Three-point Fixation Research Articles

Stem and Osteotomy Length are Critical for Success of the Transfemoral Approach and Cementless Stem Revision

The transfemoral approach is an extensile surgical approach that is performed routinely to facilitate cement and implant removal and improve exposure for revision stem implantation. Previous studies have looked at clinical results of small patient groups. The factors associated with fixation failure of cementless revision stems when using this approach have not been examined. We determined (1) the clinical results and (2) complications of the transfemoral approach and (3) factors associated with fixation failure of revision stems when using the transfemoral approach. We retrospectively examined all our patients in whom femoral stem revision was performed through a transfemoral approach between December 1998 and April 2004 and for whom a minimal followup of 2 years was available. One hundred patients were available for this study. The mean (± SD) postoperative followup was 5 years (± 1.64 years). The average Harris hip score improved from 45.2 (± 14.02) preoperatively to 83.4 (± 11.86) at final followup. Complete radiographic bony consolidation of the osteotomy site was observed in 95% of patients. Dislocations occurred in 9% of patients. Four revision stem fixation failures were observed, all occurring in patients with primary three-point fixation. Three-point fixation was associated with short osteotomy flaps and long revision stems. The transfemoral approach is associated with a high rate of osteotomy flap bony healing and good clinical results. When using the transfemoral approach, a long osteotomy flap should be performed and the shortest possible revision stem should be implanted. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Percutaneous elastic intramedullary nailing of metacarpal fractures: Surgical technique and clinical results study

BackgroundWe reviewed our results and complications of using a pre-bent 1.6 mm Kirschner wire (K-wire) for extra-articular metacarpal fractures. The surgical procedure was indicated for angulation at the fracture site in a true lateral radiograph of at least 30 degrees and/or in the presence of a rotatory deformity.MethodsA single K-wire is pre-bent in a lazy-S fashion with a sharp bend at approximately 5 millimeters and a longer smooth curve bent in the opposite direction. An initial entry point is made at the base of the metacarpal using a 2.5 mm drill by hand. The K-wire is inserted blunt end first in an antegrade manner and the fracture reduced as the wire is passed across the fracture site. With the wire acting as three-point fixation, early mobilisation is commenced at the metacarpo-phalangeal joint in a Futuro hand splint.The wire is usually removed with pliers post-operatively at four weeks in the fracture clinic.ResultsWe studied internal fixation of 18 little finger and 2 ring finger metacarpal fractures from November 2007 to August 2009. The average age of the cohort was 25 years with 3 women and 17 men. The predominant mechanism was a punch injury with 5 diaphyseal and 15 metacarpal neck fractures. The time to surgical intervention was a mean 13 days (range 4 to 28 days). All fractures proceeded to bony union. The wire was extracted at an average of 4.4 weeks (range three to six weeks). At an average follow up of 8 weeks, one fracture had to be revised for failed fixation and three superficial wound infections needed antibiotic treatment.ConclusionsWith this simple and minimally invasive technique performed as day-case surgery, all patients were able to start mobilisation immediately. The general outcome was good hand function with few complications.

Endoprothetischer Glenoidersatz mit Rekonstruktionsschale (EPOCA RECO®)

