Nailing Of Long Bone Fractures Research Articles

Fast and accurate distal locking of interlocked intramedullary nails using computer-vision and a 3D printed device

IntroductionDistal locking is a challenging and time-consuming step in interlocked intramedullary nailing of long bone fractures. Current methods have limitations in terms of simplicity, universality, accuracy, speed, and safety. We propose a novel device and software for distal locking using computer vision.Methods and materialsThe device consists of an universal ancillary clamp, a telescopic arm, a viewfinder clamp, and a radio-opaque cross. The software uses a camera photo from the C-arm intensifier and adjusts for geometric projection deformities. The software employs edge detection, Hough transform, perspective interpolation, and vector calculation algorithms to locate the distal hole center. The device and software were designed, manufactured, and tested using 3D CAD, FEM, DRR, and performance testing on phantom bones.ResultsThe device and software showed high accuracy and precision of 98.7% and 99.2% respectively in locating the distal hole center and calculating the correctional vector. The device and software also showed high success ratio in drilling the hole and inserting the screw. The device and software reduced the radiation exposure for the surgeon and the patient. The success ratio of the device and software was validated by the physical testing, which simulated the real clinical scenario of distal locking. The radiation exposure was as low as 5 s with a radiation dose of 0.2mSv, drastically reducing radiation exposure during distal locking.DiscussionOur device and software have several advantages over other distal locking methods, such as simplicity, universality, accuracy, speed, and safety. Our device and software also have some disadvantages, such as reliability and legislation. Our device and software can be compared with other distal locking methods based on these criteria. Our device and software have some limitations and challenges that need to be addressed in the future, such as clinical validation, and regulatory approval.ConclusionThe device showed promising results in terms of low-cost, reusability, low radiation exposure, high accuracy, fast distal locking, high stiffness, and adaptability. The device has several advantages over other distal locking techniques, such as free-hand technique, mechanical aiming devices, electromagnetic navigation systems, and computer-assisted systems. We believe that our device and software have the potential to revolutionize the distal locking technique and to improve the outcomes and quality of life of the patients with long bone fractures.

Prevalence and associated factors of infection after intramedullary nailing of long bone fractures among patients attending St. Paul's Hospital Millennium Medical College, AaBET Hospital, Addis Ababa, Ethiopia.

The intramedullary nailing of long bone fractures is a major challenge for orthopedic surgeons, with increased risk of infection in third-world countries. Research gaps remain in Ethiopia, determining the magnitude of the problem. This study aimed to determine the prevalence and associated factors of infection after intramedullary nailing of long bone fractures in Ethiopia. This was a descriptive, cross-sectional, retrospective design study with a total census of 227 cases of long bone fractures treated with intramedullary Surgical Implant Generation Network nails at Addis Ababa Burn Emergency and Trauma Hospital from August 2015 to April 2017. Data were collected from 227 patients and descriptive analyses were done to summarize the study variables. Binary and multivariable logistic regression analyses were performed at a p value of 0.05 with a 95% confidence interval and adjusted odds ratio. The mean age of patients was 32.9 years, with a male-to-female ratio of 3.5:1. Only 22 (9.3%) of the 227 patients with long bone fractures treated with intramedullary nails developed a surgical site infection, and 8 (3.4%) were developed deep (implant) infections requiring debridement. Road traffic injuries were the leading cause of trauma (60.9%), followed by falls from a height (22.7%). Debridement was done within 24 h for 52 (61.9%) and within 72 h for 69 (82.1%) patients with open fractures. Only 19 (22.4%) and 55 (64.7%) patients with open fractures and tibial long bone fractures received antibiotics within 3 h. Open fractures and tibial fractures had higher percentages of infection, 18.6% and 12.1%, respectively. Previous use of an external fixator (44.4%) and prolonged surgery (12.5%) were associated with higher proportions of infection. This study found that the prevalence of infections after intramedullary nailing of long bone fractures in Ethiopia was 44.4% after external fixation, compared to 6.4% after intramedullary nail was inserted directly. Proper control measures are needed to reduce morbidity and complications related to long fracture treatment, such as open fractures, tibial fractures, the use of an external fixator, delayed debridement and skin closure, and prolonged surgery developed surgical site infection rate.

