Intramedullary Nail Placement Research Articles

8079 PPI Breaks a Leg! An Unusual Case of Atypical Femur Fracture

Abstract Disclosure: M. Sedghian: None. M. Flanagan: None. D. Pinkhasova: None. K. Selk: None. G. Moloney: None. Background: Atypical femur fractures (AFF) occur along the shaft of the femur extending from the subtrochanteric region proximally to the distal femoral metaphysis. These fractures have an increased incidence in patients taking bisphosphonates and denosumab for osteoporosis and develop as stress reactions in the lateral cortex of the femoral shaft (beaking). However, few cases that meet the characteristics of these fractures have occurred in patients who have never used antiresorptive drugs. We present a case with a history of long-term proton pump inhibitor (PPI) use and possible association with AFF. Clinical Case: The patient is a 68-year-old female with a past medical history of hypothyroidism who presented to the emergency department (ED) after an atraumatic femur fracture and consequently ground level fall. The patient reported experiencing a distinctive cracking sound in her femur while leaning over to wash her feet, resulting in a fall that prompted her to seek immediate care in the ED. Upon initial evaluation, radiographic imaging was significant for displaced left mid-femoral diaphyseal fracture and right femur lateral cortex thickening consistent with AFF. Labs were consistent with elevated PTH to 100.7 [18.4-80.1], Vit D2 1,25 (OH)2 <8 pg/mL, Vit D 25OH 34 ng/ml [30-100], and Calcium level of 9.5. Upon further history taking, the patient stated that she has been taking PPIs intermittently for more than 10 years. She denied a history of bisphosphonate and denosumab exposure, non-Hodgkin's lymphoma, rheumatoid arthritis, and COL1A2 variant mutations as main predisposing factors for atypical femur fractures. She had potential steroid exposure for less than a year before hospitalization as she was on "adrenal complex" from her functional medicine provider. The patient underwent open reduction and internal fixation of the left femur with placement of intramedullary nail and prophylactic fixation with placement of intramedullary nail of the right femur as there was radiographic evidence of beaking. Discussion/Conclusion: Several studies suggested a possible association between PPIs and fracture risk, especially hip fractures, but the relationship remains contentious. Overall, PPIs are positively associated with elevated fracture risk in multiple studies. Increased gastrin production and hypochlorhydria are the two main mechanisms that affect bone remodeling, decreasing bone turnover, impairing calcium absorption, and altering homocysteine levels through impairment of folate and vitamin B12 absorption.This case supports a potential association between long-term PPI use and atypical femur fractures. There have been other case reports that also highlight this potential risk of PPI use. This shows the importance of more comprehensive research on this topic as the number of patients on long-term PPIs is growing in outpatient settings. Presentation: 6/2/2024

Application of the "3-2-1" body surface localization method in intertrochanteric femoral fractures: a technical note.

In femoral intertrochanteric fractures, poor incision positioning may result in inaccurate intramedullary nail placement direction, which increases the difficulty of reduction and thus the size and number of incisions. Repeated intraoperative fluoroscopy not only increases the radiation exposure of the surgeon but also affects the operative outcomes. This technical note proposes a method of identifying incision positioning preoperatively using the "3-2-1" body surface localization method. This auxiliary positioning technique uses a body surface locator and the lower limb force axis. It can predict the incisions for the needle insertion point, spiral blade, and locking nails, create minimally invasive incisions, avoid incorrect incision position, facilitate accurate intraoperative intramedullary nail placement, reduce the incision size, intraoperative bleeding, and radiation exposure, and improve surgical efficiency and reduction quality.

Reply to Letter to the Editor: Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks.

Reply to Letter to the Editor: Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks.

Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks.

Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks.

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.

Imaging Evaluation of Insertion Point Accuracy in Retrograde Intramedullary Femoral Nailing.

