Nail Entry Point Research Articles

Comparative Analysis of Infrapatellar and Suprapatellar Nailing Techniques for Tibial Shaft Fractures

Introduction: Tibial shaft fractures pose a significant challenge in orthopaedic practice, often necessitating surgical intervention for optimal recovery. The selection of the entry point for intramedullary nailing, particularly between the suprapatellar and infrapatellar approaches, remains a debated aspect in fracture management. While both approaches aim to restore stability and function, their nuances influence outcomes and patient experiences. This study aims to comprehensively compare the suprapatellar and infrapatellar approaches, analyzing surgical techniques, complications, and functional outcomes to inform clinical decision-making. Methodology: A retrospective comparative analysis was conducted on patients undergoing intramedullary nailing for tibial shaft fractures, comparing outcomes between the suprapatellar and infrapatellar approaches. Data collection included patient demographics, fracture characteristics, intraoperative details, and postoperative outcomes. Statistical analysis was performed using appropriate tests, with a significance level set at p < 0.05. Result: Operative time was longer in the infrapatellar group (137.8 minutes) compared to the suprapatellar group (114.4 minutes). The mean radiation dose was higher in the infrapatellar group (74.3 cGY/cm2) and lower in the suprapatellar group (48.5 cGY/cm2). Postoperative outcomes showed a mean Lysholm score of 74 in the infrapatellar group and 90 in the suprapatellar group. one case of infection and one case of malunion were reported in the infrapatellar group, while the suprapatellar group had one infection case but no instances of non-union or malunion. Conclusion: This study provides valuable insights into the surgical and clinical outcomes of the suprapatellar and infrapatellar approaches for tibial shaft fractures. While both techniques offer viable options, the suprapatellar approach may offer advantages in terms of operative efficiency and functional recovery.

Comparison of effectiveness of long and short proximal femoral nail anti-rotation in treatment of type A2.3 intertrochanteric fracture of femur

To compare the effectiveness of long and short proximal femoral nail anti-rotation (PFNA) in the treatment of type A2.3 intertrochanteric fracture of femur (IFF). The clinical data of 54 patients with type A2.3 IFF admitted between January 2020 and December 2022 were retrospectively analyzed. According to the length of PFNA nail used in the operation, they were divided into long nail group (PFNA nail length>240 mm, 24 cases) and short nail group (PFNA nail length≤240 mm, 30 cases). There was no significant difference in baseline data such as gender, age, fracture side, body mass index, and time from fracture to operation between the two groups ( P>0.05). The operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, intraoperative reduction quality score, fracture healing, and complications of the two groups were recorded and compared. Harris score was used to evaluate the hip function of patients at 1 year after operation. According to the relationship between the fracture line of type A2.3 IFF and the lesser trochanter, the two groups of patients were divided into type Ⅰ(the fracture line extends to the level of the lesser trochanter), type Ⅱ(the fracture line extends to less than 2 cm below the lesser trochanter), and type Ⅲ (the fracture line extends to more than 2 cm below the lesser trochanter), and the postoperative stability and internal fixator loosening of each subtype were evaluated. The operation time, intraoperative blood loss, and intraoperative fluoroscopy frequency in short nail group were significantly less than those in long nail group ( P<0.05). There was no significant difference in the intraoperative reduction quality score between the two groups ( P>0.05). Patients in both groups were followed up 12-18 months, with an average of 13.5 months. The postoperative stability score of short nail group was significantly lower than that of long nail group ( P<0.05). The Harris score in the long nail group was significantly higher than that in the short nail group at 1 year after operation ( P<0.05), but there was no significant difference in Harris score grading between the two groups ( P>0.05). Complications occurred in 3 cases of the long nail group (including 1 case of coxa varus caused by external nail entry point and 2 cases of loose internal fixator), and 7 cases of the short nail group (including 1 case of coxa varus caused by external nail entry point and 6 cases of loose internal fixator). Neither group had any anterior femoral arch damage, there was no significant difference in the incidence of complications between the two groups ( P>0.05). The number of type Ⅲ patients was relatively small and not included in the statistics; there was no significant difference in the postoperative stability score and the incidence of internal fixator loosening between the long and short nail groups in type Ⅰ patients ( P>0.05). In type Ⅱ patients, the postoperative stability score and the incidence of internal fixation loosening in the long nail group were significantly better than those in the short nail group ( P<0.05). Long PFNA fixation for type A2.3 IFF has longer operation time and more intraoperative blood loss, but the overall stability of fracture is better after operation. For type A2.3 IFF with fracture line extending to less than 2 cm below the lesser trochanter, long PFNA is used for fixation, although the surgical trauma is large, but the postoperative stability is better than that of short PFNA; for type A2.3 IFF with fracture line extending to the lesser trochanter, there is no significant difference in postoperative stability between long and short PFNAs.

