Locked Nailing Research Articles

Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures

Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking. All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations. Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6-54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18-68 min) for tibial fractures and 55 min (range 47-150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity. The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.

Extension Malunion of the Femoral Component After Retrograde Nailing

Supracondylar femoral fracture is a complex complication after total knee arthroplasty (TKA). One potential complication of retrograde locked nailing is malunion in extension of the femoral prosthetic component--produced by an overly posterior nail entry point in the intercondylar notch. The aim of this study was to determine the repercussion of this deformity on the midterm radiological and functional outcomes of TKA. Retrospective review. From 2001 to 2006, 30 patients were treated for supracondylar femoral fracture above TKA with a retrograde locked nail. In 7 patients (6 women and 1 man) with a mean age of 78.8 years (range, 74-84 years), more than 10 degrees of hyperextension (mean of 18.5 degrees) of the femoral component on the sagittal plane was observed without any significant misalignment on the coronal plane. Functional outcomes were assessed using the Knee Society Score. After a mean follow-up of 68.5 months (range, 48-111 months), all patients' fractures with a hyperextension of the femoral component had consolidated with no clinical or radiological signs of TKA loosening. These patients presented "good" functional outcomes at final follow-up. These results should be interpreted with caution. However, isolated hyperextension of the femoral component of a TKA after placing a retrograde nail for a periprosthetic fracture does not seem to significantly affect the functional or radiological outcomes at ∼6-years follow-up. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Su1.3 Angle stable plate or angle stable locked nail fixation in distal radius fractures. An experimental examination and phase I clinical study

Su1.3 Angle stable plate or angle stable locked nail fixation in distal radius fractures. An experimental examination and phase I clinical study

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.

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.

Biomechanical comparison of locked plate osteosynthesis, reamed and unreamed nailing in conventional interlocking technique, and unreamed angle stable nailing in distal tibia fractures

The treatment of distal tibia shaft fractures is still problematic because of the thin soft tissue envelope and less stable osteosynthesis. Therefore, nonunions are often seen in this region. When reamed nailing is performed, construct stiffness can be increased and fracture gap movement can be reduced, but in open fractures the question whether reamed nailing is before unreamed nailing is still uncertain. Therefore, unreamed nails with angle stable interlocking options were produced with the idea to improve the biomechanical properties of unreamed nails. This study compared reamed and unreamed nailing either with angle stable or conventional interlocking to plate osteosynthesis. The hypothesis was that angular stability in unreamed nailing will increase the construct stiffness and reduce the fracture gap movement. In this study, four groups of five artificial tibiae were treated with different osteosynthesis techniques. Group 1 was treated with a reamed nailing technique, group 2 with a distally angle stable locked nail in an unreamed technique, group 3 with an unreamed nail in a conventional locking technique, and group 4 with a locked medial plate system. After osteotomy of the intersection of the distal 4/5 to 5/5 of the tibia, stiffness of the implant-bone construct and micromovement of the fragments were measured. In addition, the range of motion at the mechanical zero under torsional load was calculated. Biomechanical tests showed that the stiffness of the reamed nail constructs was significantly higher than the compared implants. The unreamed conventionally locked nail and unreamed distally angular stable locked nails were less stiff than the larger sized reamed nail, but the implant-bone construct showed higher stiffness values than the locked plate osteosynthesis. Regarding stiffness of the two unreamed groups, no significant differences were found. The interfragmentary movement in axial and torsional force exhibited the highest range of motion for locked plating, while the reamed nail significantly exhibited the least. The range of motion at the mechanical zero under torsional load was the lowest for the unreamed and angle stable locked nail. Under biomechanical considerations, the treatment of distal tibia fractures using the reamed nailing technique is before unreamed nailing, but distal angle stable interlocking of the nail may also be a satisfactory method.