When compared with visual retrograde intramedullary nail placement in the femur, fluoroscopic retrograde intramedullary nail placement in the femur improved the accuracy of insertion. Ninety-six patients treated with retrograde intramedullary nailing of the femur for femoral fracture were included in this retrospective case-control study, including 48 patients treated with nailing under direct vision and 48 patients treated with nailing under fluoroscopy. Influencing factors potentially associated with the deviation of the needle insertion point on the coronal and sagittal planes (including the needle insertion method, use of limited open reduction, side, intramedullary nail diameter, mechanism of injury, and fracture classification) were analyzed univariately; then, the variables with a p value < 0.20 on univariate analysis were included in the linear regression equation to assess the independent factors associated with needle insertion point deviation. On the coronal plane, the insertion point deviation in the visual nail placement group (1.11 ± 4.08 mm) was not significantly different (p = 0.13) from that in the fluoroscopic nail placement group (-0.44 ± 3.48 mm); on the sagittal plane, the insertion point deviation in the visual nail placement group (4.91 ± 4.67 mm) was significantly greater than that in the fluoroscopic nail placement group (2.08 ± 2.97 mm) (p < 0.01). Visual nail placement was a risk factor for insertion point deviation on the sagittal plane compared with fluoroscopic nail placement (β = -0.84, p < 0.01). Compared with visual nail placement, fluoroscopic nail placement improves the accuracy of insertion on the sagittal plane, with no difference between the two methods on the coronal plane. These findings indicate that surgeons should exercise more caution when placing nails under direct vision.

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study.

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

Retrograde Intramedullary Nailing of Pediatric Femoral Shaft Fractures Does Not Result in Growth Arrest at the Distal Femoral Physis-A Retrospective Cases Series.

To evaluate femoral growth after placement of retrograde intramedullary nails in the treatment of pediatric femoral shaft fractures. Retrospective case series. Large urban trauma center in Mongolia. Twenty-nine pediatric patients who sustained a diaphyseal femoral shaft fracture were included in the study. Retrograde intramedullary nail fixation with the standard, fin, or pediatric fin Surgical Implant Generation Network nail across an open distal femoral physis. The main outcome measure was the distance traveled by the intramedullary nail with respect to the distal femoral condyles and distal femoral physis from initial surgery to follow-up. The mean age of patients was 10.7 years (range: 7-14 years). Follow-up occurred at a mean of 292 days (range: 53-714 days). Both condyle distance and physis distance were significantly positively correlated with follow-up days, with Pearson R values of 0.90 (P < 0.001) and 0.84 (P < 0.001), respectively. Multiple regression analysis revealed that follow-up days was the only significant predictor of physis distance, whereas age, sex, percent growth plate violation, and nail fully traversing physis were not significant predictors. The nail completely crossed the physis in 5 patients and no growth arrests were found. This is the first study, to our knowledge, to evaluate treating femoral shaft fractures with a retrograde nail across an open distal femoral physis. In the pediatric population, the use of a retrograde femoral intramedullary nails does not seem to cause growth arrest of the injured femur during the postoperative period and may be a reasonable treatment option when other surgical options are not available. Additional study is necessary to further evaluate the safety profile. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Clinical Characteristics and Survival of Multiple Myeloma Patients with Fractures