Unravelling variations: an examination of entry point selection in proximal femoral cephalomedullary nailing

BackgroundThe exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This study aimed to explore the variability in the selection of the entry point among trauma surgeons, hypothesizing potential differences and their association with surgeon experience.MethodsIn this prospective multicenter study, 16 participants, ranging from residents to senior specialists, partook in a simulation wherein they determined the optimal entry point for the implantation of a proximal femoral nail antirotation (PFN-A; DePuy Synthes) in various femora. The inter- and intra-observer variability was calculated, along with comprehensive descriptive statistical analysis, to assess the variability in entry point selection and the impact of surgeon experience.ResultsIn this study, the mean distance from the selected entry points to the calculated mean entry point was 3.98 mm, with a smaller distance observed among surgeons with more than 500 implantations (ANOVA, p = 0.050). Intra-surgeon variability for identical femora averaged at 5.14 mm, showing no significant differences across various levels of surgical experience or training. Notably, 13.6% of selected entry points would not allow a proper intramedullary positioning of the implant, thereby rendering anatomical repositioning unfeasible. Among these impossible entry points, a significant skew towards anterior placement was observed (70.6% of the impossible entry points), with a smaller fraction being overly lateral (27.5%) or medial (13.7%). On a patient level, the impossibility rate varied widely from 0 to 35% among the different femora examined, with a significantly higher rate seen in younger patients (mean age 55.02 versus 60.32; t-test for independent samples, p = 0.04).ConclusionsSignificant variations exist in surgeons’ selection of entry points for proximal femoral nailing, underscoring the task’s complexity. Experience does not prevent the choice of unfeasible entry points, emphasizing the inadequacy of a universal approach and pointing towards the necessity for a patient-specific strategy for improved outcomes.Trial registration number: DRKS00032465.

Research on Locating Device for the Entry Point of Intramedullary Nail Based on Inertial Navigation

To introduce a locating device for the entry point of intramedullary nail based on the inertial navigation technology, which utilizes multi-dimensional angle information to assist in rapid and accurate positioning of the ideal direction of femoral anterograde intramedullary nails' entry point, and to verify its clinical value through clinical tests. After matching the locating module with the developing board, which are the two components of the locating device, they were placed on the skin surface of the proximal femur of the affected side. Anteroposterior fluoroscopy was performed. The developing angle corresponding to the ideal direction of entry point was selected based on the X-ray image, and then the yaw angle of the locating module was reset to zero. After resetting, the locating module was combined with the surgical instrument to guide the insertion angle of the guide wire. The ideal direction of entry point was accurately located based on the angle guidance. By setting up an experimental group and a control group for clinical surgical operations, the number of guide wire insertion times, surgical time, fluoroscopy frequency, and intraoperative blood loss with or without the locating device was recorded. Compared to the control group, the experimental group showed significant improvement in the number of guide wire insertion times, surgical time, fluoroscopy frequency, and intraoperative blood loss, with a statistically significant difference (P<0.01). The locating device can assist doctors in quickly locating the entry point of intramedullary nail, effectively reducing the fluoroscopy frequency and surgical time by improving the success rate of the guide wire insertion with one shot, improving surgical efficiency, and possessing certain clinical value.

Choice of Entry Point Does Not Affect Clinical and Radiological Outcomes in Antegrade Intra-medullary Nailing in Patients with Shaft of Femur Fracture: A Prospective Randomized Controlled Trial.

