Retrograde Locked Intramedullary Nailing Research Articles

Preliminary Experience With Commercially Available Trabecular Metal Tibial Cones Combined With a Retrograde Locked Intramedullary Nail for Bony Defects in Tibiotalocalcaneal Arthrodesis.

Critical sized bone defects in the ankle are becoming increasingly more common in patients undergoing limb reconstruction with tibiotalocalcaneal arthrodesis. Bulk allografts have not fared well over time. There have been scattered preliminary reports using custom spinal cages or 3D-printed Titanium Implants to address the critical bony defect; however, the cost of these devices is prohibitive in many clinical practice settings. The purpose of this investigation is to report the preliminary experience using a commercially available Trabecular Metal (Zimmer-Biomet) tibial metaphyseal cone combined with a retrograde locked intramedullary nail to address this challenging problem. Eight consecutive patients underwent tibiotalocalcaneal arthrodesis using a commercially available Trabecular Metal tibial metaphyseal cone combined with a retrograde locked intramedullary nail. Five developed bone loss secondary to neuropathic (Charcot) bony resorption and 3 underwent surgery for failed total ankle arthroplasty. All 8 patients eventually achieved clinical and radiographic healing and were able to ambulate with standard footwear. One patient developed a postoperative wound infection at the site of calcaneal locking screws, which resolved with debridement and parenteral antibiotic therapy. Critical bone defects about the ankle have successfully addressed with custom 3D titanium implants. This small series suggests that similar clinical outcomes can be achieved with the use of a commercially available porous tantalum metaphyseal spacer borrowed from our arthroplasty colleagues, combined with the use of a retrograde locked intramedullary nail.Levels of Evidence: Level 4: Retrospective case series.

Comparative study of two retrograde locked intramedullary nail designs for ankle arthrodesis: A finite element analysis.

Ankle arthrodesis is the gold standard for treatment of end-stage arthritis. The goal of ankle arthrodesis is to obtain bony union between the tibia and the talus. Retrograde intramedullary nailing is typically reserved for ankle and subtalar joints arthrodesis. The purpose of this study is to evaluate the effect of two different materials, two locking pin configurations and two nail designs of a retrograde locked intramedullary nail used for ankle arthrodesis. Using the finite element analysis, a numerical study of ankle arthrodesis was developed to evaluate the effect of materials: TI-6Al-4V and stainless steel AISI 316 LVM; two locking pin configurations: five and six pins, on two intramedullary nails: Ø10 × 180 mm and Ø11 × 200 mm. A model of a healthy foot was created from tomographic scans. It was found that the mechanical stimulus required to achieve bone fusion were higher for Ø10 × 180 nails (6.868 ± 0.047) than the Ø11 × 200 nails (5.918 ± 0.047; p < 0.001; mean ± SEM). We also found that six-pin configuration had a higher mechanical stimulus (6.470 ± 0.047) than the five-pin configuration (6.316 ± 0.046; p = 0.020). Similarly, it was higher for titanium (6.802 ± 0.047) than those for stainless steel (5.984 ± 0.046; p < 0.001). Finally, the subtalar zone presented higher values (7.132 ± 0.043) than the tibiotalar zone (5.653 ± 0.050; p < 0.001). The highest mechanical stimulus around the vicinity of tibiotalar and subtalar joint was obtained by Ø10 × 180 nails, made of titanium alloy, with 6P.

Locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, fracture table and power reaming: retrograde affords greater procedural efficiency than antegrade approach.

To compare the intraoperative procedural efficiency of antegrade and retrograde locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, power reaming devices and fracture tables. A secondary analysis of prospectively collected data was conducted on 238 isolated diaphyseal femur fractures fixed with SIGN Standard and Fin nails within three weeks of injury. The data included baseline patient and fracture characteristics, nail type and diameter, fracture reduction methods, operative times and outcome measures. There were 84 and 154 fractures in the antegrade and retrograde groups respectively. Both groups were similar vis-a-vis baseline patient and fracture characteristics. Closed reduction of the fractures was significantly easier for retrograde than an antegrade approach. The retrograde approach more readily permitted the use of Fin nails. The mean nail diameter used for retrograde was significantly larger than that for antegrade. The time taken to achieve retrograde nailing was significantly lesser than that of antegrade. There was no statistically significant difference between the outcomes of the two groups. In the absence of expensive fracture-surgery gadgets, retrograde nailing offers many procedural advantages over antegrade, such as easier closed reduction and canal reaming, the greater possibility of using the Fin nail with fewer interlocking screws and shorter operative times. However, we acknowledge the lack of randomisation and the presence of an unequal number of fractures in the two groups as limitations of this study.

