Locked Intramedullary Nailing Research Articles

Locked Intramedullary Total Wrist Arthrodesis

Total wrist arthrodesis is commonly performed using fixation plates, which can produce soft tissue irritation, often require removal, and limit the ability to position the hand in space. The Skeletal Dynamics IMPLATE is an intramedullary total wrist fusion device designed to provide stable fixation while avoiding the problems associated with plates. Radial and metacarpal locked intramedullary nails are inserted and joined by a connector. Desired hand placement is achieved by selecting the proper connector length and angle, then orienting it appropriately. Fusion mass compression is obtained by virtue of longitudinal threads on the radial nail that allow for length adjustment. Seven wrists in three men and four women were treated with this device and followed for a minimum of 24 weeks. In all cases, local cancellous bone graft was used and the third carpometacarpal (CMC) joint incorporated into the fusion. The median age was 49 (range, 28-71) years. Indications for fusion were two posttraumatic arthritides, three rheumatoid arthritides, one spastic deformity, and one infection. Patients were evaluated before surgery and at final follow-up using the Fernandez pain score and grip strength measurements using a hand-held dynamometer. All patients improved their grip strength and decreased their pain scores. All fusions united, and none of the patients presented dorsal soft tissue problems or required implant removal. One rheumatoid patient required secondary surgery for removal of a retained palmar osteophyte. This device delivers stable fixation, facilitates hand placement, and does not require removal.

Utilization of the AO LockingRatNail in a Novel Rat Femur Critical Defect Model

ABSTRACTBackground: Our objective was to utilize a commercially available rodent locked intramedullary nail in a rat femur diaphyseal defect. This model is needed for future studies where materials in the critical defect could be modified with agents to fight infection (antibiotics) or promote osteogenesis. Methods: After unsatisfactory attempts to develop a reliable femur critical size defect model utilizing various forms of fixation, a locked intramedullary nailing system (AO LockingRatNail) was employed in 105 male Sprague Dawley rats. A 5 mm critical size mid-diaphyseal femoral defect was created using a pneumatic sagittal saw. The intramedullary nail was placed in the femur in a retrograde manner. A prefabricated polymethyl-methacrylate (PMMA) spacer was utilized to fill the defect. Once adequate alignment was achieved, two locking pegs were placed (one distal, one proximal) to provide stable fixation. Results: The technique was successful in 90% of femurs (95 of 105). The majority of complications centered on failure of the placement of locking pegs (7 of 10). One rat presented with migration of the nail out of the knee. Two rats presented with fractures not recognized intraoperatively. These complications occurred early in the study and decreased as surgical experience increased. Surgery was tolerated well by the rats as reflected by significant weight postoperative gain (p < .001). Conclusions: The AO LockingRatNail is a novel, reproducible, and successful method for stabilization of critical size femoral diaphyseal defects in the rat. This model has future value in the examination of the biological processes involved in the healing of critical bone defects.

Locked Intramedullary Nailing in the Treatment of Femoral Shaft Fractures in Children Younger than 12 Years of Age

Although flexible intramedullary nailing is a popular treatment option for femoral shaft fractures in juvenile and young adolescent patients, it may not be appropriate in some patients because of patient size and/or fracture configuration. Retrospective review over a 3-year period identified 17 skeletally immature patients (18 fractures) with femoral shaft fractures treated with noncannulated rigid locked intramedullary nailing because of a length-unstable fracture or patient overweight or obesity. The 14 males and 3 females had an average age of 10 years at the time of injury (range, 7.6 to 11.9 y). Their average weight was 38.3 kg (range, 22.7 to 52 kg), with an average body mass index of 18.9 (range, 13.9 to 26.9). All fractures united at an average of 13 weeks, with no osteonecrosis, malalignment, malunion, or hardware failure. Preliminary results suggest that noncannulated, rigid, locked intramedullary nails can be used safely and effectively for selective fixation of femoral shaft fractures in skeletally immature patients younger than 12 years of age. Level IV.