The choice of entry point, Greater trochanter (GT), or Piriformis entry (PE) for antegrade intramedullary nailing (IMN) of the femur is crucial. This study was performed to compare these two entry points in the patients with shaft of femur fractures regarding intra-operative parameters, radiological and functional outcomes. Twenty-four patients underwent GT entry nailing, while 25 patients underwent PE nailing. Surgical time, Intra-operative blood units transfused, Intra-operative fluoroscopy exposure by number of C-arm shots taken, mean drop in hemoglobin, and incidence of iatrogenic fracture were recorded. Patients were followed up at 4weeks, 6weeks, and 6months to look for radiological healing and improvements in functional outcome using Modified Harris Hip Score (MHHS). MRI of bilateral hips with pelvis was done in 25 patients at 6months of follow-up to detect any preliminary signs of AVN. The mean drop in hemoglobin in the GT group was significantly lesser than the PE group (p = 0.02). Mean MHHS at 4weeks post-op was also significantly higher in the GT group (p = 0.01). There was no significant difference between both the groups regarding surgical duration, fluoroscopy exposure, radiological and functional outcomes in the long term. None of the patients who underwent MRI displayed any preliminary sign of AVN. GT entry nails lead to lesser surgical time, fluoroscopy exposure, and intra-operative blood loss. Both the nailing systems achieve excellent fracture unions and comparable functional outcomes in the long term, and there is a minuscule risk of AVN in adult patients undergoing IMN.

An evolutionary perspective to intramedullary nail fit - comparing present-day data with a historical specimen collection.

Manufacturers aim to design implants fitting for the broadest possible population segment. Due to the scarcity of available morphological data of intact long bones, anatomical collections of historical bone specimens may represent valuable additional sources. Previous work on femoral morphology measurements suggests that historical specimens are widely consistent with data from present-day populations. This study aimed to investigate whether this also applies to the anatomical fitting of a clinically used femoral nail. Nail fit was computer-graphically quantified through virtual implantation into CT-based 3D models of 52 femora, comprising a subset representative of the present-day Caucasian population (n = 31), a subset from a historical medieval European bone collection (n = 20), and additionally, a dataset from a natural ice mummy from the Neolithic period. Nail fit was assessed by nail protrusion (area and distance) to the inner cortex surface and the distal nail tip's position in the medullary canal. Assessed measurements and parameters of the present-day Caucasian subset were mostly consistent with those of the medieval European subset. After adjusting for multiple testing, only the distance from lateral nail entry point to shaft axis remained significantly (p = 0.03) different when comparing our modern and medieval subsets. Subsequent bivariate (Spearman) correlation analyses for both subsets (modern and medieval) combined showed that of the three variables representing basic demographic parameters, individual age, biological sex, and femur length, most statistically significant associations to the examined nail fit measurements were found for age (six measurements at a level of p < 0.05), however, with a relatively weak monotonic correlation (rho values ranging between ±0.31 and ±0.37). The measurements for the Iceman's femur lie within the range of the modern and historical subgroups, but in some cases, differ by more than one standard deviation from the mean. Our results confirm previous findings, suggesting that more recent historical bone specimen collections may indeed be a convenient and easily accessible source of new 3D morphological data and complement existing data to be used for the development of femoral nails.

Antegrade Flexible Nailing for Pediatric Metaphyseal-diaphyseal Junction Distal Radius Fracture, is it Safe?

Fractures involving the distal radius metaphyseal-diaphyseal junction (MDJ) present a unique challenge for pediatric orthopedic surgeons. These fractures are too proximal for percutaneous K -wire fixation and too distal for retrograde flexible nailing. The purpose of this study was to: (1) determine the safety of a described antegrade approach from the posterior interosseous nerve (PIN); (2) assess the efficacy of antegrade nailing in cases of distal MDJ fractures; and (3) describe a standardized lateral approach to the proximal radius. A cadaveric study was performed using 10 adult forearms. Anterograde flexinail was introduced at the proximal radius based on the described "safe zone". Distal MDJ fractures were created using osteotomes. We evaluated the distance between the entry point to the PIN in addition to the quality of the reduction for the fracture. The average distance between the entry point and piercing instrument to the PIN was 5.4 cm (range: 4.7 to 6.0 cm). When grouped based on sex, the average distance was significantly further for males (5.8 cm, range: 5.2 to 6.0 cm) versus females (4.9 cm, range: 4.7 to 5.2 cm), P =0.004. Fracture reduction was not maintained after the introduction of the antegrade flexible nail across the fracture site. For all specimens, >25% displacement was seen on the anterior-posterior imaging. Our modified lateral approach to the starting point in the proximal radius is safe as long as the entry point for antegrade flexible nailing stays proximal to the radial tuberosity during the lateral approach to the proximal radius while the elbow is flexed and the forearm pronated.