Background Multiple myeloma (MM) is an incurable and heterogeneous disease; often presents with skeletal-related events, including pathological fractures. Lytic bone disease is mediated mainly by dysregulation of interleukin 6 (IL-6), osteocalcin production, osteoblastic inhibition, osteoclast activation which prevents fracture healing. MM patients with fractures have a significantly higher risk of dying compared to those without fractures, highlighting the importance of preventing bone disease in MM. Usually, when it has manifested, it is necessary to provide adequate multidisciplinary treatment that could improve quality of life and survival. Methods Records of patients with MM and pathological fractures, requiring surgery were identified through National Cancer Institute of Colombia registry. A total of 799 MM records were reviewed; 10% of them required orthopedic surgery treatment. Thirty-six patients were excluded because loss of to follow up. A descriptive analysis of the clinical characteristics of the patients was carried out, as well as a bivariate analysis of the clinic and the outcomes, and finally, an analysis of overall survival of the entire sample using the Kaplan Meier method and with respect to the time of surgery before or after starting antimyeloma treatment. Results Forty-four patients with MM required surgery, since they had pathological fractures. Median age at diagnosis was 61 years (32-79), 26 were female and 18 were male patients. The most frequent MM subtype among these patients was the producer of immunoglobulin G (IgG) and the associated CRAB component, different from lithic lesions was anemia. A total of 75 fractures were confirmed in the 44 patients. The most frequent site of fractures was the femur, followed by spine and humerus. Twenty-five percent presented with two or more bone segments affected. Median number of days from fracture to surgery was 23 days (2-487). The orthopedic procedure that was mostly performed in the series was the placement of intramedullary nails. Postoperative complications included transfusions (47.72%), ICU requirement (9.09%), and electrolytic disbalances that required correction (9.09%). From the whole complete series, 63.3% of patients received chemotherapy prior to the surgical procedure with a median of 4 cycles. Twelve patients died corresponding to 27.9%, having found an early post-operative mortality in the first month of 4.54% and 12 months of 13.63%. There were no significant differences in survival with respect to the start of chemotherapy before or after surgery, but there was a trending for a better outcome in patients who did not receive preoperative chemotherapy. Conclusions Multiple myeloma remains as an incurable disease to date, frequently presenting skeletal-related events that affect quality of life and survival. There is a high risk of postoperative complications such as requiring intensive care, transfusions, and electrolyte disturbances in these patients. Despite not having found statistically significant differences regarding the start of chemotherapy; before or after the surgical procedure with respect to survival, improvement can be see it, when anti-myeloma therapy has not been started at the time of surgery. Prospective studies are required to elucidate whether there is benefit in delaying chemotherapy until after the patient is brought to fracture correction. Disclosures No relevant conflicts of interest to declare.

Evaluation of a Model-based Dose Calculation Algorithm (Acuros) for Intraosseous High Dose Rate Brachytherapy (HDR) With Intramedullary Nailing for Bone Metastases

A standard practice for patients with long bone metastases after intramedullary nailing is treatment with postoperative two-dimensional external beam radiotherapy (2D EBRT), delivered to the length of the implanted hardware. Our goal is to use intraoperative, intraosseous HDR brachytherapy delivered prior to intramedullary nailing to deliver an ablative dose to a limited volume immediately surrounding the tumor. This work evaluates the dosimetric effects resulting from treatment through a metal intramedullary drill bit, which in turn, dramatically reduces the volume potentially harboring subclinical contamination from the drill path and subsequent intramedullary nail placement. A model-based dose calculation engine was commissioned using the IROC data-set. Additionally, the accuracy of dose calculations was verified at several distances from the source in water using a custom 3D-printed phantom with a series of concentric rings holding Gafchromic-EBT3 film. A separate set of films from the same batch was calibrated with a 6MV-LINAC beam. Treatment plans were generated for two different source configurations (a single dwell position and a linear array of dwell position) with a standard 4.7Fr catheter surrounded by the stainless-steel drill bit. Measurements were performed at 1cm, 2cm, 3cm, 4cm, and 5cm from the active source and compared with dose calculations from the TG-43 and Acuros algorithms. Without the drill bit surrounding the catheter, measurements were in good agreement with the dose calculated by the treatment planning system (<1.0% on average). The maximum dose deviation (1.5%) was observed at 1cm from the source, as expected due to the steep dose gradient. With the stainless-steel drill bit surrounding the catheter, the Acuros dose calculations agreed with film measurements (<1.5% on average) with the largest difference at 1cm (<2.5%). Using TG-43 for dose calculation, we observed larger deviations from measurements (average 6.3%). At larger distances, 5cm, the agreement is within <1% of the calculated dose by Acuros. A model-based dose calculation engine was commissioned using a consensus dataset. This dose engine was secondarily verified with film measurements about a linear catheter surrounded by a stainless-steel intramedullary drill bit for the purpose of facilitating accurate dose calculations for intraoperative HDR brachytherapy of long bone metastases.

