Closed intramedullary nailing of the femur with a Kuntscher nail.
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Nail involvement in leprosy: a study of 300 patients.
Three hundred leprosy patients were recruited to study the pattern and frequency of nail changes. Nail changes, like longitudinal ridging in finger nails, transverse striations involving both finger and toe nails etc. which occurred with similar frequency in the PB and MB patients in comparison with the control group, were excluded from the analysis. Out of a total number of 150 PB patients, 84 (56%) showed nail changes. Fifty-eight (38.6%) patients showed changes in the finger nails, with an average of 3.2 involved nails per patient. Fifty-three (35.3%) patients showed changes in the toe nails, with an average of 3.0 nails per patient. The most common change observed was longitudinal melanonychia (32.4%) in the finger nails and longitudinal ridging (46.3%) in the toe nails.In comparison, 131/150 (87.3%) MB patients showed nail changes. Finger nail changes were seen in 102 (68%) patients with an average of 5.5 nails affected per patient. Changes in toe nails were seen in 116 (77.3%) patients, with an average of 6.0 nails involved per patient. The most common nail change observed was longitudinal melanonychia in 89/523, (17%) of the total involved finger nails and subungual hyperkeratosis in 164/702, (23.4%) of the total toe nails involvement. Out of a total of 32 colony patients, 31 (96.9%) showed nail changes both in finger and toe nails with an average of 7.9 and 8.4 affected nails per patient, respectively. The most common nail change observed was rudimentary nail(s) on fingers (29%) and toes (21.1%). Among MB patients, a significantly higher number had finger nail involvement in LL group. The frequency of nail involvement for both fingers and toes was significantly greater in LL as compared to BL group of patients. The frequency of nail involvement was significantly more in patients having disease for more than 5 years and in those having trophic changes secondary to loss of sensations and impaired circulation.
Adult↗
Condylocephalic nails versus extramedullary implants for extracapsular hip fractures.
BACKGROUND: Condylocephalic nails are intramedullary nails which are inserted up through the femoral canal from above the knee, for example Ender and Harris nails. OBJECTIVES: To compare condylocephalic nails with alternative implants (extramedullary implants such as fixed nail plates and sliding hip screws, or other intramedullary nails) for the treatment of extracapsular hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline (1983 to August 1999) and reference lists of relevant articles. Date of the most recent search: August 1999. SELECTION CRITERIA: Randomised or quasi-randomised trials comparing condylocephalic nails with other implants. DATA COLLECTION AND ANALYSIS: All reviewers independently assessed trial quality and extracted data. Data were pooled where relevant and possible. Ender nails and Harris nail data were presented separately. Results from fixed nail plates and sliding hip screws were sub-grouped to explore differences in these two implant types. MAIN RESULTS: Eleven trials were included. Ten compared Ender nails with either a fixed nail plate or a sliding hip screw. One compared the Harris condylocephalic nail with a sliding hip screw. The only advantages of condylocephalic nails were a reduced deep wound sepsis rate (0.9% versus 4.2%; odds ratio 0.26, 95% confidence interval 0.12 to 0.56), length of surgery and operative blood loss. However there was an increased risk of re-operation (20.9% versus 5. 5%; odds ratio 3.78, 95% confidence interval 2.67 to 5.36) and later fracture of the femur when compared with extramedullary implants. There was also an increased risk of cut-out of the implant from the femoral head for Ender nails compared with the sliding hip screw, but not for fixed nail plates. Backing out of the nail was a frequent complication (30%) of Ender nails and often resulted in revision surgery. Ender nails also had an increased risk of shortening of the leg and external rotation deformity and potentially a poorer return to previous walking ability. An increase in residual pain resulting from an excess of knee pain was also evident in patients undergoing condylocephalic nailing. There was no apparent difference in mortality between the condylocephalic nail and extramedullary implant groups. REVIEWER'S CONCLUSIONS: Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, re-operation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw. The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate.
Bone Nails↗
Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union.
