Retrograde Intramedullary Fixation Research Articles

Anatomic Structures at Risk When Utilizing Percutaneous Intramedullary Fibular Screw Fixation for Lateral Malleolus Fractures: A Cadaveric Study

Category: Ankle Introduction/Purpose: Isolated lateral malleolus fractures are a common ankle fracture that a foot and ankle surgeon will encounter. Retrograde intramedullary fixation for unstable lateral malleolus fractures has become a viable option for patients at higher risk for potentially devastating wound complications. The aim of this cadaveric study was to assess the relative risk of injuring adjacent anatomic structures with percutaneous implantation of an intramedullary fibular screw for lateral malleolus fractures to minimize iatrogenic injury. Methods: Seven fresh-frozen below-the-knee cadaver specimens were used for this study. Prior to investigations, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. Lateral dissection of the lateral malleolus was performed after screw placement to determine the proximity of the peroneus longus (PL), peroneus brevis (PB), and sural nerve (SN) to the inserted hardware. The mean, standard deviation, and range for distances were calculated for all structures. Analysis of variance (ANOVA) was used to determine statistical significance. Results: Percutaneous intramedullary fibular screw placement was performed in seven specimens, six females and one male, with an average age of 79.3 +- 8.1 years. Amongst the seven specimens, only one resulted in an injury to a structure of interest (sural nerve). The peroneus longus and peroneus brevis were not injured in any of the specimens. Table 1 shows the average distance between the guidewire and each structure of interest. Conclusion: This study shows the potential risks to lateral structures when placing an intramedullary fibular screw for unstable lateral malleolus fractures. We suggest that orthopedic surgeons exercise caution when performing critical steps of the procedure to minimize avoidable injury to structures of importance that may increase the morbidity of the patient.

Treatment of periprosthetic supracondylar fractures after CR total knee arthroplasty with retrograde intramedullary nailing in an elderly population: a long term evaluation.

Retrograde intramedullary fixation has been proposed to improve the rate of union providing greater stability in patients with a posterior cruciate ligament retaining femoral TKA component and decreasing soft-tissue trauma. This study assessed the clinical and radiographical outcome of retrograde intramedullary nailing (RIN) for the treatment of periprosthetic supracondylar fractures of the femur in an elderly population. Between January 2014 and December 2018, 16 patients with PSF underwent RIN. The clinical outcome was evaluated using the Knee Society Score (KSS) and the Short-form health survey (SF-12). The radiographic outcome was evaluated directly on the X-rays. Complications were also described. 13 patients (11 females and 2 males) with a mean age of 84 years old (range, 77-89) were evaluated clinically and radiographically, after a mean of 48.3 months (range, 24-73 months). The SF-12 scores were similar to normative values for subjects in the comparable age group. Radiographic union was obtained in all patients after an average of 14,8 weeks (range, 12-40 weeks) postoperatively. RIN is a safe and effective treatment for PSF, above all in the elderly population. The overall clinical and radiographic result was satisfactory.

Antegrade Intramedullary Fixation for Clavicular Shaft Fracture: A Technical Trick.

The standard open reduction and internal fixation technique with a plate and screws for a simple mid shaft clavicular fracture necessitates a relatively large incision and can also lead to variable amount of keloid scar formation. Historically, other techniques of more minimally invasive retrograde intramedullary fixation with the entry point posterolaterally on the shoulder have shown their own disadvantages and complications. We present a surgical technique of antegrade intramedullary fixation for mid shaft clavicular fractures and an illustrative case series.

Osteosynthesis of Fractures of the Metacarpal Neck with Self-Compressing Screw - Preliminary Analysis of 21 Cases.

Objective The present study aims to analyze the clinical results of the surgical treatment of metacarpal neck fractures with retrograde intramedullary fixation using cannulated headless screws (Herbert type). Methods Retrospective study of 21 closed fractures deviated from the metacarpal neck in 21 patients operated between April 2015 and November 2018. Results The sample included 19 men and 2 women. The mechanisms that caused the trauma were punching, falling to the ground and motor vehicle accident (n = 14, 5 and 2). The affected metacarpals were the 5 th , 3 rd , and 2 nd (n = 19, 1 and 1). Surgical indications were neck-shaft diaphysis of the metacarpal > 30° for the 2 nd and 3 rd metacarpals and > 40° for the 5 th metacarpal, shortening ≥ 5mm, rotational deviation, and the desire of the patient not to use plaster cast. In the immediate postoperative period, patients remained without immobilization and were instructed to mobilize their fingers according to tolerance. All patients had total active mobility > 240° and returned to their former occupations. All fractures consolidated and there were no reinterventions. Discussion The great advantages of the headless screw technique are its low morbidity, sufficient stability to avoid external immobilization, and reproducibility at low cost. Conclusion This is an easy, fast technique that has excellent results for the surgical treatment of displaced fractures of the neck of the metacarpals.