Nailing of long bone fractures in precarious situations: focus on the Surgical Implant Generation Network (SIGN) nail

Le développement économique des pays à faibles revenus a pour corollaire une augmentation considérable des véhicules motorisés, et en particulier des motocyclettes. Les accidents de la circulation augmentent ainsi que les fractures qui y sont associées. Le traitement des fractures des os longs repose dans la majorité des cas sur l´enclouage centro-médullaire verrouillé, procédé rarement disponible en situation sanitaire dégradée. Pour apporter à ces pays un traitement optimal, le clou SIGN (Surgical Implant Generation Network) a été développé en 1999 par Lewis Zirkle. Il est actuellement utilisé gratuitement dans 53 pays. En contrepartie une base de données internationale doit être remplie afin de l´évaluer et de le faire évoluer. A la lumière de nos expériences en Haïti et au Burundi et d´une revue de la littérature, nous décrivons ici ses particularités conceptuelles et techniques, dont l´implantation dans les pays francophones reste limitée.

The Poller Screw Technique: A Method of Fine-Tuning the Reduction in Locked Nailing

Intramedullary nailing is the treatment of choice for diaphyseal fractures in long bones. However, nailing of long bone fractures at the metaphyseodiaphyseal junction is technically difficult and can cause malalignment because of the mismatch in the diameter of the bone. One of the most common and recently described methods of correcting deformity during nailing is the poller screw technique. We describe a modified technique to correct malreduced fractures with the nail in situ, which we have used successfully in 3 patients.

Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture.

Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03–0.07), coronal plane malunion (5%, CI: 0.03–0.08), deep (5%, CI: 0.03–0.11) and superficial (6%, CI: 0.03–0.11) infections, and secondary procedures (8%, CI: 0.04–0.18).When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits.Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040

Radiation Exposure to the Surgeon, Surgical Assistant, and Scrub Nurse During Closed Intramedullary Nailing of Long Bones-Does It Vary Depending on the Experience of the Surgeon?

To assess radiation exposure (RE) to the surgical team and fluoroscopy time (FT) during closed nailing of long bone fractures performed under fluoroscopic guidance with regard to surgeon's experience. Prospective observational study. Level-1 trauma center. Surgical team, comprising a surgeon, a surgical assistant, and a scrub nurse, for closed nailing procedures performed in 202 consecutive closed tibial and femoral diaphyseal fractures. Dosimeter provided to each member of surgical team. Surgeon experience level (trainee, senior registrar, and consultant). RE (microsieverts) to the surgical team and FT (minutes) were recorded from the dosimeter and fluoroscopic unit, respectively, and correlated with surgeon's experience. In tibial nailing, mean RE (in µSv) per procedure to surgeon, surgical assistant, and scrub nurse was 15.2, 9.2, and 2.0 for trainees, 14.5, 8.1, and 1.6 for senior registrars, and 13.6, 7.4, and 1.5 for consultants, respectively. In femoral nailing, mean RE per procedure to surgeon, surgical assistant, and scrub nurse was 181.6, 113.6, and 37.1 for trainees, 110.1, 66.7, and 20.4 for senior registrars, and 79.9, 30.9, and 12.5 for consultants, respectively. RE to the surgeon was highest followed by surgical assistant and scrub nurse irrespective of operating surgeon's experience in both tibial and femoral nailing (P < 0.001). In tibial nailing, there was a significant difference in FT only for the stage of guide wire passage (P = 0.041), whereas in femoral nailing, total FT (P < 0.001), nail entry verification (P = 0.02), guide wire passage (P = 0.013), nail introduction (P = 0.006), and distal locking (P < 0.001) showed a significant difference. RE was maximum for operating surgeon and least for scrub nurse irrespective of operating surgeon's experience in both femoral and tibial nailing. FT and RE to the surgical team decreased with increasing experience of the surgeon in femoral nailing. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Rust score–An adequate rehabilitation guide for diaphyseal femur fractures managed by TENS