OBJECTIVES: To investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunion after intramedullary (IM) nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing. DESIGN: Retrospective consecutive clinical series. SETTING: Level I trauma center and tertiary university hospital. PATIENTS: Twenty-three patients were identified whose radiographs failed to show progression of healing for four months after treatment with a reamed IM femoral nail. Nineteen patients had undergone primary IM nailing of an acute femoral shaft fracture, one patient had been converted to an IM nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing. INTERVENTION: All patients were treated by exchange reamed femoral nailing. The diameter of the new nail was one to three millimeters larger than that of the previous nail (the majority were two millimeters larger). The intramedullary canal was overreamed by one millimeter more than the diameter of the nail. Most of the nails were statically locked, and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed or by applying compression with a femoral distractor. MAIN OUTCOME MEASUREMENTS: Radiographic evaluation of union was determined by the presence of healing on at least three of four cortices. Factors reviewed included the patient's age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures. RESULTS: Tobacco use was found to have a detrimental impact on the success of exchange reamed nailing. All eight of the nonsmokers healed after exchange reamed nailing, whereas only ten of the fifteen smokers (66.7 percent) healed after exchange reamed nailing. Overall, exchange reamed femoral nailing was successful in eighteen cases (78.3 percent). Three patients achieved union with additional procedures. Intramedullary cultures were positive in five cases; all of these achieved successful union. CONCLUSIONS: Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed IM nailing has low morbidity, may obviate the need for additional bone grafting, and allows full weight-bearing and active rehabilitation. Tobacco use appears to have an adverse effect on nonunion healing after exchange reamed femoral nailing.
Adolescent↗
Nail transfer: evolution of the reconstructive procedure.
Reconstruction of a missing or deficient nail is an interesting and challenging undertaking for plastic surgeons, but little has been published concerning this topic. In the past 23 years, from 1973 to 1995, we performed 24 operations for nail reconstruction in 19 patients. A free nail graft was used in 14 operations, and a vascularized nail flap was used in 10. Vascularized nail flaps were divided into three categories: long-pedicle vascularized nail flaps (3 nails), vascularized nail flaps supplied by arterial inflow from the venous system (termed venous flaps, 3 nails), and short-pedicle vascularized nail flaps (4 nails). In only one case of free nail graft did the grafted nail necrose secondary to infection. The other 23 nails (13 free nail grafts, 10 vascularized nail flaps) survived completely, and good nail growth was obtained. With progress in plastic surgery, reconstructive procedures for nails have changed. In this paper, we will report the evolution of our reconstructive procedure and current strategy of nail reconstruction.
Adult↗
Nail lichen planus in children: clinical features, response to treatment, and long-term follow-up.
OBJECTIVE: To report clinical features, response to treatment, and long-term follow-up of nail lichen planus in children. DESIGN: Retrospective study involving 15 children with nail lichen planus. SETTING: Outpatient consultation for nail disorders at the Department of Dermatology of the University of Bologna, Bologna, Italy. PATIENTS OR OTHER PARTICIPANTS: We diagnosed nail lichen planus in 15 children younger than 12 years, including 10 children with typical nail matrix lesions, 2 children with 20-nail dystrophy (trachyonychia), and 3 children with idiopathic atrophy of the nails. Only 2 of the 15 children had oral lichen planus; none had cutaneous lesions. A nail biopsy confirmed the diagnosis in all cases. INTERVENTION: Intramuscular triamcinolone acetonide, 0.5 to 1 mg/kg per month, was prescribed to children with typical nail lichen planus and prolonged from 3 to 6 months until the proximal half of the nail was normal. No treatment was prescribed to patients with 20-nail dystrophy or idiopathic atrophy of the nails. RESULTS: Treatment with systemic corticosteroids was effective in curing typical nail lichen planus. Two children experienced a recurrence of the disease during the follow-up. Recurrences were always responsive to therapy. The 2 children with 20-nail dystrophy improved without any therapy. Nail lesions caused by idiopathic atrophy of the nails remained unchanged during the follow-up period. CONCLUSIONS: Nail lichen planus in children is not rare but probably underestimated. It often presents with atypical clinical features such as 20-nail dystrophy or idiopathic atrophy of the nails.
Child↗
Influence of flexible nailing in the later phase of fracture healing: strength and mineralization in rat femora.