Alleviation of pain, restoration of function and active range of motion in the shoulder in case of cuff tear arthropathy. Cuff tear arthropathy with an insufficient coracoacromial arch and salvage operation of failed hemiprosthesis or reverse shoulder prosthesis. Active or chronic infections. Lesions of the plexus. Insufficiency of deltoid muscle or subscapularis muscle. Neurologic diseases. Young active patients. Deltopectoral approach. Resection of the humeral head and removal of the failed implant, respectively. Periarticular arthrolysis with preservation of neurovascular structures. Exposure of the glenoid and three-point fixation of the reconstruction socket (EPOCA RECO) at the glenoid, the acromion and the coracoid process. Cemented fixation of the polyethylene inlay. Cemented or cementless implantation of the humeral stem in 25 degrees retroversion related to the long axis of the forearm. Reconstruction of the subscapularis muscle. Bedding of the arm in a Gilchrist brace. Passive and active- assisted exercises including continuous passive motion. From 2002 to 2007, a total of 35 reconstruction sockets (EPOCA RECO) were implanted in 34 patients (six men, 28 women - one bilateral implantation was performed at an interval of 8 months in a female patient). Five EPOCA RECO implants had to be removed due to major complications. Three patients died, another three patients refused the follow-up examination. The remaining 23 patients (three men, 20 women, average age at the time of surgery 76 years [64-88 years]) were examined 2 years (4-60 months) postoperatively. The preoperative gender-related Constant Score was 21 and improved significantly (p < 0.001) to 58 postoperatively. The pain was significantly reduced. Range of motion for active elevation, internal and external rotation was improved (preoperatively/ postoperatively): elevation 37.2 degrees/65 degrees; internal rotation 14.8%/50%; external rotation 11.3%/47.5%. All patients would undergo the operation again. Overall, there were five major and two minor complications (complication rate 20%).

Arthroscopic three-point double-row repair for acute bony Bankart lesions

After mobilizing anteroinferior osseous Bankart lesion from the glenoid neck, a suture anchor loaded with differently colored non-absorbable braided sutures is placed on the medial edge in the glenoid neck along the rim fracture through the anterior-inferior trans-subscapularis tendon portal. Two same-colored suture limbs on the anchor are then pulled through the labrum using PDS suture shuttling simultaneously. These steps are repeated for the others suture limbs. The two same-color suture limbs located inferiorly are retrieved using the trans-subscapularis tendon portal. Both suture strands are threaded through the eyelet of a PushLock anchor on the distal end of the driver. The anchor is advanced into the pilot hole completely. These steps are repeated for a second anchor at the upper edge of the fracture in the glenoid rim using the anterior portal. This technique confers effective, firm fixation of the bony Bankart lesion by three-point fixation without the suture material crossing the glenoid cavity.

Bilateral atlas laminar hook combined with transarticular screw fixation for an unstable bursting atlantal fracture

The unstable atlas burst fracture ("Jefferson fracture") is a fracture of the anterior and posterior atlantal arch with rupture of the transverse atlantal ligament and an incongruence of the atlanto-occipital and the atlanto-axial joint facets. The posterior atlantoaxial fusion is frequently used to reconstruct the stability of atlantoaxial joint. Conventional posterior atlantoaxial fixations are associated with high rates of pseudoarthrosis and chronic atlantoaxial instability. As a modified three-point fixation the bilateral C1-2 transarticular screws combined with C1 laminar hook and bone grafts can provide best biomechanical stability, but no standard protocol has been reported for the use of this fusion technique. A retrospective review of clinical series should be conducted to evaluate the clinical outcome of bilateral atlas laminar hook combined with transarticular screw fixation for unstable bursting atlantal fracture. From March 2002 to March 2006, there were total 12 cases of unstable atlantal bursting fractures, 10 males and 2 females, age ranging 18-54, with mean of 36 years old. All patients were operated on posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation after atlantoaxial joint were reduced and followed up for 12-24 months. The medical records and radiographs of the 12 patients were reviewed. Each patient underwent a complete cervical radiograph series including lateral flexion-extension view and a computed topographic scan. The Frankel grades and ASIA scores were applied to assess the neurologic status. In all patients, a good bony fusion of the atlanto-axial segment was achieved. All patients showed significant improvement of the neurologic defect and no instability on their follow-up plain radiographs and computerized tomography in follow-up interval. For the patients who suffer from the unstable bursting atlantal fracture, the nonoperative methods could carry some clinical complications including infection, nerve injury, etc. and is frequently failure, Posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation is an effective treatment.