IntroductionThe optimal mode of treatment among the wide variety of surgical and nonsurgical treatment options for children between 5 and 15 years of age continues to be controversial. Elastic stable intramedullary nailing of long bone fractures in the skeletally immature has gained widespread popularity because of its clinical effectiveness and low risk of complications. Methods and methodologyFrom Jan 2015 to August 2016, 35 patients including 37 limbs with diaphyseal fractures of the femur in the age group 5–15 years were managed by Titanium Elastic nailing and their clinico-radiological and functional outcome was assessed at 1 year post operatively as per the Flynn’s criteria. RUST score was used as a guide for post-operative rehabilitation. Results37 patients were managed by TENS nailing including 28 males and 9 females. The outcome in proximal, middle or distal fractures of the shaft were found to be similar and the difference was statistically insignificant. Similarly, the difference in the outcomes as per fracture patterns was also found to be statistically insignificant. Partial weight bearing was allowed after a score of 6 was achieved and full weight bearing after a score of 8. ConclusionAs per the Flynn’s criteria, 75% of the patients (28 out of 37) were found to have an excellent outcome while 7 had a satisfactory outcome and two had a poor outcome. RUST score can be used as an effective guide for post op rehabilitation.

Common techniques useful to the practicing or training orthopaedic surgeon on call in a pediatric hospital

This article highlights surgical procedures with which orthopaedic residents entering a pediatric rotation should be familiar. Closed reduction and percutaneous pinning of supracondylar humeral fractures, in situ pinning of slipped capital femoral epiphysis, and flexible intramedullary nailing of long bone fractures are described. Although these are just a few of many procedures a resident will learn while on a pediatric rotation, they probably are the most utilized while on call at a pediatric hospital.

PYCNODYSOSTOSIS: SURGICAL CHALLENGES OF INTRAMEDULLARY NAILING FOR LONG BONE FRACTURES: A CASE REPORT

Pycnodysostosis, known as osteopetrosis acro-osteolytica, is a rare sclerotic bone disease with an autosomal recessive heritage pattern. Characteristic features of the disease are short stature, delayed closure of cranial sutures, partial or total dysplasia of the phalanges, obtuse mandibular angle, skeletal abnormalities and increased bone density. Type I collagen catabolism and bone resorption are defective in these patient due to lysosomal cysteine protease and cathepsin K enzyme defects resulting in dense and more brittle bones. Herein, we report a 45-year-old pycnodysostozis patient with a subtrochanteric transverse fracture of the left femur. We aim to reveal the difficulties encountered during intramedullary nailing of long bone fractures of patients with pycnodysostosis.

Fluoroscopic freehand and electromagnetic-guided targeting system for distal locking screws of humeral intramedullary nail.

The current techniques used to lock distal screws for the nailing of long bone fractures expose the surgeons, radiologists and patients to a hearty dose of ionizing radiation. The Sureshot™ Distal Targeting System is a new technique that, with the same results, allows for shorter surgery times and, consequently, less exposure to radiation. The study was performed on 59 patients (34 males and 25 females) with a simple humerus fracture diagnosis, type 1.2.A according to the AO classification, who were divided into two groups. Group 1 was treated with ante-grade intramedullary nailing with distal locking screws inserted with a freehand technique. Group 2 was treated with the intramedullary nail using the Sureshot™ Distal Targeting System. Two intra-operative time parameters were evaluated in both groups: the time needed for the positioning of the distal locking screws and the time of exposure to ionizing radiations during this procedure. Group 2 showed a lower average distal locking time compared to group 1 (645.48″ vs. 1023.57″) and also a lower average time of exposure to ionizing radiation than in group 1 (4.35″ vs. 28.96″). The Sureshot™ Distal Targeting System has proven to be equally effective when compared to the traditional techniques, with the added benefits of a significant reduction in both surgical time and risk factors related to the exposure to ionizing radiation for all the operating room staff and the patient.

Intramedullary nails: should it be removed after fracture healing?

Background: Intramedullary Nailing of long bone fracture is a common surgery done in orthopaedics. It offers early weight bearing and less chances of malunion than cast and other conservative treatment. Removal of intramedullary nail after the bone has united is a matter of debate, we reviewed 48 cases in terms of improve in symptoms ,functional status and complications associated with hardware removal. Methods: Retrospective study was conducted in tertiary care centre.48 patients were enrolled in the study who were admitted for Tibia nail removal or exchange nailing. The mean age was 37.9 years ranging from 20-69 years. There were 28 males and 20 females in our study. On follow up visits x-rays were taken at 3 weeks and patients were assessed for improvement in symptoms, pain status, functional outcome and complications of nail removal. Results: Out of 48 patients operated, 43 (89.58%) tibial intramedullary nail were removed over a period of 5 years. Out of 23 patient insisting nail removals due to anterior knee pain only 21 nails were removed and 19 patients who requested nail removal only 16 nails could be removed. Complications were seen in 13% of nail removals. Overall, 72.09% (31/43) of patients were satisfied with their IMN removal. The mean VAS score was 2 after nail removal. Conclusions: We conclude that removal of tibia nail should be done if patient complaints of pain. Radiographs must be assessed for fracture union and patient must be warned about the complications associated with the hardware removal.