In this experimental study, the influence of flexible nailing in the later phase of femoral fracture healing was investigated. Sixty rats were randomly assigned to three groups. In 20 rats no intervention was performed, and they served as a control group. Fracture and reamed nailing with a rigid steel nail was performed in the left femur in the other 40 rats. These rats were reoperated after 30 days, and the medullary nail was removed. In one group (20 rats) a flexible polyethylene nail was installed (flexibly nailed group), while the rats in the other group received a steel nail identical to the one that was removed (rigidly nailed group). At 60 and 90 days, the left femurs of 10 animals in each group were studied clinically, radiologically, and biomechanically, and bone mineralization was measured by dual-energy X-ray absorptiometry. Radiographs in two planes revealed a clearly visible fracture line in both intervention groups at 60 days. At 90 days, the fracture line was clearly visible in the flexibly nailed group, while bridging callus was apparent after the rigid nailing. At 60 and 90 days, the callus area in the flexibly nailed group was significantly larger than that in the rigidly nailed bones. Biomechanically, flexible nailing reduced maximum bending load and fracture energy at 60 and 90 days compared with findings in rigidly nailed bones, while bending rigidity was similar in the two groups. All values for biomechanical characteristics were reduced at 60 and 90 days in flexibly nailed bones compared with intact femurs, while in the rigid nailing group, bending load and fracture energy were similar to those in intact bones at 90 days. Bone mineral content in the callus segment and diaphysis was greater in the rigidly nailed bones than in the flexible nailing group at 60 days, while at 90 days, no differences were detected. In conclusion, this animal study indicates that: (1) flexible nailing in the later phase of fracture healing increases callus formation, while (2) the quality of bone healing is reduced.
Absorptiometry, Photon↗
An in vitro biomechanical comparison of two interlocking-nail systems for fixation of ostectomized equine third metacarpal bones.
OBJECTIVE: To compare the mechanical properties of 2 interlocking-nail systems for fixation of ostectomized equine third metacarpi (MC3): (1) a standard interlocking nail with 2 parallel screws proximal and distal to a 1-cm ostectomy; and (2) a modified interlocking nail with 2 screws proximal and distal to a 1-cm ostectomy with the screws offset by 30 degrees. ANIMAL OR SAMPLE POPULATION: Twelve pairs of adult equine forelimbs intact from the midradius distally. METHODS: Twelve pairs of equine MC3 were divided into 2 test groups (6 pairs each): torsion and caudocranial 4-point bending. Standard interlocking nails (6-hole, 13-mm diameter, 230-mm length) were placed in 1 randomly selected bone from each pair. Modified interlocking nails (6-hole, 13-mm, 230-mm length, screw holes offset by 30 degrees) were placed in the contralateral bone from each pair. All bones had 1-cm mid-diaphyseal ostectomies. Six construct pairs were tested in caudocranial 4-point bending to determine stiffness and failure properties. The remaining 6 construct pairs were tested in torsion to determine torsional stiffness and yield load. Mean values for each fixation method were compared using a paired t test within each group. Significance was set at P <.05. RESULTS: Mean (+/-SEM) values for the MC3-standard interlocking-nail composite and the MC3-modified interlocking-nail composite, respectively, in 4-point bending were: composite rigidity, 3,119 +/- 334.5 Nm/rad (newton. meter/radian) and 3,185 +/- 401.2 Nm/rad; yield bending moment, 205.0 +/- 18.46 Nm and 186.7 +/- 6.17 Nm; and failure bending moment, 366.4 +/- 21.82 Nm and 378.1 +/- 20.41 Nm. There were no significant differences in the biomechanical values for bending between the 2 fixation methods. In torsion, mean (+/-SEM) values for the MC3-standard interlocking-nail composite and the MC3-modified interlocking-nail composite were: composite rigidity, 135.5 +/- 7.128 Nm/rad and 112.5 +/- 7.432 Nm/rad; gap stiffness, 207.6 +/- 10.57 Nm/rad and 181.7 +/- 12.89 Nm/rad; and yield load, 123.3 +/- 2.563 Nm and 107.5 +/- 8.353 Nm, respectively. Composite rigidity and gap stiffness for standard interlocking-nail fixations were significantly higher than the modified interlocking-nail fixation technique in torsion. Yield load had a tendency to be higher for the standard interlocking-nail fixation (P =.15). CONCLUSIONS: No significant differences in biomechanical properties were identified between a standard interlocking nail and one with the screw holes offset by 30 degrees in caudocranial 4-point bending. The standard interlocking nail was superior to the modified interlocking nail in torsional gap stiffness and composite rigidity. The torsional yield load also tended to be higher for the standard interlocking nail. CLINICAL RELEVANCE: The standard interlocking nail with parallel screw holes is superior to a modified interlocking nail with the screw holes offset by 30 degrees in ostectomized equine MC3 bones in vitro when tested in torsion.