Ideal entry point and direction of retrograde intramedullary nailing of the tibia

PurposeTo determine the ideal entry point and direction of retrograde intramedullary nailing of the tibia.MethodsThe imaging data of patients with distal tibial fractures from June 2020 to December 2021 in our hospital were collected, and computer-aided design was performed. The relevant data were imported into the software for processing, so as to obtain a distal tibial fracture model and simulate the retrograde intramedullary nail placement in the tibia. The entry points and angles at which the intramedullary nail could be inserted successfully and the fracture could be maintained in good alignment were overlapped and counted to obtain the safe entry range and angle. The center of this safe range is the ideal entry point for retrograde intramedullary nailing of the tibia, and the mean value of the angle is the ideal direction of entry.ResultsThe ideal entry point of the retrograde intramedullary nailing was located at the midpoint of the medial malleolus in the C-arm fluoroscopic anteroposterior (AP) and lateral view. The ideal nail entry direction was located at the anatomic axis of the medial malleolus in the AP position and at the anatomic axis of the distal tibial metaphysis in the lateral position.ConclusionThe ideal point and direction of nail insertion for retrograde tibial intramedullary nailing is a "double midpoint, double axis" approach.

A Central Collinear Start Point for Reconstruction Nailing of Femur Fractures: A Technical Trick and Case Series.

Summary: Selecting the optimal entry point for reconstruction nailing is critical to avoid iatrogenic malalignment and optimize mechanical stability. In-line nailing is familiar to surgeons and desirable for its on-axis position. However, there are several potential drawbacks. We describe a modified entry point and present an accompanying clinical series emphasizing an entry point in line with the medullary canal and central on the femoral neck. This central collinear start point is anterior to the traditional piriformis start point and may obviate some of the potential drawbacks with traditional piriformis nailing.

Optimizing the Entry Point for Reconstruction Nailing of the Femur.

Varus after antegrade medullary nailing of the proximal femur is associated with worse outcomes. Anecdotally, a more medialized "trochiformis" entry is beneficial to avoid varus with valgus-bend (greater trochanteric entry) femoral nails. However, the optimal entry point remains unknown. The purpose of this study was to define the optimal entry point for reconstruction nailing. Using standing alignment radiographs from 51 patients, we templated the ideal entry point for straight and valgus-bend nails from three major manufacturers using TraumaCad software. We measured the distance from the tip of the trochanter to the ideal entry site for each nail. We compared piriformis (PF) with trochanteric (GT) entry for each company and across manufacturers. The mean greater trochanter offset from the femoral axis was 15.2 mm. The mean PF entry was 5.9 to 6.7 mm medial to the mean GT entry for each company's nail and was statistically distinct. No differences were observed in GT and PF entry points across manufacturers. Only 2 of 153 ideal GT entry points were lateral to the tip of the trochanter. An increased neck-shaft angle (NSA) and increased GT offset were correlated with a more medial ideal entry point. The ideal entry point for GT nails is similar across manufacturers and is medial to the tip of the greater trochanter; however, PF and GT entry sites remain distinct. During preoperative planning and when executing femoral nailing intraoperatively, it may also be important to consider the NSA and GT offset of a patient before committing to a certain entry point.

Risk Factors Associated with Intraoperative Iatrogenic Fracture in Patients Undergoing Intramedullary Nailing for Atypical Femoral Fractures with Marked Anterior and Lateral Bowing.