Comparison of 3D Printed Spherical Implants versus Femoral Head Allografts for Tibiotalocalcaneal Arthrodesis

Successful tibiotalocalcaneal (TTC) arthrodesis can be difficult to achieve in patients with bulk bone defects even with the use of femoral head allograft. Retrograde intramedullary nail placement through custom 3-dimensional (3D) spherical implants is an innovative option for these patients. The purpose of this study was to compare fusion rates, graft resorption, and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant (n = 8) or femoral head allograft (n = 7) were included in this study. The rate of successful fusion of the tibia, calcaneus, and talar neck to the 3D sphere or femoral head allograft was compared between the groups. The rate of total fused articulations was significantly higher in the 3D sphere group (92%) than the femoral head allograft group (62%; p = .018). The number of patients achieving successful fusion of all 3 articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%, p = .22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p = .016). There were no significant differences between the groups in terms of complications. These data demonstrate that the use of a custom 3D printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail and may result in improved rates of successful arthrodesis.

Humeral intramedullary nail placement through the rotator interval: an anatomic and radiographic analysis

Antegrade humeral intramedullary nails are an effective fixation method for certain proximal humeral fractures and humeral shaft fractures. However, owing to potential rotator cuff damage during nail insertion, shoulder pain remains a common postoperative complaint. The purpose of this study was to provide quantitative data characterizing the anatomic and radiographic location of the rotator interval (RI) for an antegrade humeral intramedullary nail using a mini-deltopectoral approach. Six consecutive fresh-frozen intact cadaveric specimens (mean age, 69 ± 12.8 years) were obtained for our study. Demographic data were collected on each specimen. A mini-deltopectoral approach was used, followed by placement of a guidewire in the RI. Quantitative anatomic relationships were calculated using a fractional carbon fiber digital caliper. Radiographic measurements were performed by 2 orthopedic residents and 1 practicing fellowship-trained orthopedic surgeon. In addition to re-measurement of similar anatomic relationships on radiographs, the ratio of the distance from the lateral humeral edge to the starting point relative to the width of the humeral head on the anteroposterior (AP) view was calculated. Similarly, on the lateral view, the ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width was calculated. In all cases, the described approach allowed for preservation of the biceps tendon and access to the RI for guidewire insertion, with no subsequent rotator cuff or humeral articular cartilage damage identified following nail insertion. The ratio of the distance from the lateral humeral edge to the starting point relative to the humeral head width on the AP view was 0.4 ± 0.0. The ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width on the lateral view was 0.3 ± 0.0. This study demonstrates the clinical feasibility of a mini-deltopectoral approachand shows that the ideal starting point through the RI radiographically lies along the medial aspect of the lateral third of the humeral head on the AP viewand along the posterior aspect of the anterior third of the humeral head on the lateral view.

Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus

BackgroundNeurovascular insult, nonunion, and iatrogenic rotator cuff injury are concerns when using an intramedullary nail (IMN) for proximal humerus fracture. The purpose of this study was to identify a reproducible starting point and intraoperative imaging for nail insertion optimizing nail depth, tuberosity screw position, and protecting the axillary nerve and rotator cuff insertion. Our hypothesis was that a more medialized starting point would protect soft tissue structures and improve locking screw positioning.MethodsTen fresh-frozen cadavers underwent antegrade IMN with Grashey and modified lateral “precipice” view imaging. A guidewire was positioned medial to the coracoacromial ligament (CAL) in 5 cadavers and lateral to the CAL in 5. Distances from the nail entry point to anatomic landmarks were measured. Anatomic and histologic evaluations were performed, characterizing the nail perforation zone. Radiographs were compared between groups.ResultsThe medial CAL group had a greater distance of screw fixation to the axillary nerve, a shorter distance of greater tuberosity (GT) screw fixation at the rotator cuff insertion on the infraspinatus and teres minor tubercles, and greater screw spread with improved lesser tuberosity capture. Two laterally placed implants violated the rotator cuff tendon. Imaging demonstrated that the ideal starting pin position was medial to the articular margin at a distance equal to the width of the rotator cuff insertion footprint.ConclusionsMedial placement optimized fixation of the GT, avoided violation of the rotator cuff tendon and footprint, and was associated with an increased distance of proximal locking screw to the axillary nerve.