Animals↗
A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing.
OBJECTIVES: Antegrade femoral intramedullary nailing through a greater trochanteric insertion site has been proposed for the treatment of subtrochanteric fractures. The currently available trochanteric nails have dissimilar characteristics, and the most appropriate insertion site for satisfactory subtrochanteric fracture alignment has not been determined. This study is an analysis of 5 different trochanteric femoral nails and 3 different insertion sites using a cadaveric model of a reverse obliquity subtrochanteric femur fracture to determine the optimal trochanteric entry site. SETTING: OSHA-approved cadaveric laboratory with an OEC 9800 (General Electric Company, Fairfield, CT) fluoroscopic C-arm. METHODS: Twenty-one embalmed human cadaveric femurs were stripped of soft tissues. Three different starting points on the anteroposterior radiograph were used: at the tip of the greater trochanter, and 2 to 3 mm medial and lateral to the tip. A reverse obliquity subtrochanteric fracture was created. The Trochanteric Antegrade Nail (TAN), Gamma nail (2nd and 3rd generations), Trochanteric Fixation Nail (TFN), and the Holland Nail were then inserted. The proximal bend and radius of curvature were calculated for each nail. Varus and valgus angulation as well as lateral gapping were measured on radiographs; also calculated were the mean, range, and standard deviation. Statistical analysis was performed on angulation and gapping at the fracture site by using Fisher least significant differences analysis, based on a 2-way ANOVA test. RESULTS: The Holland nail had a proximal bend of 10 degrees and a radius of 300 cm. TAN was 5 degrees and 350 cm, TFN was 6 degrees and 150 cm, Gamma 2 was 4 degrees and 300 cm, and Gamma 3 was 4 degrees and 200 cm. The tip starting point led to the most neutral alignment regardless of nail. The lateral starting point led to varus with all nails. The medial starting point led to valgus of >6 degrees with the Holland and TFN; Gamma and TAN had better alignment with <4 degrees of valgus. Gapping of the lateral cortex was greatest with a lateral starting point. CONCLUSIONS: An analysis of 5 trochanteric intramedullary nails with different proximal bends and 3 different starting points in the greater trochanter showed that the tip of the trochanter is close to the "universal" starting point. In this cadaveric subtrochanteric fracture model, the tip starting point led to the most neutral alignment regardless of nail used. The lateral starting point led to varus and gapping of the lateral cortex with all nails. CLINICAL RELEVANCE: Subtrochanteric fractures treated with a trochanteric antegrade nail should have an acceptable reduction before nail insertion. The tip of the trochanter, or even slightly medial, on anteroposterior fluoroscopy is recommended as the universal starting point for these nails. However, slight deviations from this point and nail geometry can cause fracture site malalignment. A lateral starting point led to varus alignment and should be avoided.
Bone Nails↗
Closed reduction of forearm refractures with flexible intramedullary nails in situ.
BACKGROUND: Refractures of the forearm after flexible intramedullary nailing are rare. An alternative to nail replacement is closed reduction with the nails in situ. We successfully performed this maneuver on a thirteen-year-old boy. However, no data on the stability of previously bent nails are available. The purpose of the present study was to assess the mechanical stability of titanium and stainless steel flexible intramedullary nails after one cycle of reversed bending. METHODS: In an in vitro study, ten titanium and eighteen stainless steel 3.0-mm flexible intramedullary nails were subjected to an increasing lateral bending force until the point of first plastic deformation. As an analogy to the clinical case, they were then bent to an angle of 21 degrees and were manually reduced back to their original straight position and the experiment was repeated. The forces needed to achieve first plastic deformation and modified spring constants (force/deflection) were calculated and were compared between the native and previously bent nails. RESULTS: The average force required for permanent deformation of the previously bent nails was reduced by 37% for both titanium and stainless steel nails (from 21 to 13.2 N for titanium nails [p < 0.01] and from 25 to 15.7 N for stainless steel nails [p < 0.001]). The average modified spring constant decreased by 15.1% (from 0.814 to 0.691 N/ degrees ) for titanium nails (p < 0.001) and by 12.2% (from 0.991 to 0.870 N/ degrees ) for stainless steel nails (p < 0.001). Overall, steel nails were stiffer and stronger than titanium nails were. There was no macroscopic evidence of metal fracture or fatigue after one cycle of reversed bending to 21 degrees. CONCLUSIONS: Closed reduction of a forearm refracture with flexible intramedullary nails in situ is a safe, noninvasive, and effective alternative to nail replacement. However, mechanical stability of the nails is significantly reduced after the procedure. Therefore, the patient should be instructed to avoid any excessive forces to the forearm until fracture union has been documented radiographically, and casting for a limited time may be appropriate.