Background and objectives: Iatrogenic fractures are potential complications during intramedullary (IM) nailing for atypical femoral fractures (AFFs). The risk factors associated with iatrogenic fractures remain unclear, although excessive femoral bowing and osteoporosis are hypothesized to be contributing factors. The present study aimed to determine the risk factors for the occurrence of iatrogenic fractures during IM nailing in patients with AFFs. Materials and Methods: This retrospective cross-sectional study evaluated 95 patients with AFF (all female; age range: 49-87 years) who underwent IM nailing between June 2008 and December 2017. The patients were divided into two groups: Group I (with iatrogenic fracture: n = 20) and Group II (without iatrogenic fracture: n = 75). Background characteristics were retrieved from medical records and radiographic measurements were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors for the occurrence of intraoperative iatrogenic fractures. Receiver operating curve (ROC) analysis was conducted to determine a cut-off value for the prediction of iatrogenic fracture occurrence. Results: Iatrogenic fractures occurred in 20 (21.1%) patients. The two groups exhibited no significant differences regarding age and other background characteristics. Group I exhibited significantly lower mean femoral bone mineral density (BMD) and significantly greater mean lateral and anterior femoral bowing angles than Group II (all p < 0.05). There were no significant differences in AFF location, nonunion, and IM nail diameter, length, or nail entry point between the two groups. In the univariate analysis, femoral BMD and lateral bowing of the femur differed significantly between the two groups. On multivariate analysis, only lateral bowing of the femur remained significantly associated with iatrogenic fracture occurrence. The ROC analysis determined a cut-off value of 9.3° in lateral bowing of the femur for prediction of iatrogenic fracture occurrence during IM nailing for AFF treatment. Conclusions: The lateral bowing angle of the femur is an important predictive factor for intraoperative iatrogenic fracture occurrence in patients undergoing IM nailing for AFF treatment.

Determination of intramedullary nail based on centerline adaptive registration.

Objective: Internal fixation with intramedullary nails is a gold standard for the treatment of femoral shaft fractures. However, both the mismatch between intramedullary nails and the medullary cavity and inaccurate positioning of entry points will lead to deformation of intramedullary nails after implantation. The study aimed to determine a suitable intramedullary nail with an optimal entry point for a specific patient based on centerline adaptive registration. Method: A homotopic thinning algorithm is employed to extract centerlines of the femoral medullary cavity and the intramedullary nail. The two centerlines are registered to obtain a transformation. The medullary cavity and the intramedullary nail are registered based on the transformation. Next, a plane projection method is employed to calculate the surface points of the intramedullary nail laid outside the medullary cavity. According to the distribution of compenetration points, an iterative adaptive registration strategy is designed to decide an optimal position of the intramedullary nail in medullary cavity. The isthmus centerline is extended to the femur surface, where the entry point of the intramedullary nail is located. The suitability of an intramedullary nail for a specific patient was calculated by measuring the geometric quantities reflecting the interference between the femur and nail, and the suitability values of all nails are compared and the most suitable one is determined. Results: The growth experiment indicated that the bone to nail alignment is indeed affected by the extension of the isthmus centerline, including the extension direction and velocity. The geometrical experiment showed that this method could find the best registration position of intramedullary nails and select the optimal intramedullary nail for a specific patient. In the model experiments, the determined intramedullary nail could be successfully placed into the medullary cavity through the optimal entry point. A pre-screening tool to determine nails which can be successfully used has been given. In addition, the distal hole was accurately located within 14.28s. Conclusion: These results suggest that the proposed method can select a suitable intramedullary nail with an optimal entry point. The position of the intramedullary nail can be determined in the medullary cavity, while deformation is avoided. The proposed method can determine the largest diameter intramedullary nail with as little damage to the intramedullary tissue as possible. The proposed method provides preparation aid for internal fixation with intramedullary nails guided by navigation systems or extracorporeal aimers.

The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not

The evaluation of proximal humerus fractures (PHFs) should be aimed to answer the following four questions: (1) does the fracture need surgery in each particular patient? (2) if surgery is recommended, is it better to proceed with internal fixation or shoulder arthroplasty, (3) if internal fixation is recommended, what is the ideal fixation device strategy, and (4) how can outcomes be optimized? This review article tries to answer these questions and provides some clarity regarding what works and what does not in PHFs treated with intramedullary nailing. According to published articles on the treatment of PHFs with intramedullary nails, it is difficult to draw conclusions about outcomes and complications due to great variation in age, type of fracture, and nail designs included in the studies. However, the literature seems to support the use of modern nail designs for PHFs, especially in fractures of the surgical neck as well as varus posteromedial and valgus fractures with no tuberosity involvement. Although the results of IMN in PHF seem to be better in two-part fractures, in more complex fractures, the quality of the reduction achieved seems to influence functional outcomes. Tuberosity malreduction leads to poor clinical outcomes, high rate of complications, and an increased risk of avascular necrosis. Malreduction of the humeral head increases the risk of postoperative loss of reduction, especially for varus posteromedial impacted fractures. A medial nail entry point decreases the risk of postoperative varus malunion, preserves the rotator cuff tendon, and avoids iatrogenic fractures of the GT. To decrease the risk of postoperative stiffness, fracture fixation should be stable enough to allow early mobilization.