SIGN Nail Experience in Manipal Teaching Hospital

Fifty-two patients who underwent intramedullary nailing of long bone fractures using the SIGN nail at the Department of Orthopedics, Manipal Teaching Hospital from July 2010 to July 2014 were reviewed. Healing of the fracture, incidence of post-operative complications, implant failures, weight bearing capability were described and analyzed based on the medical records and official website of SIGN. Demographic of patients, fracture configuration, size of nail and screws used, the pre and post-operative radiographs were also reviewed. Post operatively with a mean follow-up of 6 months, 46.1% of the patients had beginning callus, 40.4% of the patients were already healed, 3.8% had infection and outcome was undetermined in 9.7%. No implant failure was noted in this study.

Use of blocking screws in intramedullary nailing of long-bone fractures

Use of blocking screws in intramedullary nailing of long-bone fractures

Removal of a broken distal cannulated intramedullary femoral nail with solid reamer with closed methods and without using C-arm: A case report

Intramedullary nailing of long bone fractures is an accepted technique with the advantages of not disturbing the fracture hematoma and the biomechanical superiority over plating.1 However, problems with the nail are not infrequent, with broken nails and locking screws particularly posing a difficult problem for the orthopedic surgeon, especially when nail get broken due to cyclical stress of retrauma at site of distal screw placement as this the one of the weak part of intramedullary nail. Many techniques are described for extraction of the distal broken intramedullary nail that require special equipment like olive wires or laparoscopic grabbers.1–3 There are many difficulties at times This equipment may not be always readily available which can make the process quite difficult. In remote parts of developing nation availability of C-arm is also an issue. We describe a simple reproducible method of extraction of the distal broken cannulated femoral nail fragment by antegrade approach without using C-arm and opening fracture site by using solid K-nail reamer. We have successfully used this technique to extract nail which is broken at D1 SCREW site, by using sequential K-nail reamer of size smaller than nail diameter in a young adult male patient.

Preface

This year marks the 75th anniversary of the introduction to modern surgery of the revolutionary nail developed by Prof G. Kuntscher. His intuitions and studies as well as his techniques of closed intramedullary (IM) nailing of long bone fractures, continue to remain a pivotal cornerstone in orthopedic culture and practice. In Italy in the early 80s, the widespread use of IM nailing for mid-shaft femur or tibia fractures was relegated to major academic hospitals. The Rizzoli Institute in Bologna that I attended as an orthopedic resident was one of them, where innovative surgeons such as L. Gui and M. Campanacci were practicing. Bob D’ Ambrosia from New Orleans was always fascinated and interested with new techniques or implants. In the mid 80s he took me to Strasbourg, France to observe firsthand the results of the modified Kuntscher nail that Arsene Grosse had developed, the G-K nail. Subsequently, I exchanged Ilizarov’s know-how with nailing technique pearls in Memphis with Charlie Taylor, of the closed-section Russell-Taylor nail. Then I had the opportunity to learn the tip and tricks of IM nailing directly from the TIO Editor-in-Chief, Bruce Browner, in Houston, in the late 80s, working at Hermann Hospital. Dr Browner was introduced to the system by “Sig” Hansen from Seattle and subsequently mastered his experience at Shock Trauma in Baltimore with colleagues such as Brumback, Burgess, and Poka. Thus, not only I learned from the masters, but I have been a first-line spectator of historical changes in intramedullary stabilization of long bone fracture with reamed nails. Intramedullary nailing, truly one of my passions in orthopedic traumatology, remains a challenging art, an act of surgery that is performed daily on thousands of individuals all over the globe and where no single fracture is identical to the other. Major successions of changes and improvements have been made in nail design, metallurgy, and radiographic imaging. Still, preoperative planning, positioning of the patient and selection of treatment options continue to remain of paramount importance. This issue of Techniques in Orthopaedics contains the first of two parts dedicated to “Updates on Intramedullary Nailing.” I have selected some of the most comprehensive new aspects of intramedullary nailing, in traumatology as well as in reconstructive surgery. An international faculty shares it expertise, presenting new management approaches to help understanding and solving old problems, from limb lengthening to stabilization of femur, tibia, and femoral neck fractures. Articles that discuss up-to-date clinical evidence of compartment syndrome as well as original improved contemporary technical optional approach for tibia fractures are included. Contributions from Europe in the field of antibiotic-coated implants as well as the latest on lengthening over a nail are presented. A major thank you goes to Bruce Browner, who never ceases to impress me with his extraordinary, contagious enthusiasm about new projects. I hope that I have been able to pass it myself to some other young orthopedic trauma surgeon. This two-part TIO series is dedicated to all those whom I have lost and in particular to Mrs Florence L. Nathan: without her I would have not been where I am and a lot might have not been achieved.