Extramedullary Motorized Lengthening of the Femur in Young Children.

Limb lengthening by distraction osteogenesis is now achievable via motorized intramedullary devices, mitigating many complications of lengthening by external fixation. In young patients, antegrade intramedullary nailing of the femur risks avascular necrosis of the femoral head. A method of extramedullary placement of a motorized expandable intramedullary nail has been employed by the senior author to safely achieve femoral lengthening without the use of an external fixator in young patients. Eleven skeletally immature patients with lower limb length discrepancy were reviewed who underwent extramedullary placement of a magnetic, expandable intramedullary nail for lengthening of the femur. Surgical details, lengthening parameters, and complications were reviewed and classified according to the modified Clavien-Dindo Classification. Average lengthening was 32.3 mm (range: 27 to 40 mm) comprising an average 14.8% of femoral segment length. The average lengthening duration was 6.3 weeks, and average full weight-bearing began at 12.6 weeks. All but 1 patient underwent early removal of the device at an average of 4.5 months, and 5 had immediate plating of the femur. Complications rates were comparable to other methods of femoral lengthening, including varus or procurvatum through the regenerate, and unplanned reoperation in 3 of 11 cases. Preoperative considerations included careful planning of implant length due to short femoral segments and protection of the knee joint from contracture or iatrogenic instability. Extramedullary placement of a magnetic expandable intramedullary lengthening nail can achieve lengthening of the femur without the use of external fixation. Considerations with this technique include careful planning of implant length relative to trochanteric-physeal distance, protection against knee subluxation during lengthening, and mitigating deformity of the regenerate. Off-label, extramedullary use of these devices can be considered to decrease the burdens of external fixation in young children. The technique begs the advent of future all-internal technology specifically designed for safe limb lengthening in this age group. Level IV-retrospective case series.

Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point.

Tibia fractures are common injuries that can often be effectively treated with intramedullary nail (IMN) fixation. The ideal starting point for IMN reaming and nail placement is well described and regarded as a crucial aspect in the technique. The purpose of this study is to determine the accuracy and precision with which the starting point is established and if this is maintained after nail insertion during fracture fixation. Fifty consecutive tibia fractures treated by IMN fixation sized 9 to 13 mm through an infrapatellar or medial parapatellar approach and 50 treated with a suprapatellar approach were evaluated. The starting point for reaming and IMN placement was measured using intraoperative fluoroscopy. Postoperative radiographs were used to determine the center of the IMN after placement. The distance between the measured points and the ideal starting point was measured. Deviation from the ideal entry point on intraoperative fluoroscopy averaged 4.6 ± 4.0 mm medially, 2.9 ± 3.7 mm anteriorly, and 2.7 ± 3.3 mm distally. In 30% of cases, the final IMN position varied from the entry point by greater than one SD in the coronal or sagittal plane. No difference between approaches was appreciated. Although the ideal starting point for tibial IMN fixation is known, this is frequently not the starting point accepted in practice. Final position of the IMN is independent of IMN size or approach and is not markedly different than the obtained starting point. Therapeutic level III.

