnetic actuation offers outstanding options.The mechanism of the Phenix M2® bone lengthening nail (Phenix Medical, France) is driven by a strong external magnet. The device can provide lengthening, shortening and bone transport. Between December 2011 and November 2012 we applied the nail in 10 patients with an average age of 25 years (range 15–40 years). There were 6 femoral and 4 tibial procedures.The intended distraction goal was achieved in 8 of 10 patients. In three cases we simultaneously corrected malalignment. Average lengthening was 4.6cm (range 1.3–7.6cm). Average distraction index was 0.85mm/day (range 0.6–1.3mm/day). Average weight bearing index was 27days/cm (range 16–37days/cm). Three patients had revisions due to early distraction arrest.The early results are comparable to those of other intramedullary systems in the literature like the ISKD®, the Albizzia® or the Fitbone® system. All intramedullary procedures require accurate analysis and planning, advanced operative technique and close follow-up. The custom made design of the Phenix nail with unique options for size, stroke and locking provides new options for small bones and improved stability. The shortening option may be helpful for soft tissue problems, joint subluxation and additional stimulation of bone formation. Magnetic forces have to be considered and too much soft tissue around the nail might be a limiting factor.The magnetically actuated Phenix nail offers new therapeutic options in limb lengthening.

Pulmonary fat embolism and related effects during femoral intramedullary surgery: An experimental study in dogs

The aim of the present study was to develop an animal model of pulmonary fat embolism (PFE) caused by femoral intramedullary procedures, and to investigate the initial changes in the hemodynamics, cytokines and risk factors of PFE. Sixteen dogs were randomly divided into two groups: Group A (intramedullary reaming and bone cement injection, n=8) and Group B (surgical approach without opening the medullary cavity, n=8). The hemodynamics, arterial blood gases and relevant cytokines were evaluated, and the lungs were examined using Oil Red O staining. In the animals of Group A, the heart rate, central venous pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure and extravascular lung water (EVLW) were increased compared with the baseline levels, while the mean arterial pressure was decreased immediately following the reaming and bone cement infusion (P<0.05). Furthermore, there was a significant reduction in the pH and the arterial oxygen tension (PaO2), and a significant increase in the arterial carbon dioxide tension (PaCO2; P<0.05 for all) following the bilateral intramedullary surgery. The EVLW was correlated with the PaO2 (P<0.001) and PaCO2 (P=0.046). Following surgery, there was a significant increase in tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and IL-6 levels in Group A (P<0.05). However, there were no significant changes in these parameters in Group B. The parameters tested, with the exception of pH, were significantly different in Group A compared with those in Group B (P<0.05) following the bilateral intramedullary surgery. Oil Red O staining was positive for all animals in Group A and negative for those in Group B. Femoral intramedullary surgery may induce PFE and subsequently affect hemodynamics and arterial blood gases. EVLW was correlated with the PaO2 (P<0.001) and the PaCO2 (P=0.046). These results demonstrated that EVLW and cytokines may serve as predictors of the development of fat embolism syndrome (FES).

New Technique for Dorsal Fragment Reduction in Distal Radius Fractures by Using Volar Bone Fenestration.

Introduction:For intra-articular distal radius fractures (AO Classification, type B2) with a displaced dorsal fragment, there remains much discussion on the fixation method for the dorsal fragment. To reduce the displaced dorsal fragment, we developed a new technique consisting of fenestration of the volar bone cortex, reduction using an intramedullary procedure, and fixation using a volar plate. This avoids necessity of dorsal approach.Technical Note:We performed this surgical technique in 2 patients and achieved a good reduced position without much injury to the bone cortex at the site of volar plate placement. This surgical technique allows reduction of the dorsal fragment using an intramedullary procedure by only a volar approach, and, therefore, does not affect the dorsal soft tissue (extensor tendon). For intra-articular distal radius fractures, complete reduction of the articular surface is extremely difficult, and, in patients with a remaining gap on the articular surface, a variable angle locking screw system may be useful. In the 2 patients, the angle of the locking screw was adjusted to catch the displaced dorsal fragment, and adequate reduction and fixation could be achieved.Conclusion:This technique using fenestration of the volar bone cortex allows reduction and fixation of the displaced dorsal fragment in distal radius fractures and thus avoids the necessity of a dorsal approach.