Structures at Risk with Plantar Approach Retrograde First Metatarsal Charcot Beam Screw Insertion

Category: Diabetes, Midfoot/Forefoot Introduction/Purpose: The plantar approach for medial column retrograde intramedullary fixation of Charcot midfoot deformity allows for easy access to the ideal starting point on the metatarsal head and is supported by good clinical outcomes data. The primary argument against this approach is iatrogenic damage to the plantar structures of the metatarsophalangeal joint (MTP), which could cause tendon imbalances resulting in hallux malleus deformity. However, thus far, such complications have rarely been reported. Based on available literature, it is unclear what types of plantar structure injury occur and at what frequency. The purpose of this study was to describe plantar first metatarsophalangeal joint structure damage caused by plantar approach retrograde intramedullary medial column beam fixation. Methods: This was an IRB-exempt study. For each of 10 human cadaveric specimens, a 6.5 mm cannulated screw system was used for plantar approach retrograde medial column intramedullary fixation. This entailed using fluoroscopy to percutaneously localize a 2.8-millimeter (mm) guide wire to the center-center position on the first metatarsal head and then advanced it into the center of the medial cuneiform. A small sagittal plane skin incision was made around the wire and subcuticular tissue was bluntly divided. Next, a 4.8-mm cannulated drill was passed through a drill sleeve over the wire. Then, a countersink was used without a tissue protector. Finally, the 6.5-mm screw was inserted until it was recessed beneath subchondral bone. The specimens were then dissected to evaluate damage to the plantar structures of the 1st MTP joint. Damage to named structures was categorized as none, less than 50%, greater than 50%, and 100%. Results: The plantar plate was less than 50% damaged in all specimens. The flexor hallucis longus (FHL) tendon had less than 50% damage in 8 specimens. In one of two specimens with greater than 50% FHL damage, the torn portion of the tendon was tenodesed to the first metatarsal head by the screw (Figure). Although the medial flexor hallucis brevis (FHB) tendon was less than 50% damaged in 3 specimens and undamaged in the remainder, the medial sesamoid was less than 50% damaged in 8 specimens. In contrast, less than 50% damage occurred to the lateral FHB and lateral sesamoid in only 2 and 3 specimens, respectively. Additionally, some erosion of the plantar base of the proximal phalanx was observed in one specimen. Conclusion: The plantar structures of the hallux MTP are a tightly constrained system, which are violated during plantar approach retrograde intramedullary medial column fixation. No structures were completely transected and high-grade damage (greater than 50%) was infrequent, occurring in only two FHL tendons. Low-grade damage (less than 50%) was frequently observed to involved the FHL, medial sesamoid, and plantar plate. Based on the current findings, an FHL splitting or preserving approach is advisable to avoid high-grade damage if plantar approach is desired. A dorsal arthrotomy approach avoiding plantar structures may also be considered.

Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density?

ObjectivesOsteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible.The aim of the present study was to biomechanically compare retrograde intramedullary fixation of the superior pubic ramus using either one large- or two small-diameter screws.Materials and MethodsA total of 12 human cadaveric hemipelvises were analysed in a matched pair study design. Bone mineral density of the specimens was 68 mgHA/cm3 (standard deviation (sd) 52). The anterior pelvic ring fracture was fixed with either one 7.3 mm cannulated screw (Group 1) or two 3.5 mm pelvic cortex screws (Group 2). Progressively increasing cyclic axial loading was applied through the acetabulum. Relative movements in terms of interfragmentary displacement and gap angle at the fracture site were evaluated by means of optical movement tracking. The Wilcoxon signed-rank test was applied to identify significant differences between the groupsResultsInitial axial construct stiffness was not significantly different between the groups (p = 0.463). Interfragmentary displacement and gap angle at the fracture site were also not statistically significantly different between the groups throughout the evaluated cycles (p ⩾ 0.249). Similarly, cycles to failure were not statistically different between Group 1 (8438, sd 6968) and Group 2 (10 213, sd 10 334), p = 0.379. Failure mode in both groups was characterised by screw cutting through the cancellous bone.ConclusionFrom a biomechanical point of view, pubic ramus stabilisation with either one large or two small fragment screw osteosynthesis is comparable in osteoporotic bone. However, the two-screw fixation technique is less demanding as the smaller screws deflect at the cortical margins.Cite this article: Y. P. Acklin, I. Zderic, S. Grechenig, R. G. Richards, P. Schmitz, B. Gueorguiev. Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density? Bone Joint Res 2017;6:8–13. DOI: 10.1302/2046-3758.61.BJR-2016-0261.