Staged Protocol for the Treatment of Chronic Tibial Shaft Osteomyelitis With Ilizarov’s Technique Followed by the Application of Intramedullary Locked Nail

Open tibial shaft fractures are the most common open fractures, and many complications can occur. During the treatment period, infection leading to osteomyelitis was the most common complication. However, no consensus exists regarding the ideal management for such cases in the literature.The purposes of this retrospective study were to review the treatment of patients with chronic tibial shaft osteomyelitis over the past 14 years who were referred to the authors' institution and to provide a staged protocol for spontaneous wound healing. The staged protocol included: (1) radical debridement for infected bone and soft tissue; (2) immediate application of Ilizarov's apparatus for all patients except those needing delayed application; (3) osteotomy in healthy bone; (4) simultaneous distraction-compression osteogenesis and histogenesis; (5) additional docking-site bone grafting; and (6) shifting the external fixator to a locked nail when callus formation was visible at the distraction site. Union was achieved in 15 of 16 patients, with an average external fixation time of 4.5 months (range, 3-6 months). No deformity or leg-length discrepancy greater than 1 cm occurred.In the treatment of chronic osteomyelitis, this staged protocol was safe and successful and allowed for union, realignment, reorientation, and leg-length restoration. Regarding the soft tissues, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simultaneous reconstruction for bone and soft tissue defects without flap coverage.

Functional Impact of Tibial Malrotation Following Intramedullary Nailing of Tibial Shaft Fractures

Tibial malrotation is a complication that is seen in approximately 30% of patients following locked intramedullary nailing. In this cohort study, we evaluated the hypothesis that tibial malrotation would lead to impaired functional outcomes. Patients with a unilateral tibial shaft fracture who were managed with intramedullary nailing between 2003 and 2007 were identified with use of ICD-10 (International Classification of Diseases, 10th Revision) codes. After institutional review board approval and written informed consent had been obtained, specific assessment of eligible patients was achieved with use of computed tomography, functional measures (Lower Extremity Functional Scale, Olerud-Molander Score, six-minute walk test), and physical examination. Measures were compared between patients with and without tibial malrotation (defined as tibial rotation of ≥ 10°) on imaging studies. Of the 288 patients who were identified, 100 were eligible for the study and seventy consented to participate. The mean duration of follow-up (and standard deviation) for these seventy patients was 58 ± 11 months. Twenty-nine patients (41%) had tibial malrotation. Lower Extremity Functional Scale scores were similar between the groups with and without malrotation (mean, 70.8 ± 8.6 points compared with 72.6 ± 8.7 points; p = 0.41). The results for the other functional tests were also similar. Despite high rates of tibial malrotation following locked intramedullary nailing of isolated tibial diaphyseal fractures, this finding does not have a significant intermediate-term functional impact.

Biomechanical comparison of intramedullar versus extramedullar stabilization of intra-articular tibial plateau fractures

Fractures of the proximal tibia occur very often and are a great challenge for trauma surgeons to stabilize. Although locked nails were developed to stabilize these fractures, this technique has not been sufficiently investigated. The purpose of this study was to biomechanically assess the stability of locked intramedullary nailing compared to locked plating. 16 fresh frozen human cadaveric tibiae were osteotomized in the meta-diaphyseal intersection with an osteotomy gap of 10 mm and a single osteotomy through the medial epicondyle to simulate a 41-C.2 fracture. Stabilization was performed with an angle stable locked Targon-TX nail (n = 8) and two additional canulated screws. The other testing group (n = 8) was treated with two canulated screws and a five-hole LCP-PLT. The bones were tested in a cyclic testing protocol with increasing loads under compression and a load sharing of 60 % through the medial tibial plateau and 40 % to the lateral side. Stiffness and fracture gap movement were measured and failure mode was assessed. No significant differences were found between the two implants regarding load until failure. The stiffness of the intramedullary nailing group (927 N/mm) was statistically significantly higher than the stiffness of the plating group (564 N/mm). No differences were found for fracture gap movement in the z-axis. However, differences were found for dislocation of the proximal-lateral and proximal-medial fragments, with absolute values of 0.099 mm in the plate group and 0.66 mm in the nailing group at 800 N. Prior to failure, fracture gap movement was 0.22 mm for the plating group and 1.66 mm for the nailing group, a difference that was also statistically significantly different. The nailing group failed by screw cut-out while the plating group failed by screw breakage. Nailing of proximal tibia fractures leads to a stiffer implant-bone construct than plating. Since no adverse effects were found after nailing it seems to be a good alternative to plating for intra-articular proximal tibia fractures, especially in patients with soft tissue problems.