Medialized Trochanteric Entry Nailing Is a Safe and Effective Method for High-Energy Subtrochanteric Femur Fracture Treatment.

Fixation of subtrochanteric femur fractures using intramedullary nails can provide high rates of osseous union. However, a lateral starting point or a medial trajectory can result in varus alignment, typically seen with trochanteric entry nails. Even with piriformis nails, medial comminution can result in secondary malalignment and varus. Varus can predictably result in nonunion and need for repeat operations. Medialized trochanteric entry nailing has been reported previously as a method to prevent varus alignment in low-energy, atypical subtrochanteric femur fractures in association with bisphosphonate use. We present a surgical technique using a medialized trochanteric nail entry point to provide proper alignment and avoidance of varus malreduction in 24 patients with a subtrochanteric femur fracture after a high-energy traumatic event.

A Novel Surgical Technique for Extraction of a Firmly Integrated Broken Intramedullary Nail.

AimTo present a novel technique developed in our institution to remove incarcerated and broken intramedullary (IM) tibial and femoral nails.BackgroundIM nails are commonly used to treat diaphyseal fractures in both the tibia and femur. These nails can become problematic for the orthopaedic surgeon when they need to be removed, especially in the rare event that the nail has failed and broken. This can leave part of the nail deep in the bone and incarcerated. Multiple techniques have been described to remove a broken nail but we present a novel technique developed based on our experience.TechniqueAfter all other methods to remove the broken nail have failed, a window technique can be employed. This requires a small window of bone to be removed from the cortex overlying the remaining IM nail. A carbide drill is then used to drill a hole into the nail to gain purchase. The edge of an osteotome is placed in the hole in the nail through the window and gently hammered upwards to push the nail towards the over-reamed nail entry point. The nail is repeatedly drilled and pushed until the nail can be removed. The bone window is then replaced.ConclusionThis is a novel technique that works when all other options including hooks, wire stacks and specialist nail removal techniques have failed. It is simple, efficient and effective for both the tibial and femoral nails.How to cite this articleSomerville CMB, Hanschell H, Tofighi M, et al. A Novel Surgical Technique for Extraction of a Firmly Integrated Broken Intramedullary Nail. Strategies Trauma Limb Reconstr 2022;17(1):55–58.

A Clinical Case Report: Closed Extraction of a Broken Distal Piece of the Tibial Intramedullary Nail Remaining for 8 Years

Aim: Closed extraction of a broken distal piece of the intramedullary nail is very challenging. We herein report a case of the broken distal piece of the tibial intramedullary nail remaining for 8 years, which was successfully extracted by closed method using a self-made broken nail extractor.&#x0D; Case Presentation: A 51-year-old male patient was admitted to our hospital for extraction of the broken distal piece of the tibial intramedullary nail for 8 years. The preoperative X-ray films showed the broken intramedullary nail was cannulated and the outer diameter is 10 mm, larger than the isthmus of the medullary cavity.&#x0D; Results: After reaming with Φ 11 mm drill, the self-made broken nail extractor was inserted into the medullary cavity from the nail entry point and passed through the canal of the broken nail, and successfully pulled out the broken nail.&#x0D; Conclusion: Our technique is a simple reproducible alternative that has high extraction success rate for broken distal piece of cannulated intramedullary nails.

Self-Made Minimally Invasive Broken Nail Extractor for Distal Broken Segment of Cannulated Intramedullary Nails: One Case Application Report and Literature Review

Introduction: Successful minimally invasive extraction of a broken intramedullary distal piece of the nail is very challenging. We herein report a simple and reproducible technique of extraction of broken cannulated intramedullary nails using a self-made minimally invasive broken nail extractor. Case Presentation: We present a 48-year-old male patient who was admitted to our hospital for internal implant removal, whose right tibial fracture had healed, and a broken intramedullary nail was retained at the distal of the tibial for 12 years. The preoperative X-ray films showed the broken intramedullary nail was cannulated and the outer diameter is 10 mm, larger than the isthmus of the medullary cavity. Results: After reaming with Φ 11 mm drill, the self-made broken nail extractor was inserted into the medullary cavity from the nail entry point and passed through the canal of the broken nail, and successfully pulled out the broken nail. Conclusion: Our technique is a simple, reproducible alternative that has a high extraction success rate for the distal broken segments of cannulated intramedullary nails.