New Forceps and Spatula for Easy Retropupillary Implantation of Iris Claw Lenses in Aphakia: Experience in 4 Years of Use

Retropupillary implantation of an iris claw lens offers a rapid and atraumatic approach for rehabilitation of aphakic eyes. The difficulty in the implantation process arises because of the possibility of losing the intraocular lens (IOL) into the vitreous cavity and the need to change the hand holding the forceps during the enclavation. The new forceps design radically changes the method of grasping an IOL. It contains an extendable supporting plate with a hook-like end. The instrument achieves a horizontal three-point fixation at the edge of the implant in the 6 and 12 o''clock position in order to prevent slippage into the vitreous cavity during the inclination. The supporting plate also has a horizontal mark to facilitate the centration of the IOL behind the pupil level. A long vitreoretinal-type shaft has been turned 90 degrees to exclude the possibility of an accidental release during implantation. A special slender long spatula with an internal twist enables one-hand enclavation through the same side port without the need to change the hand holding the forceps. The author has implanted over 100 iris claw IOLs during the last 4 years without any intraor postoperative complications. The new forceps and spatula enable safe, easy, and rapid implantation of iris claw IOLs into the retropupillary space.

Operative management for atlantoaxial instability in case of bilateral high-riding vertebral artery

In case of atlantoaxial instability dorsal C1-C2 screw fixation is the most appropriate procedure to get immediate and sufficient three-point fixation. However, this method cannot be performed in bilateral high-riding vertebral arteries because of high risk of VA injury. In a 66-year-old woman who presented with neck pain due to atlantoaxial instability bilateral high-riding VAs were detected in CT. To avoid VA injury a dorsal stabilization procedure with a hook-rod system and interspinous autologous iliac crest graft was performed. The intra- and postoperative courses had no complications and the hook-rod construction clinically led to immediate postoperative stability. After 24 months the patient was painfree. In case of atlantoaxial instability and bilateral high-riding VAs dorsal C1-C2 fixation procedure with a hook-rod system and interspinous bone grafting seems to be an appropriate alternative surgical technique and can get immediate and clinically sufficient stability with no risk of VA injury.

Un système calibre de positionnement de l’opéré pour PTH

Component malpositioning in total hip arthroplasty (THA) may lead to dislocation of the prosthesis. Improper positioning of the patient on the table has been noted as one of the reasons for component malpositioning. Lateral position is routinely used for posterior approach to the hip and is also commonly employed for the lateral approach to the hip. We describe the use of a calibrated patient positioning device employing three-point fixation of the pelvis to keep the patient in the lateral position thus removing one of the factors for component malpositioning in total hip arthroplasty.

Rigid internal fixation of zygoma fractures: A comparison of two-point and three-point fixation

Background: Displaced fractures of the zygomatic bone can result in significant functional and aesthetic sequelae. Therefore the treatment must achieve adequate and stable reduction at fracture sites so as to restore the complex multidimensional relationship of the zygoma to the surrounding craniofacial skeleton. Many experimental biophysical studies have compared stability of zygoma after one, two and three-point fixation with mini plates. We conducted a prospective clinical study comparing functional and aesthetic results of two-point and three-point fixation with mini plates in patients with fractures of zygoma. Materials and Methods: Twenty-two patients with isolated zygomatic fractures over a period of one year were randomly assigned into two-point and three-point fixation groups. Results of fixation were analyzed after completion of three months. This included clinical, radiological and photographic evaluation. Results: The three-point fixation group maintained better stability at fracture sites resulting in decreased incidence of dystopia and enophthalmos. This group also had better malar projection and malar height as measured radiologically, when compared with the two-point fixation group. Conclusion: We recommend three-point rigid fixation of fractured zygoma after accurate reduction so as to maintain adequate stabilization against masticatory forces during fracture healing phase.

Rigid internal fi xation of zygoma fractures: A comparison of two-point and three-point fi xation

ABSTRACT Background:Displaced fractures of the zygomatic bone can result in significant functional and aesthetic sequelae. Therefore the treatment must achieve adequate and stable reduction at fracture sites so as to restore the complex multidimensional relationship of the zygoma to the surrounding craniofacial skeleton. Many experimental biophysical studies have compared stability of zygoma after one, two and three-point fixation with mini plates. We conducted a prospective clinical study comparing functional and aesthetic results of two-point and three-point fixation with mini plates in patients with fractures of zygoma.Materials and Methods:Twenty-two patients with isolated zygomatic fractures over a period of one year were randomly assigned into two-point and three-point fixation groups. Results of fixation were analyzed after completion of three months. This included clinical, radiological and photographic evaluation.Results:The three-point fixation group maintained better stability at fracture sites resulting in decreased incidence of dystopia and enophthalmos. This group also had better malar projection and malar height as measured radiologically, when compared with the two-point fixation group.Conclusion:We recommend three-point rigid fixation of fractured zygoma after accurate reduction so as to maintain adequate stabilization against masticatory forces during fracture healing phase.