L-T4.1 Long-term stability of angle-stable versus conventional locked intramedullary nails in a distal tibia fracture model

L-T4.1 Long-term stability of angle-stable versus conventional locked intramedullary nails in a distal tibia fracture model

L-F3.3 The patellofemoral kinematics following locked intramedullary nailing treatment for femur shaft fracture

L-F3.3 The patellofemoral kinematics following locked intramedullary nailing treatment for femur shaft fracture

Technique for Locking Intramedullary Nails Without Imaging

Surgeons have always tried to find different ways of performing distal locking. We describe an easy and reproducible technique to perform distal locking without using image intensifier, one that lends itself to confirmation during the process.

Infection of the fracture hematoma from skeletal traction in an asymptomatic HIV-positive patient

Infection of the fracture hematoma from skeletal traction in an asymptomatic HIV-positive patient

The Development of a Neuropathic Ankle following Successful Correction of Non-Plantigrade Charcot Foot Deformity

The treatment of Charcot foot arthropathy has traditionally involved immobilization during the acute phase followed by longitudinal management with accommodative bracing. In response to the perceived poor outcomes associated with nonoperative accommodative treatment, many experts now advise surgical correction of the deformity, especially when the affected foot is not clinically plantigrade. The significant rate of surgical and medical-associated morbidity accompanying this form of treatment has led surgeons to look for improved methods of surgical stabilization, including the use of the circular ring external fixation. Over a 7-year period, a single surgeon performed surgical correction of non-plantigrade Charcot foot deformity on 171 feet in 164 patients with a statically applied circular external fixator. Following successful correction, five patients developed a neuropathic deformity of the ipsilateral ankle after removal of the external fixator and subsequent weight bearing total contact cast. Three of the five patients progressed to successful healing of the neuropathic (Charcot) ankle arthropathy following treatment with a series of weightbearing total contact casts. Two underwent successful ankle fusion with retrograde locked intramedullary nailing. This unusual clinical scenario likely represents either a progression of the disease process in the foot or a complication associated with surgical correction of the original neuropathic foot deformity. A better understanding of this observation will likely become apparent as we acquire more experience with this disorder.

Results of Proximal Ulna Fractures Treated with a Multiplanar, Locked Intramedullary Nail: First Multicenter Experience: Level 4 Evidence

28 consecutive patients with displaced olecranon fractures underwent open reduction and internal fixation using a multiplanar, locked intramedullary implant (OlecraNail, Mylad Orthopedic Solutions) and were followed for a minimum of 12 months (range: 12-18 months). Of the 28 fractures, 18 were transverse or oblique (AO/OTA 21-B1.1), 10 were comminuted (AO/OTA 21-B1.2; B1.3), 4 of which also involved the coronoid, and 7 were nonunions. Average patient age was 45 years (range: 25 to 65 years). Patient clinical outcome measures where monitored at approximately six weeks, twelve weeks, and one year following the surgery. Included in this evaluation was range of motion, visual analog pain score, and strength. Patients were immobilized for 3-5 days postoperatively, after which motion was allowed. Strengthening was initiated at 6 weeks. Radiographs were taken at each follow up visit until union. Complications and subjective complaints were noted. The purpose of this study is to evaluate a new multiplanar, locked intramedullary implant indicated for both transverse and comminuted olecranon fractures. This is the first clinical report of this particular type of implant.