L-F1.2 Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement

Introduction: Locked nail osteosynthesis allows a minimal invasive stabilisation of the very frequent proximal humerus fractures. However most patients are elderly with poor bone quality and the proximal humerus is biomechanically highly loaded. The factors influencing the cut out risk was examined in an alternating load test model. Material and Methods: As standard model a PHN series with spiral blade and screw fixation. As test, Implanta – a device with the option of 4 locked screw fixation and additional possibility of a fork blade over the central screw – was tested under different locking alternatives. (HGN = Humerus Gliding Nail.) A subcapital defect osteotomy for deformation testing (1000 Cycles between 50 and 150N) and an osteotomy along the column anatomicum for cut out were tested with 1000 Cycles between 50 and 300N load. In each group 5 sow bones were tested. Results: the deformation in all groups increased from the first to the 1000th Cycle. The mean deformation was 1mm for the HGN blade, 1.1 for the HGN screw and 1.55mm for the PFN Group. The standard deviation was gug and the results not significant different. In the cut out test the rate of cut out was similar for the PHN and the HGN with a single screw, whereas the cut out for the HGN with 4 screws was reduced by 50% and the use of the blade additional with the central screw reduced the cut out risk by 66%. However standard deviation was very high. Conclusion: for a reduced deformation and cut out risk the most important factor is the number of locking elements. The combination of locked screws with a fork blade with a higher implant bone contact surface improves the cut out rate but in the small series the differences are not significant.

L-S1.4 Angle-stable plate or angle-stable locked nail fixation in distal radius fractures. An experimental examination and phase in clinical study

L-S1.4 Angle-stable plate or angle-stable locked nail fixation in distal radius fractures. An experimental examination and phase in clinical study

L-F1.1 Experimental examination of factors influencing the deformation cut out risk in locked nail osteosynthesis of proximal humerus fractures

L-F1.1 Experimental examination of factors influencing the deformation cut out risk in locked nail osteosynthesis of proximal humerus fractures

Retrograde Nailing of a Femoral Supracondyle

Because standard femoral supracondylar nails have certain disadvantages, they are often replaced by traditional femoral or tibial locked nails. The purpose of this study was to make a biomechanical comparison between both types of traditional locked nails to determine which technique was more suitable for treating unstable femoral supracondylar fractures. Fourteen left Sawbones femurs (Pacific Research Laboratories, Vashon, Washington) were osteotomized in the femoral supracondylar area. One centimeter of the medial cortex in the proximal fragment was obliquely removed to simulate an unstable fracture without shortening. Seven specimens were treated with traditional retrograde dynamic femoral locked nails, and the other 7 with traditional retrograde dynamic tibial locked nails. All specimens were tested with a servohydraulic materials testing machine to compare their relative stability. Static compression, dynamic cyclic compression, and static compression to failure were tested. An extensometer was used to measure the displacement of fragments. Displacement between the fragments increased following the increment in loads in both nails. The load-displacement curve was nearly linear up to 1000 N for both nails. The femoral nail had a greater stiffness compared with the tibial nail at 100 and 200 N (P=.02 and P=.04, respectively) in static compression and at 700 to 1000 N (P=.01 in each case) in dynamic cyclic compression, as well as larger loads in static compression to failure (8663 vs 7547 N, respectively; P<.001). Clinically, a traditional femoral locked nail may be more suitable to replace a standard femoral supracondylar nail in a retrograde fashion to treat an unstable femoral supracondylar fracture.

Comments to the article by Wu: Retrograde dynamic locked nailing for valgus knee correction: a revised technique

We read with great interest the work of Chi-chuan Wu on the use of retrograde dynamic locked nailing for valgus deformity of knee [1].We would like to congratulate the author for devising a new technique for this deformity. The author has concluded that the use of intramedullary nail provides better biomechanics when compared to the use of plate and that patients have better symptomatic relief. However, we would like to bring forth a few points to the authors notice: 1. Most of the patients were young (average age of 28 years) in the study group when compared to the studies in which plating was used in whom the predominant reason for the osteotomy was osteoarthritis. So, for the outcome of time to union, postoperative satisfaction would be biased. It would have been better if the author would have created a control group in whom plating is used to overcome the bias. 2. The author did not comment on the stability of the implant in this study. Ito et al. [2] concluded that retrograde nail was noted to provide equal or greater stability than the plate, except when large torsional loads are anticipated. As the patient population in the study group was comprised of young individuals with high impact activities, concern regarding the stability of the implant exists. 3. The use of retrograde nails further entails potential risk of knee sepsis, damage to articular cartilage, and ligaments while inserting the nail. We conclude that the use of retrograde nail to correct the valgus deformity in young adults is a promising technique. However, a comparative trial with a longer follow-up would further shed more light on the advantages of this technique over plating.