C1 lateral mass screws for posterior segmental stabilization of the upper cervical spine and a new method of three-point rigid fixation of the C1-C2 complex

To describe our experience with C1 lateral mass screws as part of a construct for C1-2 stabilization and report an alternate method of C1-C2 complex three-point fixation. All patients that had at least one screw placed in the lateral mass of C1 as part of a construct for stabilization of the C1-C2 complex entered this study. In selected patients who had a higher chance of nonunion an alternate construct was used: transarticular C1-C2 screws combined with C1 lateral mass screws. Twenty-one C1 lateral mass screws were placed in 11 patients. In three patients the alternate construct was used. All patients had a demonstrable solid and stable fusion on follow-up. C1 lateral mass screws are safe and provide immediate stability. The use of C1-C2 transarticular screws combined with C1 lateral mass screws is a feasible and also an excellent alternative for a three-point fixation of the C1-C2 complex.

Three-Point Fixation of Stomach to Abdominal Wall in the Percutaneous Endoscopic Gastrostomy Procedure

Three-Point Fixation of Stomach to Abdominal Wall in the Percutaneous Endoscopic Gastrostomy Procedure

Role of transarticular screw fixation in tuberculous atlanto-axial instability

Prospective study of 27 consecutive cases of tuberculous atlanto-axial instability operated between 1998 and 2003. Early surgical stabilization of tuberculous atlanto-axial instability has gained popularity. This is largely due to success of chemotherapy in rapid control of infection. Although selective atlanto-axial fusion techniques are advocated in other indications, their role in tuberculosis remains confined to atlanto-axial wiring techniques that are mechanically unsound. The role of three-point rigid fixation using trans-articular screws (TAS) remains unclear. The objectives of this study are: (1) To define the role of trans-articular screws in tuberculous atlanto-axial instability based on radiological criteria. (2) To attempt to separate patients that can be treated by selective atlanto-axial fixation as against the standard occipito-cervical fusion (OCF). (3) Compare the clinical and radiological outcome parameters between the two groups. Twenty-seven consecutive patients of tuberculous atlanto-axial instability were operated between 1998 and 2003. The pattern of articular surface destruction and the reducibility of the atlanto-axial complex were assessed on plain radiographs and MRI. The reducibility of the C1-C2 joint was graded as reducible, partially reducible and irreducible. Pattern of the C1-C2 articular mass destruction was grouped as minimal, moderate and severe. The patients were divided into two surgical groups based on radiological findings and were treated with TAS (n=11) and OCF (n=16) fusion. The three-point fixation provided by the TAS allowed early brace free mobilization by 3 months with fusion rate of 100%. Fusion occurred in 83.16% in the OCF group. Implant failure occurred in two patients who underwent OCF. The patient satisfaction rate in the TAS group and the OCF group was 90.90 and 62.50%, respectively. Results in 27 consecutive patients demonstrate improved patient fusion and satisfaction rates in the TAS group. Judicious selection of patients for TAS fixation is possible with relatively few complications in tuberculosis of the atlanto-axial complex. This, however, requires a thorough understanding of the MRI pattern of involvement of the atlanto-axial complex that is difficult in non-endemic areas.