Retrograde Intramedullary Fixation of Long Bone Fractures Through Ipsilateral Traumatic Amputation Sites

The technique of retrograde intramedullary fixation of fractures through open traumatic amputations has not been previously described. We performed a retrospective case series at a tertiary-care military hospital setting. Ten patients met inclusion criteria. All were male, and all were injured through improvised explosive device. Outcome measures included the incidence of fracture nonunion, osteomyelitis or acute infection, heterotopic ossification (HO), as well as successful prosthesis fitting and ambulation. Average time to fixation after injury and amputation closure was 11.7 and 12.2 days, respectively. Follow-up averaged 20.2 months. The radiographic union rate was 100%, and time to osseous union averaged 7.5 months. One patient had an amputation site infection requiring revision, but none of the nails was removed for infectious reasons. HO occurred in 7 patients, and 2 patients required revision for symptomatic HO. All patients were successfully fitted with prostheses and able to ambulate. To our knowledge, this is the only series in the literature to specifically describe retrograde intramedullary fixation of long bone fractures through the zone of traumatic amputation sites. The infectious risk is relatively low, whereas the union rate (100%) and successful prosthesis fitting are high. For patients with similar injuries, retrograde intramedullary fixation through the zone of amputation is a viable treatment option.

Modified retrograde percutaneous intramedullary multiple Kirschner wire fixation for treatment of unstable displaced metacarpal neck and shaft fractures

The purpose of this prospective study was to evaluate the functional and radiographic outcomes of our new surgical technique, retrograde percutaneous intramedullary multiple Kirschner wire (K-wire) fixation, for the treatment of unstable displaced metacarpal neck or shaft fractures. Between March 2005 and April 2010, 56 consecutive patients with 65 metacarpal fractures were treated with closed reduction and retrograde intramedullary fixation with at least 2 K-wires. The average follow-up duration was 13 months. The clinical outcome was assessed by the total active motion (TAM) of the digit, presence of rotational deformity, grip strength, patient satisfaction, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. The radiographic outcome was assessed by the time to union, dorsal angulation, and shortening. The average operating time was 11 min (range, 6-17 min) for isolated single metacarpal fractures and 18 min (range, 13-25 min) for isolated simultaneous 2-metacarpal fractures. There was no significant difference in the average TAM of the digit between the injured and uninjured hands in both neck and shaft fractures. Four patients developed extensor tendon irritation during follow-up, but the irritations disappeared completely after removal of the wires, and there was no need to perform tenolysis. The average DASH score was 8.7 (range, 0-21). Radiographic union was achieved in all patients at a mean of 5.2 weeks. Radiographic assessment revealed a significant reduction in the average dorsal angulation to 8° (SD, 2) in neck fractures and to 4° (SD, 2) in shaft fractures postoperatively. The average shortening was corrected significantly to 1 mm (SD, 2) in neck fractures and to -1 mm (SD, 2) in shaft fractures postoperatively. Based on our experience, our retrograde intramedullary K-wire fixation technique is an acceptable alternative modality for the treatment of unstable displaced metacarpal fractures. This straightforward technique can facilitate early hand mobilization, correct the deformity, and provide good clinical and radiographic outcomes.