FUNCTIONAL OUTCOME OF ANTEGRADE AND RETROGRADE INTRAMEDULLARY INTERLOCKING NAIL FOR THE TREATMENT OF SHAFT OF HUMERUS FRACTURE - A PROSPECTIVE COMPARATIVE STUDY

Background: Antegrade or retrograde locked intramedullary nailing are both effective treatments for humeral shaft fractures; however, these two techniques have not been sufciently compared. In this study, mid humeral shaft fractures treated with these two strategies using the identical locking nails were evaluated for efcacy and potential risks. 50 fractures in 50 Methodology: patients with humerus mid-shaft fractures were randomly assigned to get either antegrade or retrograde locked nailing using sealed-envelope method in this prospective comparative research. Clinical outcomes including fracture healing time, complications, functional recovery of the elbow and shoulder, and time for functional recovery were evaluated. There was no statistically signicant difference in the time of union i Results: n this trial, with an average of 13.6 weeks in the Antegrade group and 14 weeks in the Retrograde group. The two treatment groups in the current research were similar in terms of demographics, fracture patterns, surgical indications, and treatment. The antegrade nailing patients regained functional recovery faster while comparing to retrograde nailing patients. Antegrade nailing is advised for patients with proxima Conclusion: l fractures, young age and patients with tiny medullary canal whereas retrograde nailing is advised for fractures which are distal with broad medullary canal or prior shoulder issues. Due to less complications of elbow stiffness , shortened surgery duration, early functional recovery and since humerus generally tends to have narrow medullary canal we conclude that antegrade nailing is favoured over retrograde nailing for patients with humerus shaft fractures.

Retrograde Intramedullary Interlocking Nailing in Fractures of the Distal Femur: A Review of 20 Cases with an Average Follow-Up of One Year

Objectives: In patients with distal femur fractures, we studied the role of retrograde locked intramedullary nails. Methods: Retrograde locked intramedullary nailing was used to treat the distal femur fractures of 20 patients (15 males, 5 females; mean age 47 years; range 25 to 69 years). Two patients had fracture of the distal femur and shaft. The fractures were classified as A1 (n=12), A2 (n=6), A3 (n=2), by the AO classification. There were two Grade I open fractures and 18 closed fractures. Three fractures were managed with percutaneous technique. At the mean first follow-up time of 18 months (range 15-48 months and mean second follow up at 27 months (range 12 to 68 months), the concluding functional results were assessed by using the modified Hospital for Special Surgery (HSS) knee assessment scale. Results: The average time to achieve union was 24.2 weeks (range 14 to 42 weeks). One patient had a delayed union (44 weeks). Five knees (25%) had normal joint range of motion, ten knees (50%) were having range of motion from 100° to 110°, three knees (15%) were having range of motion of 80°, and two knees (10%) were having range of motion below the 80°. According to the modified HSS knee scale, the results were excellent in eleven cases (55%), good in six (30%), moderate in two (10%), and poor in one case (5%). In two patients (10%), the postoperative radiographic examination revealed varus angulation (10°), healing took place with severe distortion in one subject. None of the patient had any deep infection or wound issues. Conclusion: Retrograde femoral nailing is an effective method for treating distal femoral shaft fractures. The healing rate of femoral shaft fractures fixed with a retrograde nail is the same regardless of fracture location, patient age, gender, or degree of comminution. For good results surgical treatment, post-surgery immediate knee mobilisation and avoiding nail tip prominence in the knee are essential.

Diagnosis and Treatment of Neuropathic Ankle Fractures.