Relationship Between the Lateral Plantar Artery and the Retrograde Intramedullary Nail During Tibiotalar and Subtalar Arthrodesis: A Fresh Cadaveric Study.

Tibiotalocalcaneal (TTC) arthrodesis with retrograde intramedullary nailing has become established. Iatrogenic injury to the vasculature (eg, lateral plantar artery [LPA] pseudoaneurysm) during insertion of the nail has been reported. The aim of this study was to identify the safe zone that avoids injury to the LPA during TTC arthrodesis. The retrograde lateral curved nail entry point should be in line with the midpoint of the tibial medullary canal and the lateral column of the calcaneus. Enhanced 3-dimensional computed tomography scans of 26 fresh cadaveric feet were assessed. The closest distance between the LPA and the edge of the nail entry point was measured in the plantar view. The closest mean distance between the LPA and the edge of the nail entry point was 6.7 mm for all 26 feet, 12.8 mm for 3 feet (11.5%) in which the LPA did not cross the medial wall of the calcaneus, 8.1 mm for 9 (34.1%) in which the point where the LPA crossed the medial wall of the calcaneus was anterior to the center of the nail entry point, and 4.2 mm for 14 (53.8%) feet in which this point was posterior to the center of the nail entry point. Care should be taken to avoid the LPA during reaming at the nail entry point, especially when the point where the LPA crosses the medial wall of the calcaneus is posterior to the center of the nail entry point. IV, cadaveric study.

Outcomes of closed interlocking intramedullary nailing of the tibia without fluoroscopy in resource-limited settings: experience from two hospitals in Cameroon.

Introductionclosed static interlocking nailing with c-arm guidance is the standard procedure for the treatment of closed diaphyseal leg fractures. It is still very difficult to carry out such procedures in a low-income setting because of few or absent image intensifiers (c-arm) despite the necessity. The aim of this study was to describe the outcomes of patients with tibial fractures treated with closed interlocking intramedullary nails without c-arm guidance in a Cameroonian population.Methodsthis was a prospective study including adult patients treated for tibial fractures without a c-arm in two regional hospitals.Resultsfinally, 22 patients were included. The mean age was 34 ± 12.6 years with a male predominance (16 males and 6 females). Ninety percent of the fracture lines were simple or with a wedge fragment grade 42A or 42B respectively according to the AO classification. The mean surgery time was 1 hour 26 ± 34 minutes. The various aspects evaluated were the nail entry point which was good in 19 (86.4%) cases; proper nail driving which was considered good in 15 (68%) cases; the distal locking which was missed in 6 (27.3%) cases. Bone consolidation was obtained in an average of 4 ± 1.2 months in all 22 cases.Conclusionin resource constraints settings where c-arm are not always available, closed interlocked nail of tibia without c-arm guidance still gives overall good results. Nevertheless, there is a need to improve equipment in sub-Saharan African hospitals to make trauma surgery with c-arm a gold standard as currently recommended.

Research progress in osteonecrosis of femoral head following femoral intertrochanteric fractures in adults

To summarize the research progress of osteonecrosis of femoral head (ONFH) following femoral intertrochanteric fractures in adults. Relevant literature at home and abroad was extensively reviewed to summarize the pathogenesis, high-risk factors, and treatment of ONFH after femoral intertrochanteric fracture in adults. ONFH after femoral intertrochanteric fracture mostly occurs within 2 years after operation, with a lower incidence. At present, it is believed that comminuted and large displacement fractures caused by high-energy injuries, fracture line close to the base of neck, excessive external rotation deformity, improper intramedullary nail entry points, and rough intraoperative manipulating may injury the deep branch of the medial circumflex femoral artery, causing ONFH. Hip replacement is the main treatment for necrosis, which can achieve good results. Addressing the above risks, excessive external rotation, overstretching, and rough manipulating should be avoided. Anatomical reduction should be performed during the operation, the nail entry point should be accurate and avoid repeated drilling and thermally bone necrosis.