Prospective Multicenter Trial of Modified Retrograde Percutaneous Intramedullary Kirschner Wire Fixation for Displaced Metacarpal Neck and Shaft Fractures

The purpose of this prospective multicenter study was to assess the clinical and radiographic outcome of a newly devised technique of retrograde intramedullary fixation with multiple Kirschner wires in metacarpal neck and shaft fractures. Between May of 2002 and June of 2007, a total of 121 metacarpal fractures in 105 patients that were treated with the authors' modified intramedullary Kirschner wire fixation technique were included in this study. The average follow-up period was 10 months. The surgical outcome was assessed by clinical and radiographic data. The average range of motion in the metacarpophalangeal joint of the injured side was not significantly different from that of the uninjured side. There was no case of residual rotational deformity postoperatively, and the average Disabilities of the Arm, Shoulder and Hand questionnaire score was 8.5 (range, 0 to 41). Average dorsal apex angulation and average shortening were reduced significantly from 39.0 degrees and 3.1 mm, to 9.7 degrees and 0.0 mm, respectively, in neck fractures; and from 29.5 degrees and 3.0 mm, to 7.0 degrees and -0.1 mm in shaft fractures, respectively. Average time to union was 5.6 weeks, and there were no cases of nonunion. Modified retrograde intramedullary fixation with multiple Kirschner wires is a straightforward and reliable technique that successfully resulted in good functional and cosmetic results in addition to excellent bone healing. Therapeutic, IV.

Does fixation of femoral fractures using retrograde intramedullary nailing cause long-term knee pain: a systematic review of the literature

To perform a systematic review of the literature to discover if knee pain was a common complication in patients who underwent retrograde intramedullary fixation for femoral fractures and whether the pain persisted beyond fracture union and soft tissue healing. The literature search revealed eight articles which fit the inclusion criteria. These series were then compared and articles critiqued to allow conclusions to be drawn. Three articles compared antegrade and retrograde nails and five articles reviewed results of retrograde fixation only. Retrograde intramedullary nailing produced knee pain in 40-53% of patients compared with 20% in antegrade fixations during follow-up. These figures however, dropped substantially by final follow-up to 23-24% for retrograde and 12.5% for antegrade. Thirty-seven per cent of knee pain post operatively was associated with prominent metal work the majority of which resolved if the metal was removed. Retrograde intramedullary nailing for femoral fractures is associated with higher rates of anterior knee pain than antegrade nailing. Many cases of knee pain can be prevented with proper technique avoiding prominent metal work and many more cases settle in time with no intervention.

Fibular Rotational Osteotomy for the Treatment of Distal Tibial Osteochondroma: A Technical Modification for Deformity Correction and Improved Outcomes

The technique of choice for excision of osteochondromas located in the lateral aspect of the tibia is a transfibular approach to expose the lesion for resection. A drawback of this approach is that removal of the lesion leaves a void that may cause a visible deformity and adversely affect long-term function. Fibular rotational osteotomy followed by fibular graft may minimize the resultant deformity, producing a more satisfactory functional and cosmetic result. The authors report a retrospective case series consisting of 5 cases in which a fibular graft rotation was performed after rotational osteotomy via a transfibular approach. Retrograde intramedullary fixation by means of a Kirschner wire, in combination with the design of the fibular osteotomy, provided rotational graft and fibular stability until healing occurred.

Intramedullary Nail Fixation with Posterior-to-Anterior Compared to Transverse Distal Screw Placement for Tibiotalocalcaneal Arthrodesis: A Biomechanical Investigation

Biomechanical studies on retrograde intramedullary fixation for tibiotalocalcaneal fusion have been reported, but no studies have investigated dorsiflexion stiffness, load-to-failure, fatigue endurance, and plastic deformation using different distal screw orientations. Also, no studies have examined the effect of bone density on different distal screw orientations while using a fatigue loading mode. Eight matched pairs of cadaver legs were used. In one leg from each pair an intramedullary nail was inserted with lateral-to-medial distal screws and in the other with posterior-to-anterior screws. These samples underwent dorsiflexion fatigue testing with determination of initial and final stiffness, load-to-failure, and degree of plastic deformation at failure. DEXA scanning was done of each cadaver specimen to determine bone mineral density. Statistical analysis was performed using the Student t-test and a Pearson correlation. Significance level was set at p < 0.05. The specimens with posterior-to-anterior screws had a significantly higher fatigue endurance load-to-failure (1130.0 +/- 362.0 N compared to 801.0 +/- 227 N, p = 0.01). They also had significantly higher final stiffness (203.1 +/- 23.1 N/mm compared to 146.6 +/- 46.2 N/mm, p = 0.05) and lower plastic deformation (2.4 +/- 1.5 mm compared to 3.8 +/- 2.3 mm, p = 0.04). There was a statistically significant correlation between bone mineral density and the difference in construct deformation with posterior-to-anterior and lateral-to-medial screw orientation (r = 0.76, p = 0.03). In this biomechanical investigation of tibiotalocalcaneal arthrodesis with intramedullary nail fixation, posterior-to-anterior distal screw orientation provided more stable fixation than lateral-to-medial screw orientation.