Standard 3-view ankle radiographs are the first-line imaging modality for suspected neuropathic ankle fractures. Computed tomography is helpful to evaluate for concomitant osseous changes and soft-tissue infection. Nonoperative management may be considered for low-demand, elderly, or comorbid patients for whom surgery and anesthesia are contraindicated. However, the presence of comorbidities alone should not necessarily preclude operative intervention. Given the overall poor results of nonoperative treatment in the neuropathic ankle fracture population, operative intervention may in fact be less risky to the patient. The authors have 2 preferred treatment techniques. For cases in which the vascular supply and bone stock are adequate, open reduction and internal fixation (ORIF) with locking fixation for the fibula, a medial buttress/hook plate with lag screws for the medial malleolus, multiple syndesmotic screws for additional fixation even in the absence of a syndesmotic injury, and temporary transfixation Steinmann pins from the calcaneus into the tibia are used. For cases in which there is a concern for wound healing or previously failed ORIF, minimally invasive surgical tibiotalocalcaneal arthrodesis with a retrograde locked intramedullary nail is used.

Tibiotalocalcaneal Fusion With Antibiotic Cement-Coated Nails for Refractory Deep Infection After Ankle ORIF.

Deep infection after open reduction internal fixation (ORIF) of ankle fractures represents a challenge to the orthopaedic surgeon, particularly in patients in whom conventional surgical treatments have failed. The aim of this study was to assess the results of a modified technique of tibiotalocalcaneal fusion using a retrograde locked intramedullary nail covered in cement with antibiotics. Six patients treated using the authors' technique were analyzed retrospectively. All patients had deep infection after ankle osteosynthesis and several surgical procedures (debridement, external fixation, etc) had failed. Radiographs were analyzed to confirm the healing of the bone. Outcome was measured by maintained construct stability and eradication of infection (no clinical signs of infection and normal values of laboratory markers). The average age of the series was 64.2 (range, 50-75) years, and the average follow-up period was 19.5 (range, 8-41) months. Tibiotalocalcaneal stability and eradication of the infection were achieved in all patients, along with the normalization of clinical and radiologic parameters. In the patient who underwent a talectomy, one of the calcaneal locking screws broke, with no clinical repercussions. Tibiotalocalcaneal fusion with antibiotic cement-coated retrograde nails was useful in providing clinically acceptable results in the control of chronic infection in complex patients after the failure of previous surgeries. Level IV, therapeutic study.

Bilateral symmetrical humeral fracture on a background of multiple myeloma and humeral capillary hemangioma

A 59-year-old female who was managed for multiple myeloma presented with spontaneous bilateral pathologic fracture of the distal third of both humeri. She had associated renal impairment and background diabetes mellitus. Biopsy of her bone specimen from surgery shows features in keeping with capillary hemangioma. The patient was properly optimized for surgery; she was reviewed by a nephrologist and endocrinologist before surgery. Her blood investigations showed that she was anemic. She was transfused with fresh whole blood and also had renal dialysis. She subsequently was offered bilateral retrograde locked intramedullary nailing of both humeri, which was done 2 weeks apart under regional anesthesia (brachial plexus block). There was profuse intraoperative bleeding, which was controlled with bone wax and electrocautery. Biopsy of her bone specimen from surgery shows that she also has osseous capillary hemangioma rather than the provisional diagnosis of bilateral pathological fracture of the humerus following extramedullary manifestation of multiple myeloma. There have been suggestions in the literature that extra manifestations of multiple myeloma simulating hemangioma may be due to neoangiogenesis propagated by myeloma cells secreting vascular endothelial growth factor. We present a case of multiple myeloma with renal failure that presented to us with bilateral humeral fracture with a histological report of capillary hemangioma. We suggest that tumor-neoangiogenesis may be responsible for this type of manifestation. This case is a rare coincidental finding which has not been reported in literature, hence the objective of this presentation.

Deformity and Clinical Outcomes Following Surgical Correction of Charcot Ankle

Category:Ankle, Ankle Arthritis, Diabetes, Hindfoot, TraumaIntroduction/Purpose:Deformity associated with Charcot Foot Arthropathy leads to a poor quality of life in affected individuals. Deformity in the midfoot appears to be predictive of clinical outcomes following surgical correction. The goal of this retrospective study was to determine if that same methodology could be applied to patients treated for Charcot Foot Arthropathy involving the ankle joint.Methods:Fifty-six consecutive patients underwent surgical reconstruction of Charcot Foot deformity involving the ankle joint by a single surgeon over a fourteen year period. Preoperative patient characteristics and tibiotalar alignment, were recorded. Surgical treatment included single stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present (39 of 56, 69.6%) or retrograde locked intramedullary nailing in the absence of infection (17 of 56, 30.3%). Clinical outcomes were graded based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with therapeutic footwear or accommodative orthoses. The average follow-up was 7.5 (range 1.1-14.0) years.Results:One patient died at 134.3 weeks following surgery of unrelated causes and 8 underwent amputation. Twenty eight of 56 patients (50.0%) achieved a favorable (excellent or good) clinical outcome. There was no significant association between preoperative or postoperative alignment and clinical outcomes. Insulin-dependent diabetics were approximately 3 times more likely to have a poor clinical outcome.Conclusion:Surgical correction of Charcot deformity involving the ankle joint was associated with a high complication rate and risk for failure. The lessons learned from this highly co-morbid patient population with complex deformities can be used as a benchmark for applying modern surgical techniques.