Retrograde dynamic locked nailing for valgus knee correction: a revised technique

Traditionally, valgus knee deformity is predominately corrected by stabilisation with a plate inserted via the medial approach to the supracondylar region of the femur. However, this technique is unfavourable from both a biomechanical and a biological point of view. A revised retrograde dynamic locked nailing was developed to improve correction of this defect. Forty-one knees with valgus deformity (average tibiofemoral angle, 22°; range, 16-29°) in 25 adult patients were treated by oblique femoral supracondylar varus osteotomy and stabilised with retrograde dynamic locked nails. Postoperatively, early ambulation with protected weight bearing and range of motion knee exercises were encouraged. Thirty-five knees of 21 patients were followed-up for an average of 2.6years (range, 1.1-4.5years). All osteotomy sites healed with an average union period of 3.4months (range, 2.5-5.0months). There were no significant complications. At the latest follow-up, the average tibiofemoral angle was 7.1° valgus (range, 4-10° valgus). For all of the knees, the outcomes were satisfactory (p < 0.001). The technique described here may be a feasible alternative for correction of valgus knee deformity. The advantages of this technique include the use of a biomechanically more appropriate method, a minimal complication rate and a high rate of satisfactory outcomes.

Expandable intramedullary nails for humeral fractures: a systematic review of clinical and radiological outcomes

The Fixion(™) system (Disc-O-Tech Medical Technologies, Herzeliya, Israel), which is currently the only expandable nailing system available for use in the humerus, has a number of purported advantages over the standard locked humeral nail, including a reduction in operating and fluoroscopy time since locking screws are not required. A systematic review was undertaken of all published (AMED, CINAHL, EMBASE and Medline via the Ovid platform) and unpublished or grey literature research databases from inception until 1st December 2010. Demographic data, clinical and radiological outcomes, and complications were extracted from each study by two independent investigators, and each study underwent independent critical appraisal using the CASP appraisal tool. Thirteen studies were deemed eligible for review, identified from a total of 154 citations. These included a total of 176 patients with 180 fractured humeri treated with expandable nails. Overall, 7.8% of humeral fractures treated with an expandable nail went on to non-union. Intra- and post-operative device failure rate was found to be 1.1 and 2.8%, respectively. These data compare favourably to published data on the outcome of locked humeral nails. However, there were numerous methodological flaws in the current evidence base; there were no comparative studies, treatment groups were heterogeneous, and there was no blinding of assessors or patients. Initial data indicate that the expandable humeral nail may be an acceptable form of treatment for humeral fracture or impending fracture, but high-quality comparative studies are needed to confirm these findings.

Intramedullary fixation of forearm fractures with new locked nail

Background:Lack of availability of interlocked nails made plate osteosynthesis the first choice of treatment of forearm fractures inspite of more surgical exposure, periosteal stripping and big skin incision subsequent scar along with higher risk of refracture on implant removal. We hereby report the first 12 cases with 19 forearm bone fractures internally fixed by indegenous interlocked nail.Materials and Methods:Existing square nails were modified to have a broad proximal end of 5.5 mm with a hole for locking screw of 2.5 mm. The nail has a distal hole of 1/1.2/1.5 mm in 2.5/3/3.5 mm diameter nail, respectively. A new method of distal locking with a clip made of k wire is designed. The clip after insertion into the bone and hole in nail and opposite cortex snuggly fits the bone providing a secure locking system. Twelve skeletally mature patients, mean age 32 years (range 24-45 years) with 19 diaphyseal fractures of the forearm were treated with this indigenously made new nail. The patient were evaluated for fracture union, functional recovery and complications. The functional outcome was assessed by disabilities of arm, shoulder and hand questionnaire (DASH score).Results:Time to radiographic union ranged between 12 and 28 weeks, with a 100% union rate. Complications were minimal, with mild infection in open fracture (n=1) and delayed union (n=1) in patient with comminuted fracture of the ulna only. The clinical results were excellent. The DASH score ranged between 0 and 36 points.Conclusion:This new interlocking nail may be considered as an alternative to plate osteosynthesis for fractures of the forearm in adults. The advantages are benefit of closed reduction, smaller residual scar, reduced cost and early union with allowance of immediate movements.

Treatment of acute tibial shaft fractures with an expandable nailing system: A systematic review of the literature

Locked Intramedullary Nailing is an established method of treatment for tibial shaft fractures. Locking of tibial nails is however not without its drawbacks. Locking is time consuming, and is associated with a noteworthy complication rate. The Fixion IM nailing system is an expandable nail designed to eliminate some of these drawbacks. We have performed a systematic review of the literature to determine the safety and efficacy of this system. Publications examining the use of the Fixion system were identified from the MEDLINE and the Cochrane databases. Forty-one citations were generated by the MEDLINE search. Of these, two quasi-randomised trials and eight case series satisfied our selection criteria and were reviewed. Overall the average réopération rate for the Fixion nail was 10.2%. Shortening occurred in 3%of cases and fracture propagation was reported in 2% of cases. The Fixion cohort united at an average of 12.2 weeks and the average operative time was 54 minutes. The Fixion system eliminated complications and reoperations associated with the use of locking screws. Further studies in the form of randomised controlled trials are needed to evaluate the Fixion system against conventional locked nails.