Management of Infection After Intramedullary Nailing of Long Bone Fractures: Treatment Protocols and Outcomes

Implant related sepsis is a relatively unusual complication of intra-medullary nail fixation of long bone fractures. Depending on the extent of infection, timing of diagnosis and progress of fracture union, different treatment strategies have been developed. The aim of this review article is to collect and analyze the existing evidence about the incidence and management of infection following IM nailing of long bone fractures and to recommend treatment algorithms that could be valuable in everyday clinical practice. After searching the P u b M e d /Medline databases, 1270 articles were found related to the topic during the last 20 years. The final review included 28 articles that fulfilled the inclusion criteria.Only a few prospective studies exist to report on the management of infection following IM nailing of long-bone fractures. In general, stage I (early) infections only require antibiotic administration with/without debridement. Stage II (delayed) infections can be successfully treated with debridement, IM reaming, antibiotic nails, and administration of antibiotics. Infected non-unions are best treated with exchange nailing, antibiotic administration and when infection has been eradicated with graft implantation if it is needed. Debridement, exchange nailing and systemic administration of antibiotics is the best indication for stage III (late) infections, while stage III infected non-unions can successfully be treated with nail removal and Ilizarov frame, especially when large bone defects exist.

Harvest of cortico-cancellous intramedullary femoral bone graft using the reamer-irrigator-aspirator (RIA)

The "Reamer-Irrigator-Aspirator" (RIA) is a device that provides continuous irrigation and aspiration during intramedullary reaming of long bones. The RIA system is first used to collect the reaming material from medullary cavities, a thick paste of finely morselized osseous particles containing significantly elevated levels of stem cells and growth factors as reported by quantitative analyses. The volume of bone graft material available from an adult femur corresponds to the amount of cancellous bone graft obtained from both the anterior and posterior iliac crests. The assembly and technicalities of the RIA system require a training period to prevent any femoral fracture, which appears to be the major RIA-related complication. The elective indications for RIA bone grafting are filling of bone defects in the epiphyseal and metaphyseal regions. Diaphyseal defects may also be managed using the RIA system provided the graft is placed in a constrained system (induced membrane) to prevent dispersion of the graft into the surrounding soft tissues and is aerated with a porous material to promote its revascularization. Other RIA indications include debriding intramedullary infections and reaming for intramedullary nailing of long bone fractures to reduce the risk of fat embolization.

Orthopedic Surgery in the United States Army: A Historical Review

The contribution of American military surgeons to the development of orthopedic surgery has not previously been explored. The experiences of American military surgeons in conflicts from the Civil War to Iraq and Afghanistan have advanced the orthopedic discipline, resulting in important developments within the field, as well as scientific discoveries that have benefited both the civilian and military communities. From advances in wound care, to spinal surgery, intramedullary nailing of long bone fractures, and external fixation, American military surgeons have been pioneers of orthopedic surgery. The goal of this review was to survey the American military orthopedic experience from the American Revolution to the wars in Iraq and Afghanistan.

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.

Reamed Nailing of Long Bone Fractures. Is it Dangerous?

Reamed Nailing of Long Bone Fractures. Is it Dangerous?