Ankle fusion following failed initial treatment of complex ankle fractures in neuropathic diabetics

BackgroundUnstable ankle fractures in diabetics with peripheral neuropathy have an increased risk of postoperative complications, often leading to amputation. Primary ankle arthrodesis has been suggested as an alternative when acceptable reduction and mechanical stabilization cannot be obtained. MethodsOver a fourteen year period, thirteen diabetic patients with peripheral neuropathy underwent an attempt at primary ankle arthrodesis following the early post-fracture development of acute neuropathic (Charcot) deformity of the ankle after sustaining a low energy unstable ankle fracture. Eight patients with open wounds and osteomyelitis underwent single stage debridement of the osteomyelitis and primary ankle fusion with an ankle fusion construct circular external fixator. Five patients without evidence of infection underwent primary arthrodesis with a retrograde locked intramedullary nail used for fixation. A successful clinical outcome was achieved with either successful radiographic arthrodesis or stable pseudarthrosis, when community ambulation was achieved with commercially-available therapeutic footwear and a short ankle orthosis. ResultsEight of the thirteen patients achieved a successful clinical outcome at a mean follow-up of 48 (range 12–136) months following the initial surgery. Three achieved clinical stability following a second surgery and one following a third. One patient with radiographic nonunion expired due to unrelated causes. One patient underwent transtibial amputation due to persistent infection. Of the five patients with failure of radiographic union, three successfully ambulated in the community with a short ankle orthosis. Postoperative complications included wound and pin-site infection, infected nonunion, chronic wounds, and tibial stress fracture. ConclusionIn spite of the high risk for complications and initial failure, primary ankle fusion is a reasonable option for diabetic neuropathic patients who develop acute neuropathic arthropathy following ankle fracture.Level of evidence: Level IV retrospective case series.

Deformity and Clinical Outcomes Following Operative Correction of Charcot Ankle.

Deformity associated with Charcot foot arthropathy leads to a poor quality of life in affected individuals. Deformity in the midfoot appears to be predictive of clinical outcomes following operative correction. The goal of this retrospective study was to determine if that same methodology could be applied to patients treated for Charcot foot arthropathy involving the ankle joint. Fifty-six consecutive patients underwent operative reconstruction of Charcot foot deformity involving the ankle joint by a single surgeon over a 14-year period. Preoperative patient characteristics and tibiotalar alignment, were recorded. Surgical treatment included single-stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present (39 of 56, 69.6%) or retrograde locked intramedullary nailing in the absence of infection (17 of 56, 30.3%). Clinical outcomes were graded based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with therapeutic footwear or accommodative orthoses. The average follow-up was 7.5 (range 1.1-14.0) years. One patient died at 134.3 weeks following surgery of unrelated causes and 8 underwent amputation. Twenty-eight of 56 patients (50.0%) achieved a favorable (excellent or good) clinical outcome. There was no significant association between pre- or postoperative alignment and clinical outcomes. Insulin-dependent diabetics were approximately 3 times more likely to have a poor clinical outcome. Operative correction of Charcot deformity involving the ankle joint was associated with a high complication rate and risk for failure. The lessons learned from this highly comorbid patient population with complex deformities can be used as a benchmark for applying modern surgical techniques. Level IV, case series.

Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures

Category: Ankle Introduction/Purpose: Distal fibula fractures are most commonly fixated with plate and screw constructs. Conversely, modern generation fibular intramedullary nails are load-sharing devices that offer rigid internal fixation via percutaneous technique with only transaxial screws residing subcuticularly. The relative risk of damage to nearby structures is well characterized for plate and screws constructs; however, no such data is available for fibular nails. As a result, the purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a current generation retrograde locked intramedullary fibular nail. Methods: This was an IRB-exempt study. Ten human cadaveric lower extremities were instrumented with a contemporary retrograde locked intramedullary fibular nail with three distal locking and two syndesmotic fixation options. The cadavers were then dissected by a single experienced orthopedic foot and ankle surgeon in a standardized fashion. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (i.e. sural nerve, superficial peroneal nerve and the peroneal tendons) was measured and recorded. Levels of risk were then assigned based on observed distances as high (0 to 5 mm), moderate (5.1 to 10 mm) and low (greater than 10 mm). Results: The peroneus brevis tendon was at high risk when making the distal skin incision in all specimens (Table). When reaming and inserting the nail through the distal fibula aperture, the peroneus brevis was at high risk in 7 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. Of note, no structures were observed to have been directly damaged. Conclusion: The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, thorough blunt spreading down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times. The current findings indicate that the peroneal tendons and superficial peroneal nerve are at the highest risk, and should be considered when performing relevant clinical outcomes studies.

Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures: A Cadaveric Study.

Retrograde intramedullary fibular nail fixation is being utilized with increasing frequency, particularly in patients at higher risk of wound complications. The purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a contemporary retrograde locked intramedullary fibular nail. Ten human cadaveric lower extremities were instrumented with a fibular nail. The cadavers were dissected. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (ie, sural nerve, superficial peroneal nerve, and the peroneal tendons) was measured and recorded. Levels of risk were assigned based on observed distances as high (0 to 5 mm), moderate (5.1-10 mm), and low (greater than 10 mm). The peroneus brevis (PB) tendon was found to be less than 5.0 mm from the distal skin incision in all specimens. When reaming and inserting the nail through the distal fibula aperture, the PB was less than 5.0 mm in 6 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. No structures were violated or damaged during any portion of the fibular nail instrumentation. The peroneal tendons and superficial peroneal nerve were at the highest risk; however, no structures were injured during instrumentation. The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, blunt dissection down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times.

Ankle fusion with a retrograde locked intramedullary nail for sequela of lower extremity compartment syndrome

ObjectiveTo assess the value of ankle fusion with a retrograde locked intramedullary nail in the treatment of sequela of lower extremity compartment syndrome. MethodsThirty-five cases of equinus deformity following tibiofibular compartment syndrome treated by means of ankle fusion with a retrograde locked intramedullary nail from January 2001 to December 2010 were retrospectively reviewed. The complications, the time needed for bony fusion of the ankle joint assessed by anteroposterior and lateral X-ray photographs as well as patients’ subjective evaluation were recorded and analysed. ResultsAmong the 35 patients, 15 had previously undergone surgical treatment twice on the same limb, 13 had thrice and 7 had to be operated on four times before ankle fusion. An anterior midpoint approach to the ankle joint was adopted in 29 cases, while anterior midpoint approach plus a small incision on the posterior ankle joint was made in 17 cases, whereas lateral approach in 6 cases. Tarsus joint fusion was performed on 4 cases. The follow-up period ranged 6-124 months, averaged 40.6 months. Bone grafting was not performed in this series. Preoperative tibial shaft fracture occurred in one patient and was healed after conservative treatment. Incision dehiscence located at previous Achilles tendon incision was found in two patients. As a result, one received an intramedullary nail emplacement at calcaneoplantar part while the wound at anterosuperior part of the other one was healed by dressing change. Two patients failed to bony union 5 months postoperatively, in which one healed 10 weeks after retrieval of proximal tibial nail and another by iliac grafting. Terminal necrosis of the toe due to blood supply dysfunction was not found in this series. All the patients were satisfied with the ankle joint function postoperatively. The time for bony union on X-rays was 9.8 weeks on average. Except for one patient who demanded removal of intramedullary nail, all the intramedullary nails were not retrieved at the end of follow-up. Nail breakage happened in one patient and no other breakage or backing out of the nail was found. ConclusionsLower extremity compartment syndrome and residual ankle deformity often extremely impact ambulation and are hard to deal with because several pathologic phenomena might exist in these patients, for instance, poor skin conditions due to repeated preexisting surgery; poor perfusion in distal limbs following blood vascular injury; reflux limitation and long-term limb swelling due to muscle strength disturbance; osteoporosis as a result of long-term immobilization or limb disuse. Ankle fusion with a retrograde locked intramedullary nail is an optimal protocol to solve these clinical symptoms and rather ensures a definite fusion and firm fixation to these patients with simple manipulation and few complications.

Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating.

To review the outcome of retrograde locked nailing for aseptic supracondylar femoral nonunions following failed locked plating. Records of 20 men and 4 women aged 20 to 57 (mean, 39) years who underwent retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating were reviewed. There were 20 closed and 4 open Gustilo type II or IIIA fractures secondary to motor vehicle accidents (n=21) or falls (n=3). Patients had undergone one to 3 operations. The mean time from injury to the present revision surgery was 1.3 years. No patient had a flexion contracture. The locked plate was removed and replaced with a retrograde dynamic locked nail (with or without buttress plate augmentation) followed by bone grafting. 17 men and 4 women were followed up for a mean of 3.4 years. The rest were lost to follow-up. The 21 patients achieved bone union after a mean of 4.3 months. The mean maximal knee flexion improved from 97.1º to 107.6º (p=0.03). Knee function was excellent in one, good in 15, and fair in 5 knees. The fair outcome was due to extension contracture, varus knee deformity, or knee pain. There were 3 malunions with varus deformity of 7º, 8º, and 9º each. No patient had deep infection causing a nonunion. All 21 patients could walk without aids. Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunions following failed locked plating achieved a high union rate.

Correction of femoral supracondylar varus malunions after condylar buttress plating by using retrograde locked intramedullary nailing.

The aim of this study was to evaluate the use of retrograde locked intramedullary nailing for the treatment of varus malunion occurring following condylar buttress plating (CBP) for femoral supracondylar fractures. The study included 32 consecutive adult patients treated with retrograde locked nailing for varus malunion of femoral supracondylar fractures following CBP. Patient results were evaluated based on healing time, lower extremity alignment and knee functions. Average follow-up was 2.8 (range: 1.1 to 5.6) years for the 27 of the 32 patients who completed follow-up. All osteotomy sites healed at an average of 4.0 (range: 3.5 to 5.0) months. Average preoperative varus knee deformity was 19.6° (range: 14° to 26°). Immediate postoperative varus knee deformity was an average of 0.4° (range: valgus 2° to varus 3°) (p<0.001). At the final follow-up, the varus knee deformity was an average of 1.5° (range: valgus 1° to varus 3°) (p<0.001). Satisfactory knee function in patients improved from 0% to 93% (p<0.001). There were no serious complications. Retrograde locked nailing appears to be an excellent alternative for the treatment of varus malunion of femoral supracondylar fractures after CBP treatment. It is a simple technique with high satisfaction rates.

Sa2.4 Combined intra- and extramedullary fixation for Charcot arthropathy – a promising concept?

Results: Average follow up period was 12 months (range 8–36). All nonunions healed without the need for further surgery and the union period was median 3.5 months (range, 3–9 months). No major surgical complications were noted. Conclusion: Although exchange nailing with antegrade insertion is the first choice in the treatment of femoral shaft aseptic nonunion, especially in the distal part of the femoral shaft a reamed retrograde locked intramedullary nailing seems to be an effective treatment method for recalcitrant nonunions.

The Development of a Neuropathic Ankle following Successful Correction of Non-Plantigrade Charcot Foot Deformity

The treatment of Charcot foot arthropathy has traditionally involved immobilization during the acute phase followed by longitudinal management with accommodative bracing. In response to the perceived poor outcomes associated with nonoperative accommodative treatment, many experts now advise surgical correction of the deformity, especially when the affected foot is not clinically plantigrade. The significant rate of surgical and medical-associated morbidity accompanying this form of treatment has led surgeons to look for improved methods of surgical stabilization, including the use of the circular ring external fixation. Over a 7-year period, a single surgeon performed surgical correction of non-plantigrade Charcot foot deformity on 171 feet in 164 patients with a statically applied circular external fixator. Following successful correction, five patients developed a neuropathic deformity of the ipsilateral ankle after removal of the external fixator and subsequent weight bearing total contact cast. Three of the five patients progressed to successful healing of the neuropathic (Charcot) ankle arthropathy following treatment with a series of weightbearing total contact casts. Two underwent successful ankle fusion with retrograde locked intramedullary nailing. This unusual clinical scenario likely represents either a progression of the disease process in the foot or a complication associated with surgical correction of the original neuropathic foot deformity. A better understanding of this observation will likely become apparent as we acquire more experience with this disorder.