P5 Fractures of the tibial shaft treated with intramedullary locked nails. Our experience

P5 Fractures of the tibial shaft treated with intramedullary locked nails. Our experience

A9 Angle stable plate or angle stable locked nail fixation in distal radius fractures. An experimental examination and Phase I clinical study

A9 Angle stable plate or angle stable locked nail fixation in distal radius fractures. An experimental examination and Phase I clinical study

Intercalary defects reconstruction of the femur and tibia after primary malignant bone tumour resection. A series of 13 cases

Performing intercalary segment reconstruction after malignant bone tumour resection results in both mechanical and biological challenges. Fixation must be solid enough to avoid short-term or mid-term mechanical failure. The use of an allograft or autograft must ensure long-term survival of the reconstruction. The goal of this study was to analyse the clinical and radiological outcomes of these reconstructions. Thirteen patients were operated on eight femurs and five tibias. The median age was 20 years old (range 14-50). The most common diagnosis was osteosarcoma. The median resection length was 15cm (Q1-Q3: 6-26). A plate was used for fixation in nine cases and an intramedullary locked nail in four cases. An isolated bone autograft was used in two cases, an isolated bone allograft in one case, a dual autograft-allograft composite in six cases, and vascularised fibula and allograft combination in four cases. The cumulative probability of union was 46% (95% CI: 0-99%) at 1 year; at the final follow-up, union was achieved in 12 patients (92%). Because of non-unions, 13 iterative procedures were needed to obtain these results. A non-displaced fracture of a cuboid-shaped tibial graft occurred in one patient, which was treated conservatively. Three infections occurred. The results of intercalary segmental defects reconstruction after bone tumour resection were good, both from an oncologic and radiological point-of-view. One or more iterative procedures are sometimes needed to finally obtain bone union. We prefer to use a free rectangular cuboidal tibial graft since reconstruction with a vascularised autograft is technically more difficult. The choice of fixation methods is still controversial and no approach was found to be superior. Level IV. Retrospective study.

Functional Outcomes after Fibula Locking Nail for Fragility Fractures of the Ankle

The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of complications. It also helps to restore function and results in patient satisfaction.

Fracture shaft of humerus with anterior dislocation of shoulder treated with closed locked nailing

Correspondence: Dr. Hitesh Lal, A-1/207, Janakpuri, New Delhi – 110058. E-mail: drhiteshlall@gmail.com decided to take the patient to the operating room. The patient was taken up for surgery under general anesthesia in supine position with a sandbag below the ipsilateral shoulder. Close reduction of the dislocation was done under anesthesia with an assistant pushing manually on the head under the coracoid and another one applying traction along the axis of arm. The dislocation was surprisingly seen to reduce under radiographic control. It was decided to choose a closed interlocking nail over a plate for fixing the humerus as it is minimally invasive. But while making the entry point for the nail the head slipped again into a dislocated position even when the assistant resisted it manually with a fist pressure. A percutaneous 4 mm Steinmann pin was passed after reducing the head in an anteroposterior direction. Then 1 assistant held the head in reduced position with the help of the aforesaid pin loaded on a T handle. The operating surgeon was thus able to make an entry point with a thick Kirchner wire and the position was checked on anteroposterior and lateral views. A cannulated awl was passed over it to enlarge it and the shaft was then reamed with flexible reamer to appropriate size. A standard technique was then used to put an interlocking nail; proximal interlocking was done with the help of a targeting device and distal locking by a free hand technique. The nail of adequate length was appropriately buried in the head so as not to cause any impingement during range of motion. The rotator cuff incision at the entry site was sutured. The shoulder was then immobilized in an arm chest strapping after rechecking the position of head of humerus under C arm. Postoperative period was uneventful (Figure 2). Sutures were removed at 10 days and patient was mobilized at 15 days postoperatively. Initially pendulum exercises were started followed by shoulder range of motion and overhead abduction exercises within 10 days.