Posterior atlantoaxial three-point fixation: comparison of intraoperative performance between open and percutaneous techniques

Atlantoaxial instabilities, which require surgical fixation follow a variety of clinical disorders. Different surgical procedures are used for stabilization of the atlantoaxial complex, mainly posterior wiring techniques and transarticular screw fixation. Nowadays, often a combination of transarticular screws and a posterior one-point fixation is used to achieve a three-point fixation, with superior biomechanical stability and good clinical results. Different modifications were developed to improve this technique. In 1995, a percutaneous approach for atlantoaxial stabilization was introduced. In clinical studies, the technique showed a tendency towards better outcome. Beside the outcome, the intraoperative performance is of special interest for minimal invasive approaches. We therefore compared the operation time, screw angulation and blood loss, between the open and percutaneous posterior atlantoaxial techniques. Two groups, each consisting of 17 patients, with either open (group 1) or percutaneous (group 2) atlantoxial stabilization, were compared. The operation time was retrospectively acquired from the patient's charts. The data for blood loss was provided by our anaesthesiological department, separated for intraoperative, postoperative and total blood loss. Screw angulation was measured on the postoperative x-ray by an orthopaedic surgeon. The percutaneous group showed an average intraoperative blood loss of 239.7 ml, compared to 929.4 ml for the open group (p< or =0.001). The analogue values for the postoperative blood loss were 142.9 ml and 379.4 ml for group 2 and group 1, respectively (p=0.008). Consecutively, the total blood loss showed also a statistically significant difference (p< or =0.001). The operation time was significantly different (p< or =0.001), with average values of 175.3 min (group 1) and 110.6 min (group 2). Screw angulation showed a trend towards a steeper angulation in the percutaneous group with an average angle of 56.8 degrees , compared to 53.9 degrees (group 1), although this was not statistically significant (p=0.053). The percutaneous technique for atlantoaxial stabilization with a three-point fixation has clear intraoperative benefits, with shorter operation time and reduced blood loss. A trend towards steeper screw angulation was found and shows at least equal feasibility for transarticular screw placement with the percutaneous technique, compared to the standard open approach.

A Modification of the Mayfield Horseshoe Headrest Allowing Pin Fixation and Cranial Immobilization in Infants and Young Children

Pin fixation and rigid immobilization of the head is desirable in many neurosurgical procedures. However, these techniques are associated with complications in infants and young children. A simple modification of a commonly used cranial fixation system allows rigid, safe immobilization of the head in infants and children. A standard Mayfield horseshoe headrest and cranial fixation system was adapted to allow simultaneous use of the headrest and three-point pin fixation. The system is compatible with most neuronavigational systems. The combined horseshoe and pin system was used successfully in more than 30 patients ranging in age from 6 months to 14 years. No complications were encountered. Rigid immobilization is achievable in the pediatric population, facilitating intracranial and frameless stereotaxy procedures.

Elastic fixation of the diaphyseal fractures of the femoral bone in children

The standard treatment of most fractures of the femoral bone in children was conservative. There are a variety of circumstances (polytrauma, head injury, open fracture, vascular injuries, impossibility of the satisfactory reposition by traction) that require surgical operation. The aim of this study is the appreciation of the diaphyseal fractures' fixation using the elastic pins. We propose the experience of the use of the elastic pins in nine patients (seven boys, two girls) aged from 7 to 12 years, with closed fractures of the femoral bones' diaphysis, who were treated by close reposition method with following elastic pins' fixation. The causes of the trauma were the results of traffic incidents: six cases (66%), street incidents: three cases (34%), fall from a height. Six patients had a polytrauma and three had the isolated trauma. All fractures were closed, transverse or oblique-transverse. The time of stay in the hospital from admission to surgery was 1.5–15 hours. During the first week the patients were in a bed regimen, beginning from the second week their ambulation was exercised with crutches. Hospital stays lasted from 12 to 29 days (average 15.7 bed-days). The complete load was allowable in 8 weeks after surgery. One case demonstrated a reverse prolapse of the pins in 4 months, which were removed because of the fracture's fusion. There were no other complications. All fractures knitted well during 8–10 weeks. The observation time was from 8 to 26 months. We used the ESIP principle in the treatment of femoral fractures by two elastic pins in children aged from 7 to 12 years. This method allows one to combine stable and elastic immobilization. The stability is achieved not only by pins, but by the surrounding soft tissue. The bone forms the axial stability in the cortical contact when the pins are fixed in the metaphysis. Rotation stability is created using the incurvated pins that compose the three-point fixation. Elastic mobility allows one to have the determined motion amplitude at the fracture's site, stimulating callus formation.