Retrograde intramedullary interlocking nailing in fractures of the distal femur

We evaluated retrograde locked intramedullary nail applications in patients with distal femur fractures. Distal femur fractures of 16 patients (11 males, 5 females; mean age 45 years; range 25 to 69 years) were treated with retrograde locked intramedullary nailing. One patient had bilateral fractures. According to the AO classification, the fractures were A1 (n=8), A2 (n=4), A3 (n=4), and C1 (n=1). There were 13 closed (76.5%), and four open (23.5%) fractures. The mean time to surgery was 10 days (range 2 to 20 days). Open technique was used for nine fractures, and percutaneous technique for eight fractures. Preoperatively, three patients with a floating knee were evaluated with magnetic resonance imaging and were found to have a ruptured cruciate ligament. All patients underwent intraoperative knee examination, which showed a ruptured cruciate ligament in five patients. Functional results were assessed using the modified HSS (Hospital for Special Surgery) knee rating scale at the end of a mean follow-up period of 32.6 months (range (12 to 68 months). The mean time to union was 25 weeks (range 14 to 42 weeks). One patient had delayed union (42 weeks). Joint range of motion was normal in three knees (17.7%), was 100 to 110 degrees in nine knees (52.9%), 80 degrees in four knees (23.5%), and below 80 degrees in one knee (5.9%). According to the modified HSS knee scale, the results were excellent in five femurs (29.4%), good in six femurs (35.3%), moderate in five femurs, and poor in one femur (5.9%). Postoperative radiographic examination showed varus angulation (10 degrees ) in four patients (23.5%), and posterior angulation (10-20 degrees ) in four patients. In one patient, healing occurred with extreme deformation (30 degrees posterior angulation). None of the patients experienced wound site problems or infections. One patient developed deep vein thrombosis in the early postoperative period. Treatment of distal femur fractures with retrograde locked intramedullary nailing yields satisfactory results in adults.

Prospective Randomized Comparative Study of Antegrade and Retrograde Locked Nailing for Middle Humeral Shaft Fracture

Humeral shaft fractures can be effectively treated by either antegrade or retrograde locked intramedullary nailing, but these two methods have not been adequately compared. The present study compared the effectiveness and potential risks of these two approaches on middle humeral shaft fractures using the same locked nails. In this prospective comparative study, 92 fractures in 92 patients with middle humeral shaft fractures were randomly allocated to receive either antegrade or retrograde locked nailing by sealed-envelope technique. The clinical outcomes of fracture healing, time to healing, complications, elbow and shoulder functional recovery, and time for functional recovery were compared. Retrograde nailing required significantly longer time than antegrade nailing (64.8 vs. 51.3 minutes; p < 0.01) Except for three patients lost to follow-up, the average follow-up time was 18.6 months for 44 fractures in the antegrade group and 19.8 months for 45 fractures in the retrograde group. The fracture healed in 42 fractures (95%) in the antegrade group versus 42 fractures (93%) in the retrograde group, and this difference was not significant. After exclusion of two patients with brachial plexus injury and three with head injury, functional recovery was compared between 41 patients with antegrade and 43 with retrograde nailing. For shoulder joints, the difference in the average Neer shoulder score between the two groups was statistically significant (90.8 vs. 93.5; p = 0.03). However, if four elderly patients were excluded, the average score in the antegrade group was 91.9, and the difference became insignificant (p = 0.1). Still, the antegrade group needed significantly longer time for shoulder functional recovery (16.4 vs. 8.3 weeks; p < 0.01). For elbow joints, the average postoperative Mayo elbow performance score (96.3 vs. 94.8; p = 0.16) did not differ significantly between these two approaches, but the retrograde approach needed significantly longer time for elbow functional recovery (3.9 vs. 8.8 weeks; p < 0.01). All patients, except those with associated injuries, resumed their pretrauma occupations or activities. With proper patient selection, antegrade and retrograde nailing have similar treatment results, including healing rate and eventual functional recovery for middle humeral fractures. It is recommended that retrograde nailing be used in patients with a wide medullary canal or preexisting shoulder problems and antegrade nailing be used in patients with young age or a small medullary canal. In critically ill patients, antegrade nailing is preferred because of shorter operation time.