Comparison of Custom 3D Printed Spherical Implants vs Femoral Head Allografts for Tibiotalocalcaneal Arthrodeses

Category:Ankle Arthritis, HindfootIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis, deformity correction and salvage of failed total ankle replacement. However, union can be difficult to achieve in patients with bulk bone defects. Femoral head allograft is commonly used in the setting of TTC fusion with severe bone loss, but recent studies have reported concerns of arthrodesis rates of 50% or worse and graft collapse in these patients. Retrograde intramedullary nail placement through custom 3D spherical implants is a novel option for these patients. The purpose of this study was to compare fusion rates, graft resorption and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts.Methods:All patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant or femoral head allograft by the senior author at a single institution from 2013 to 2017 and who had at least one year of follow-up were included in this study. There were 7 patients who received a femoral head allograft and 8 patients who received a 3D printed sphere. Baseline patient and operative characteristics were collected and compared between the 3D sphere and femoral head allograft groups. The rate of successful fusion of the tibia, calcaneus and talar neck to the 3D sphere or femoral head allograft, as determined by radiographs and CT scan, as well as graft resorption and complications were compared between the groups.Results:The rates of union of the tibia (87.5% vs 71.4%), calcaneus (87.5% vs 71.4%), and talar neck (100% vs 42.9%) were higher in the 3D sphere group than in the femoral head allograft group. The rate of union of the talar neck was significantly higher to the 3D sphere implant than to the femoral head allograft (p=0.016). The number of patients achieving successful fusion of all three articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%), although not statistically significant (p=0.22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p=0.016).There were no differences between the groups in terms of complications.Conclusion:These data demonstrate that the use of a custom 3D-printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail. The rate of successful fusion of all three tibial, calcaneal and talar neck articulations was higher to the 3D sphere than to the femoral head allograft, although not statistically significant. Union of the talar neck was significantly higher to the 3D sphere implants than it was to the femoral head allograft. Subsidence was significantly higher with the femoral head allograft than the 3D sphere.

A novel technique to prevent distal anterior femoral cortical perforation

Background: Anterograde femoral intramedullary nailing is a commonly used operative technique in orthopaedic surgery. Of its related complications, distal femoral anterior cortical breach is of special concern. Methods: We describe the steps of an anterograde femoral intramedullary nailing surgical technique performed on three patients to mitigate their risk of developing an anterior distal perforation of the femoral cortex. Results: All patients presented with a proximal intertrochanteric femoral fracture and underwent an intramedullary femoral nail placement. They all had an anatomic reduction radiographically. No complications intraoperatively or at last follow-up were recorded. Conclusions: By surgically redirecting the guidewire posteriorly before placing the nail in its desired position, our surgical technique prevents the anterior intramedullary nail abutment against the femoral cortex and the risk of anterior femoral cortical perforation. Level of Evidence: V.

Safe Placement of Intramedullary Nail and Inter-Physician Variability in Guidewire Placement in Retrograde Tibiotalocalcaneal Fusions

Retrograde tibiotalocalcaneal arthrodesis is a salvage procedure for severe arthrosis and deformity of both the tibiotalar and subtalar joints and requires image-confirmed placement of a retrograde guidewire. The anatomical shape of the calcaneus creates a situation in which guidewire placement can be skewed on imaging based on the angle of either internal or external rotation. As a result, the aims of our study were to (1) determine the optimal angle(s) of rotation required to accurately depict guidewire placement on imaging and (2) evaluate and describe the effects angle of rotation has on physician assessment of guidewire placement. Using a C-arm x-ray, images of cadavers with both correctly and incorrectly placed guidewires were taken at 5° increments of internal and external rotation of the cadaveric lower extremity and assessed for accuracy of guidewire depiction. The images revealed that the correctly placed guidewire appeared displaced medially at angles of 35° and 40° of external rotation. Conversely, the incorrectly placed guidewire appeared to be correctly placed at between 10° and 40° of external rotation. These images were then disseminated to various physicians including orthopedic surgeons and podiatrists to determine the ability of physicians to correctly appreciate guidewire placement. Using the responses from 35 physicians, it was found that certain angles of internal and external rotation preclude physicians from correctly determining guidewire placement. We found, based on chi-square analysis, that we were able to reject our null hypothesis with a p value of <.001 leading to the conclusion that indeed angle of rotation and guidewire placement can lead to false depictions of guidewire placement. In conclusion, our study gave objective measurements to guide foot placement during tibiotalocalcaneal fusion to decrease the risk incorrectly depicted medial guidewire placement and subsequent incorrect intramedullary nail placement.