Allograft Ankle Arthrodesis

Allograft ankle arthrodesis using a retrograde intramedullary tibial nail is a new strategy in limb salvage for treatment of distal intraarticular tibial tumors. After tumor resection, the ankle is reconstructed using an intercalary allograft and retrograde intramedullary fixation. We retrospectively reviewed nine consecutive patients with intraarticular resection of distal tibial tumors who had allograft ankle arthrodesis reconstruction between April 1994 and August 2000. Patient charts were reviewed for: (1) local recurrence, new metastases, and survival; (2) Musculoskeletal Tumor Society score; and (3) complications or reoperations or both. Only one of nine patients had a local recurrence. Eight of nine patients achieved independent ambulation. Eight of nine patients had a Musculoskeletal Tumor Society score greater than 73%. Six of nine patients required nine additional operations. No patients required flap coverage. There were no superficial or deep infections. Allograft ankle arthrodesis is a new alternative in limb salvage for distal tibial tumors. It has oncologic outcomes (rate of local recurrence, new metastases, and survival from time of diagnosis) and functional outcomes (Musculoskeletal Tumor Society score and rates of reoperation) comparable to previously reported and accepted methods of limb salvage. Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Intramedullary Wiring of Proximal Humerus Fractures

The treatment of proximal humerus fractures is a matter of continuing scientific discussion. This study presents our results with the use of retrograde intramedullary fixation as a minimally invasive, soft tissue-preserving treatment for two-part and certain three- and four-part fractures of the proximal humerus. Patients and Method: Between 01/1994 and 02/1998, 68 consecutive patients with 69 humeral head fractures were stabilized by retrograde intramedullary wiring. Fracture reduction was performed using a closed technique and stabilized with multiple intramedullary wires, which were inserted 2 cm above the olecranon fossa. All study patients had a minimum postoperative follow-up of 12 months. Results: From these 57 follow-up patients 65% had excellent Neer and Constant scores. 25% showed a satisfactory, 10% an unsatisfactory or poor result. Conclusion: Retrograde intramedullary wiring following closed indirect reduction is a minimally invasive treatment technique that preserves soft tissue and is especially useful for treating two- and minimally displaced three- and four-part proximal humerus fractures.

"Floating knee" injuries: ipsilateral fractures of the femur and tibia.

Ipsilateral fractures of the femur and tibia have been called "floating knee" injuries and may include combinations of diaphyseal, metaphyseal, and intra-articular fractures. These are often high-energy injuries and most frequently occur in the polytrauma patient. Many of these fractures are open, with associated vascular injuries. Surgical stabilization of both fractures and early mobilization of the patient and the extremity produce the best clinical outcomes. The use of a radiolucent operating room table and the introduction of retrograde intramedullary fixation of femoral fractures have facilitated surgical stabilization of some floating-knee fracture patterns. Although treatment planning for each fracture in the extremity should be considered individually to achieve the optimal result, the effect of that decision must be considered in light of the overall injury status of the entire extremity. Collateral ligament and meniscal injuries may also be associated with this fracture complex. Complications (such as compartment syndrome, loss of knee motion, failure to diagnose knee ligament injury, and the need for amputation) are not infrequent. Better results and fewer complications are observed when both fractures are diaphyseal than when one or both are intra-articular.

Hackethal nailing in closed transverse humeral shaft fractures after failed manipulation.

A study has been carried out of retrograde intramedullary fixation with flexible Hackethal nails for closed transverse fractures through the middle third of the humerus. Thirty fractures were treated during a period of 12 years. The average age of the patients was 45 years. After operation, a brace was used for an average of 4 1/2 months. Union occurred at an average of 10 weeks with one case of delayed union. There were no infections or nerve palsies. Hackethal nailing is effective for this type of fracture when manipulative reduction has failed.