Adolescent↗
The uptake of fluconazole in finger and toe nails.
OBJECTIVE: The uptake of the antimycotic agent fluconazole in finger and toe nail following various treatment schedules was investigated in order to characterize the pharmacokinetic basis for the systemic treatment of onychomycosis with fluconazole. SUBJECTS: Between 8 and 12 healthy, male and female Caucasian subjects were included in four separate studies. Mean age of the subjects in the single studies ranged between 34 years (study 4, group 2; n = 4 male and 4 female) and 38 years (study 4, group 1; n = 4 male and 4 female). METHODS: Fluconazole was administered orally over 4 weeks in all studies. The treatment schedules were 150 mg once weekly (study 1), 300 mg once weekly (study 2), 50 mg once daily (study 3) and 150 or 300 mg once weekly in a parallel group study (study 4). At fixed times samples of blood, nail cuttings and nail dust were taken, up to two months after end of treatment. Fluconazole was analyzed in blood plasma and in the nail samples using a highly specific and sensitive gas chromatographic procedure. RESULTS: High concentrations of fluconazole were found in distal nail clippings with all three treatments. Mean maximum concentrations which occurred in the third or fourth week of treatment amounted to 2.1 microg/g (150 mg/w), 5.4 microg/g (300 mg/w) and 6.5 microg/g (50 mg/d) in finger nails and to 9.6 microg/g (150 mg/w), 12.3 microg/g (300 mg/w) and 12.2 microg/g (50 mg/d) in toe nails. The nail concentrations were 1-2 times (finger) and 2-3 times (toe) higher than the corresponding fluconazole plasma levels and were within the MIC range for dermatophytes and yeasts occurring commonly in onychomycosis. The residence times of fluconazole in the nail plate after the end of treatment was long, with approximate half-lives of 33 days in finger nail and 30 days in toe nail. In pharmacokinetic terms there was no evidence of advantages of the daily dosage (50 mg) over the once-weekly (300 mg) dosage. Fluconazole was found to penetrate into both finger and toe nails at a very fast rate. On the first two days of the 150 mg/w and 300 mg/w treatments, i.e. after the first dosage, fluconazole concentrations in the distal nail plates amounted to 50-80% of the later observed peak levels. The initial concentrations in the upper dorsal plate were particularly high, with mean peak concentrations of 11.9 microg/g (150 mg) and 33.7 microg/g (300 mg) in finger nails and 5.7 microg/g (150 mg) and 24.4 microg/g (300 mg) in toe nails. CONCLUSIONS: Fluconazole is rapidly and highly distributed into finger and foot nail, reaching there higher concentrations than in the plasma. The rapid initial uptake of fluconazole in nail, which is unlike the uptake of other antifungal agents, suggests the existence of special routes of access to the nail for fluconazole, possibly based on high diffusion rates.
Adolescent↗
Ultrasonic observation of the nail matrix.
BACKGROUND: The authors made use of echograms for the observation of the nail matrix. OBJECTIVE: To inspect the nail matrix and identify what causes nail plate deformities. METHODS: A 30-MHz frequency high-resolution B-mode was applied to normal and damaged nails. RESULTS: Clear shadows of underlying nail plates were observed beneath the proximal nail fold. Some cases with nail plate deformities showed damaged sub-proximal fold nail plates, which would indicate nail matrix deformities. CONCLUSION: The echograms had diagnostic value to nail plate deformities. If a normal echogram is obtained at the proximal nail fold, the nail bed will be the place at which the nail deformities occur. If the echogram indicates any sub-proximal fold nail plate changes, the damaged nail matrix may be attributable to the nail deformities. Echograms also gave clear echoic shadows of subungual tumors. That contributed to identifying the infiltrating border of subungual malignant melanomas around the nail matrix noninvasively.