Effect of Radiation Field Size and Dose on Local Control or Re-fracture Events after Post-Operative Radiation Following Intramedullary Nailing Procedures for Palliation of Bone Metastases

Pathologic fracture of long bones carries a heavy symptomatic burden in patients with metastatic malignancy. Standard therapy typically includes intramedullary nail placement to stabilize the bone, followed by palliative post-operative radiation therapy (PORT) to reduce the risk of re-fracture or local recurrence. The radiation dose and fields for this treatment approach have wide variation without uniform standards. We sought to estimate the distribution of PORT dose/fractionation, and field size, and estimate any potential association with the risk of re-fracture and/or local recurrence. We retrospectively analyzed patients treated at our institution with pathologic fractures of long bones, treated with intramedullary nailing of the femur, tibia, or humerus, followed by post-operative palliative radiation to that site. We stratified patients by radiation fractionation (single vs multi-fraction regimen) and by radiation field size (coverage of whole hardware [full-field] vs partial coverage of hardware [limited field]), to determine if these factors may be associated with the primary endpoint, which was defined as local re-fracture and/or local recurrence of disease within the long bone. Fisher’s exact test was used for statistical comparison due to the relative paucity of events. Eighty-six evaluable patients, treated between 2010 and 2017, were identified. Median patient age was 60 years. Median Karnofsky performance status was 70. Median follow up was 2.6 months (range, 2 weeks to 74 months). Radiation doses ranged from 8 – 30Gy, apart from one patient who received 45Gy in 3 Gy fractions. Thirty-six patients (42%) received 8 Gy in a single fraction, and fifty (58%) received multi-fraction treatment. Ten patients (12%) underwent limited field radiation, while 47 (55%) underwent full field radiation, and 29 (34%) were unevaluable for field size. Nine patients (10%) reached the primary endpoint of local recurrence and/or local refracture, consistent with historical comparison. On Fisher’s two-sided exact test, field size was not found to correlate with local recurrence/re-fracture (p=0.366). Local recurrence/re-fracture was also not significantly associated with multi-fraction radiation, compared to those who received 8 Gy in a single fraction, although was numerically worse in the multifraction group (p=0.073). Increased total dose beyond 8 Gy was not associated with improvement in local control. Similarly, irradiation of the entire hardware was not associated with improved rates of local control as compared to limited field radiation. Our findings suggest that single-fraction, limited-field palliative PORT may be sufficient to achieve adequate rates of local control, thereby allowing for expedient initiation of systemic therapy and minimal RT toxicity. Further evaluation is needed.

Huge Pseudoaneurysm of the Femoral Artery after Internal Fixation of Femoral Trochanteric Fracture

Pseudoaneurysm is one of the most serious complications of femoral trochanteric fracture surgery. Since the rupture of pseudoaneurysm may lead to death, early detection is important. We report the case of an 80-year-old male who developed pain in the proximal thigh and severe swelling after internal fixation of a femoral trochanteric fracture with a hip nail. Angiography revealed a pseudoaneurysm of a branch of the deep femoral artery near the interlocking screw. The vascular lesion was immediately treated by transcatheter embolization, and the vascular leakage was completely resolved with catheter embolization. After embolization, the patient's clinical state improved rapidly, and the laboratory values improved to normal after several weeks. The current case study reminds us that pseudoaneurysm can occur after intramedullary nail placement to treat a femoral trochanteric fracture.