Retroperitoneoscopic nephropexy for symptomatic nephroptosis using a modified three-point fixation technique

Introduction Laparoscopy has been reported as a minimally invasive approach for performing nephropexy in patients with nephroptosis. We evaluated our results after retroperitoneoscopic nephropexy using a modified three-point fixation technique. Technical Considerations Twelve women presenting with flank pain and radiologically documented nephroptosis underwent retroperitoneoscopic nephropexy. After complete dissection of the perirenal fat from the kidney, three nonabsorbable (Ethibond-0) sutures were placed on the posterior renal capsule between the upper pole, middle part, and lower pole of the kidney and the psoas muscle. The average operative time was 91 minutes (range 50 to 180), and the mean estimated blood loss was less than 50 mL in all patients. Postoperative urography revealed complete resolution of nephroptosis in all cases. On a comparative pain analog score patients had 84% improvement (range 0% to 100%). Nine patients had complete resolution of their pain, and two had improvement of 70% to 80%. One patient did not have any improvement. The mean follow-up time was 3.4 years (range 0.5 to 5.5). Conclusions Retroperitoneosopic nephropexy with a modified three-point fixation technique of the upper posterior pole, middle part, and lower pole of the kidney to the psoas muscle is a rapid and effective minimally invasive procedure for treating symptomatic nephroptosis with excellent intermediate-term results.

Treatment of Zygomatic Fractures Without Inferior Orbital Rim Fixation

Zygomatic fractures can be associated with functional and esthetic problems. Recent improvements in surgical techniques and materials have enabled stable fixation of zygmomatic fractures. Multiple-point fixation is most commonly used for internal fixation. Generally, reduction and fixation are performed through lateral brow, subciliary, temporal, or intraoral incisions (three-point fixation). Our experience indicates that postoperative scarring and sensory disturbances are caused by a subciliary incision with inferior orbital rim fixation. It is thus recommended that inferior orbital rim fixation with mini- or microplates be avoided. In patients in whom the fracture does not involve the orbital floor, reduction of the zygoma and zygomatic arch through a temporal incision is performed at this institution. Fixation of the lateral zygomaticomaxillary buttress and anterior wall of the maxilla with miniplates through an intraoral incision is also performed. If necessary, zygomaticofrontal suture fixation with a miniplate or wire is performed through a lateral brow incision. The status of inferior orbital rim reduction is confirmed by palpitation. Inferior orbital rim fixation with mini- or microplates is recommended for reduction of comminuted fractures and orbital floor fractures with herniation of internal orbit components. Patients who did not undergo inferior orbital rim fixation were free of inferior orbital rim deformity, diplopia, and postreduction rotation.

A Comparison of Combinations of Titanium and Resorbable Plating Systems for Repair of Isolated Zygomatic Fractures in the Adult