A simple method for removal of the distal segment of a broken femoral intramedullary nail: a case report.

We report a method for removing the distal segment of a broken locked intramedullary nail secondary to nonunion of the femur following radiotherapy for fibromatosis. A Kirschner wire with one tip fashioned into a hook was used to remove the distal segment without opening with the nonunion site. Details of the procedure are described. Broken intramedullary nail, removal of distal segment.

Locked intramedullary nailing in the treatment of non-union following humeral shaft fractures

The paper presents an analysis of cases of treatment of humeral shaft fracture non-union following operative treatment. Non-union was treated by locked intramedullary nailing in all patients. Bone destruction at the fracture site is an indication for using bone grafts. In our opinion autologous bone marrow injection to the fracture site is an effective method of bone union stimulation, and this non-invasive procedure may be repeated several times. Stable osteosynthesis promotes callus formation and remodeling, and enables early rehabilitation.

Validation of a standardised gait score to predict the healing of tibial fractures

There is no absolute method of evaluating healing of a fracture of the tibial shaft. In this study we sought to validate a new clinical method based on the systematic observation of gait, first by assessing the degree of agreement between three independent observers regarding the gait score for a given patient, and secondly by determining how such a score might predict healing of a fracture. We used a method of evaluating gait to assess 33 patients (29 men and four women, with a mean age of 29 years (15 to 62)) who had sustained an isolated fracture of the tibial shaft and had been treated with a locked intramedullary nail. There were 15 closed and 18 open fractures (three Gustilo and Anderson grade I, seven grade II, seven grade IIIA and one grade IIIB). Assessment was carried out three and six months post-operatively using videos taken with a digital camera. Gait was graded on a scale ranging from 1 (extreme difficulty) to 4(normal gait). Bivariate analysis included analysis of variance to determine whether the gait score statistically correlated with previously validated and standardised scores of clinical status and radiological evidence of union. An association was found between the pattern of gait and all the other variables. Improvement in gait was associated with the absence of pain on weight-bearing, reduced tenderness over the fracture, a higher Radiographic Union Scale in Tibial Fractures score, and improved functional status, measured using the Brazilian version of the Short Musculoskeletal Function Assessment questionnaire (all p < 0.001). Although further study is needed, the analysis of gait in this way may prove to be a useful clinical tool.

The Biomechanical Effect of Torsion on Humeral Shaft Repair Techniques for Completed Pathological Fractures

In the presence of a tumor defect, completed humeral shaft fractures continue to be a major surgical challenge since there is no "gold standard" treatment. This is due, in part, to the fact that only one prior biomechanical study exists on the matter, but which only compared 2 repair methods. The current authors measured the humeral torsional performance of 5 fixation constructs for completed pathological fractures. In 40 artificial humeri, a 2-cm hemi-cylindrical cortical defect with a transverse fracture was created in the lateral cortex. Specimens were divided into 5 different constructs and tested in torsion. Construct A was a broad 10-hole 4.5-mm dynamic compression plate (DCP). Construct B was the same as A except that the screw holes and the tumor defect were filled with bone cement and the screws were inserted into soft cement. Construct C was the same as A except that the canal and tumor defect were filled with bone cement and the screws were inserted into dry cement. Construct D was a locked intramedullary nail inserted in the antegrade direction. Construct E was the same as D except that bone cement filled the defect. For torsional stiffness, construct C (4.45 ± 0.20 Nm/deg) was not different than B or E (p > 0.16), but was higher than A and D (p < 0.001). For failure torque, construct C achieved a higher failure torque (69.65 ± 5.35 Nm) than other groups (p < 0.001). For the failure angle, there were no differences between plating constructs A to C (p ≥ 0.11), except for B versus C (p < 0.05), or between nailing groups D versus E (p = 0.97), however, all plating groups had smaller failure angles than both nailing groups (p < 0.05). For failure energy, construct C (17.97 ± 3.59 J) had a higher value than other groups (p < 0.005), except for A (p = 0.057). Torsional failure always occurred in the bone in the classic "spiral" pattern. Construct C provided the highest torsional stability for a completed pathological humeral shaft fracture.