Results of intraoperative neurophysiological monitoring in spinal canal surgery

Background and purposeSpine surgery carries the risk of neurological complications. Neurophysiological intraoperative monitoring (NIOM) plays some role in preventing adverse events. NIOM is a young technique, and because of its costs and additional personnel it requires constant evaluation of indications. Nowadays, it is generally assumed that if available, NIOM should be used in every intracanal surgical procedure. This study aimed to evaluate the efficacy and indications for NIOM in spine surgery in relation to procedure location. Material and methodsEffectiveness of NIOM in spinal canal surgery was evaluated by comparison of the number of neurological complications in patients treated surgically with and without NIOM. A total of 74 consecutive patients were surgically treated for spinal canal pathology at the Department of Neurosurgery, 10th Military Hospital in Bydgoszcz. Thirty-eight patients operated on with the use of NIOM were compared to a historic population of 36 patients treated before the introduction of NIOM. The number of patients with neurological complications was analyzed in three groups based on surgical location: extradural, intradural extramedullary, and intramedullary procedures. Differences between groups were tested with the Fisher exact test. ResultsThe number of neurological complications was significantly lower in the intramedullary procedure group with NIOM. There was no significant difference in the number of complications in patients undergoing intra- or extradural extramedullary procedures with versus without NIOM. ConclusionsNIOM decreases the risk of neurological complications in spinal cord surgery, but not in extramedullary spinal canal procedures.

Cortical Blindness In Fat Embolism Syndrome Following Fracture Manipulative Procedure

Fat embolism syndrome is a well-recognised sequela of long bone trauma as well as intramedullary orthopaedic procedures. However, it has rarely been described following manipulation, reduction of fracture, and application of external fixator. Furthermore, bilateral ocular blindness is seldom the first manifestation; instead respiratory and other cerebral symptoms being most common. We describe a case with this rare presentation in a patient who underwent a trial of closed reduction, then open reduction of a femur fracture, followed by external fixation performed at day 47 post-initial trauma.

The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus

Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.

Pathophysiology of Fat Embolism after Intramedullary Reaming

Primary operative stabilization by an intramedullary procedure is the treatment of first choice for fractures of long tubular bones for reasons of biomechanics, the minimally invasive approach, and the early loadability of the injured limb. Additionally, in the case of multiple injuries, the pulmonary situation can be improved so that both the duration of ventilation and the period spent in intensive care are reduced. However, a postoperative increase in the incidence of posttraumatic lung failure has been found following early intramedullary nailing and seen as being linked to the procedure. The increase in intramedullary pressure occurring on intramedullary nailing or reaming can result in release of bone marrow and fat into the venous blood system. The potentially lethal consequences may be adult respiratory distress syndrome (ARDS) and multiple organ failure. For these reasons, a method was sought to bring about a reduction in intramedullary pressure at primary nailing. These efforts led to further developments in implant and reamer design as well as in nailing techniques. However, a clear release of fat was still apparent under these conditions. This review gives an overview of pathophysiologic aspects of reamed intramedullary nailing and suggestions for the optimal reaming system. A new-designed rinsing-suction reamer is briefly presented.

DHS

The dynamic hip screw (DHS), or sliding hip screw (SHS),Richards's screw, sliding compression screw or Pohl's flanged screw, is based on an idea of Ernst Pohl, a development engineer working for Gerhard Küntscher. The advantages of this device are its high intraoperative safety, rotational stability in stable 31.A1 fractures, and the dynamics allowed in the fracture area, which leads to improved fracture healing with weightbearing. Over the years it has become apparent that it also has limitations: lacking lateral support for the unstable head-neck fragment leading to medialisation of the shaft and inadequate rotational safety in unstable 31.A2 and 31.A3-fractures.Faulty drilling with inadequate positioning of the guidewire can have deleterious effects owing to the resultant large drilling defect.The addition of a trochanteric stabilisation plate (TSP) to the implant has led to a modular system that can mitigate the weaknesses of the original version of the implant.Competition for this product emerged with the development of a closed intramedullary procedure using an implant that has been marketed as the gamma nail since the early 1990s. Nonetheless, evaluation of all randomised, prospective studies published up to 1999 inclusive has shown a lower rate of femur fractures and a lower rate of revision operation following use of the DHS.The improved versions of intramedullary devices will have to demonstrate their supposed superiority in further studies.

Überlegungen zum Osteosyntheseverfahren bei Olekranonfrakturen und Olekranonosteotomien

Tension-band-wiring is mostly used for fixation of olecranon fractures. It is the standard procedure for more than 30 years and rarely discussed critically. Plate fixation is the standard for multi fragment fractures. Up to now intramedullary procedures like Rush-pin, KUntscher-nail, Smith-Petterson-nail and Maatzscrew were not equivalent to tension-band-wiring and plate osteosynthesis. In the last years interlocking nails have been developed for use in metaphyseal fractures like proximal tibia fracture and proximal humerus fracture. A interlocking nail could combine the advantages of an intramedullary implant with the stability of an extramedullary fixation. Excision of the olecranon fragments should be reserved for those cases when anatomic restoration cannot be achieved with internal fixation. The olecranon osteotomy has in contrast to olecranon fracture a much higher rate of complication despite it is an ideal fracture. The osteotomy site has less influence on stability of the osteosynthesis like primary stability.