Multiple studies have sought to determine the postreduction stability of internal fixation in zygomaticomaxillary complex (ZMC) fractures. Three-point fixation with titanium miniplates is increasingly recommended to repair these injuries. Use of bioresorbable plates has been suggested to eliminate potential postoperative hardware complications. By quantitatively comparing different combinations of titanium and resorbable plating systems, this study attempts to demonstrate which combinations will provide stable fixation of the fractured ZMC. Osteotomies were performed on 40 zygomas in 20 fresh-frozen cadaver skulls, simulating noncomminuted ZMC fractures. The control group (group 0) consisted of titanium plates at the zygomaticofrontal (ZF) suture, infraorbital rim (IOR), and zygomaticomaxillary buttress (ZMB). Group 1 consisted of titanium plates at the ZF and IOR, and a resorbable plate at the ZMB. Group 2 used a titanium plate at the ZF, and resorbable plates at the IOR and ZMB. Group 3 consisted of resorbable plates at the ZF, IOR, and ZMB. A mechanical test system was used to apply loads in the vectorial direction of the masseter. Critical forces and patterns of hardware failure were recorded. Group 0 failed at a mean force of 589 +/- 146 N (60 kg). Group 1 failed at a mean force of 507 +/- 124 N (52 kg). No statistically significant differences between groups 0 and 1 were found. The mean force required for failure in groups 2 and 3 was lower. Differences in the force required for failure between groups 2 and 3 and the control group was significant (P <0.05). Failure patterns were analyzed. The ZF plate tended to stretch predominantly in groups 1, 2, and 3, whereas it tended to break in group 0 (P = 0.005). The IOR plate demonstrated predictable screw failure in groups 2 and 3 (P = 0.007). For group 0, the ZF was the site of the majority of critical failures. For groups 2 and 3, the IOR was almost invariably the site of critical failure (P = 0.004). At the ZMB, there was no significant association between failure modes and it was rarely the site of critical failure, regardless of the method of fixation. However, the strength of fixation was proportional to the number of titanium plates used. Overall, the method of fixation significantly affected the force required for mechanical failure of ZMC fractures (P <0.0001). The presence of teeth significantly increases the force required for implant failure in ZMC fracture fixation when combinations of plates are used (P = 0.038). All combinations of titanium and resorbable plates may be sufficient to overcome the displacing forces produced by the masseter and may be used for internal fixation of isolated ZMC fractures in the adult.

A flexible intramedullary nails for fractures in children.

©2004 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.86B7. 15273 $2.00 J Bone Joint Surg [Br] 2004;86-B:947-53. Over the past few years there has been a marked increase in the use of intramedullary fixation in the management of fractures of long bones in children. To some extent this reflects a more interventionist attitude among paediatric orthopaedic surgeons but is also due to technical developments, notably that of the elastic stable intramedullary nail (ESIN). The use of intramedullary devices to stabilise fractures is not new. In the mid-19th century, ivory pins were used for this purpose and were then gradually supplanted by various metal devices.1 These were generally rigid implants, although more flexible ones were introduced in in the 1930s. The school of rigid intramedullary fixation was typified by the Kuntscher nail, which achieved great stability in all planes by occupying the entire medullary cross-sectional area of the bone.2 However, its use in growing children was limited by the difficulties encountered in trying to avoid the physes. The Rush nail was introduced at about the same time as the Kuntscher nail.3 It was the forerunner of modern elastic intramedullary fixation in that the objective was to achieve three-point fixation on the inner aspect of the cortex. Unlike the stiff Kuntscher nail, the Rush nail was slightly flexible and it was intended that it should be pre-bent to the appropriate configuration before insertion.3 Rotational stability was poor, however, and in most situations the flexibility was insufficient to allow insertion points in the metaphysis which were well away from the active physis in children. Others, such as Hackethal4 and Marchetti,5 used bundles of thinner wires which filled the medullary cavity but with stabilisation achieved by splaying the ends of the wires within the bone well beyond the fracture. Ender6 developed this further with his nails, which were the first to feature adaptations to both ends of the nail in order to improve both control of insertion and quality of fixation. These nails could be safely inserted into the metaphysis which made them suitable for consideration in paediatric fractures. In the early 1980s, surgeons in Nancy, France, developed an elastic stable intramedullary nail based on a theoretical concept by Firica.7 Previous experience had suggested that elasticity and stability were not easily combined in one construct. However, working from the concept of three-point fixation used with a single Rush nail, these surgeons were able to improve stability significantly by using two pre-tensioned nails inserted from opposite sides of the bone. Metazieau, Ligier and their colleagues7 were able to show that titanium nails which were accurately contoured and properly inserted could impart excellent axial and lateral stability to diaphyseal fractures in long bones. Rotational stability was also better than had previously been experienced, although this was to remain the weakest point of the technique. The use of titanium nails allowed greater elasticity than was available in the steel nails of the Ender system. Most contemporary work on flexible intramedullary nailing in children’s fractures is based on the Nancy experience, although there remain pockets of Ender and Marchetti enthusiasts. For the purposes of this review, flexible intramedullary nailing is taken to mean elastic stable intramedullary nailing using the concepts espoused by the Nancy group.