Obituary: Cleber Antônio Jansen Paccola 1948-2011

Life sometimes brings surprises which we would prefer not to experience. For me, one such surprise was the severe disease which afflicted Professor Cleber Paccola some four years ago. This appeared tantamount to a death sentence, one to be executed not too far from then. However, after a delicate neurosurgical procedure, from which he recovered with no evident sequelae, he resumed his professional activities barely a month later. His determination not to let himself collapse was clear. In the remaining four years of his life, Cleber, as I knew him, fought courageously and submitted himself to a number of treatments. Despite these, there was an unfortunate decline in his condition. However, at no stage did I witness a loss of character or hope. Cleber always showed great courage, perhaps because he believed that he was cured. Relatively religious, he did not fight God, but occasionally would ask Him the reason for such suffering. Cleber’s disease returned in October 2010, taking his life prematurely eight months later. He still submitted himself to heavy chemotherapy but then suffered a stroke, leading to his hospitalisation. Even so he believed he would recover and be back at work …

Angular-Stable Locked Intramedullary Nailing of Two-Part Surgical Neck Fractures of the Proximal Part of the Humerus

The ideal fixation technique for the treatment of proximal humeral fractures remains unclear. In the present study, we evaluated the experience of three surgeons with the treatment of two-part surgical neck fractures with angular-stable intramedullary fixation. Forty-eight patients with forty-eight Neer two-part surgical neck proximal humeral fractures were managed with locked angular-stable intramedullary nail fixation by three surgeons. Shoulder pain and outcomes were quantified with Constant scores and standard radiographs. Thirty-eight patients (including twenty-eight female patients and ten male patients) with a mean age of sixty-five years were followed for at least twelve months (mean, twenty months; range, twelve to thirty-six months). All fractures healed primarily. The mean follow-up Constant score (and standard deviation) was 71 ± 12 points (range, 37 to 88 points), with a mean age-adjusted Constant score of 97% (range, 58% to 119%). The mean Constant pain score was 13 ± 2.2 (possible range, 0 to 15 points, with 15 points representing no pain). The mean forward flexion was 132° ± 22°. All fractures but one healed with a neck-shaft angle of ≥125°. Patients who were managed with locked angular-stable intramedullary nailing of two-part surgical neck proximal humeral fractures via an articular entry point had reliable fracture-healing, favorable clinical outcomes, and little residual shoulder pain.

The primary stability of angle-stable versus conventional locked intramedullary nails

The aim of this study was to compare the initial biomechanical characteristics of the angle-stable locking system for intramedullary nails using the new biodegradable sleeve with conventional locking in the treatment of unstable distal tibial fractures. Eight pairs of fresh, frozen porcine tibiae were used for this study. The expert tibial nail (Synthes) was equipped with either conventional locking screws (CL) or the angle-stable locking system (AS). This system consists of a special ASLS screw with a biodegradable sleeve. For this investigation distal tibias (5.5 cm) were used and the nails were locked with three screws in both groups. Biomechanical testing included non-destructive torsional and axial loading. The AS group showed a significantly higher torsional stiffness (70%) compared to the CL group. The range of motion was 0.5 times smaller for the AS constructs. The neutral zone was eight times higher in the CL group (p < 0.001). In axial loading the AS group also showed a 10% higher axial stiffness and a 12% lower range of motion (p < 0.001). The angle-stable locking system (ASLS) using a special screw and sleeve locking for intramedullary nails provides a significantly higher primary stability. The differences determined in this study may have clinical relevance particularly for torsional loads. For the new biodegradable angle-stable sleeve we found a comparable stability to the PEEK-based sleeve system. This system has the potential to decrease complications such as secondary loss of reduction and mal-/non-union.

Locked intramedullary femoral nailing without fracture table or image intensifier

The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18–70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist–Hansen types I and II) diaphyseal fractures of the femur.