Fingers↗
Bending and torsional stiffness in cadaver humeri fixed with a self-locking expandable or interlocking nail system: a mechanical study.
OBJECTIVES: This study was designed to gain data about a new expandable, noninterlocked intramedullary nail's capacity to stabilize unstable transverse humeral shaft fractures without the need for interlocking, thus making nail implantation simpler and to prove our goal hypothesis: that in a midshaft osteotomy of the humeral shaft the expandable humeral nail will show the same bending and torsional stiffness as an interlocked humeral nail, when implanted correctly according to the manufacturer's instructions. DESIGN: Pair randomization. SETTING: Mechanical laboratory testing. PARTICIPANTS: Eight pairs of freshly harvested cadaveric humeri. INTERVENTIONS: Fracture model was a midshaft transverse osteotomy, gapped to 3 mm. Each humerus pair received an expandable humeral nail (Fixion) or an interlocked humerus nail (Synthes) through a retrograde approach. The humeri were fixed in polymethylmethacrylate cylinders and tested in a servo-pneumatic material-testing machine. MAIN OUTCOME MEASUREMENTS: Torsional stiffness and bending stiffness of the nail-bone-construction. RESULTS: Expandable nails (interlocked nails) showed a lateral bending stiffness of 0.73 +/- 0.14 (0.63 +/- 0.1) KN/mm (P = 0.026) and a frontal bending stiffness of 0.67 +/- 0.18 (0.58 +/- 0.09) KN/mm (P = 0.084). Torsional stiffness values were 0.13 +/- 0.19 (0.43 +/- 0.09 Nm/degrees) (P = 0.012). Lower torsional stiffness in the expandable nail group was observed in humeri with a funnel shaped proximal intramedullary canal. CONCLUSIONS: The nail systems showed similar characteristics for frontal bending (P = 0.084), but not for lateral bending (P = 0.026). For lateral bending, the Fixion nail showed significantly more stiffness than the UHN nail (P = 0.026). There was significantly lower torsional stiffness with expandable nails compared with interlocked nails. Clinical correlation would suggest that in rotationally unstable fractures (A2 and A3 diaphyseal fractures), interlocked nails would provide increased stability over expandable nails.
Biomechanical Phenomena↗
Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.
BACKGROUND: Cephalocondylic intramedullary nails, which are inserted proximally to distally (cephalocondylic), have been used for the surgical treatment of extracapsular hip fractures. OBJECTIVES: To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the fourth substantive update of our original review which compared the Gamma nail with the sliding hip screw (SHS). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, several orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: May 2003. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Eighteen trials comparing the Gamma nail with the SHS were included, with data available for 2575 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate for other outcomes. Five trials involving 623 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. One trial of 206 patients with a trochanteric fracture showed no advantages for proximal femoral nail (PFN) compared with the SHS. One trial of 60 patients reported favourable preliminary results for an experimental mini-invasive static intramedullary nail compared with the SHS. One trial of 230 patients, which compared the Kuntscher-Y nail with the SHS, reported no major difference in outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Two trials, involving 65 patients with reverse and transverse fractures at the level of the lesser trochanter, compared an intramedullary nail (Gamma or PFN nail) with an extramedullary implant (a 90-degree blade plate or dynamic condylar plate). The intramedullary nails were associated with better intra-operative results and fewer fracture fixation complications for these rare fractures. REVIEWER'S CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, it appears that the SHS is superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, reversed fracture lines and subtrochanteric fractures).
Adult↗
Slotted versus non-slotted locked intramedullary nailing for femoral shaft fractures.
Experimentally, two slotted nails, the Grosse-Kempf nail and the AO/ASIF universal femoral nail, were compared to the non-slotted Grosse-Kempf nail and control bone using a cadaver femoral osteotomy. The stiffnesses and strengths of the osteotomies fixed with slotted nails in 10-30 degrees torsion were 6-8% and the values of non-slotted nails 40% of control bone. The maximal moments were 14-18% and 48%, respectively. In the "clinical range" of torsion, the implant-bone construct never failed or was deformed. Clinically, 46 femoral shaft fractures were randomized to treatment with Gross-Kempf nails, 24 with slotted nails and 22 with non-slotted nails. Four complications in the slotted nail group and three in the non-slotted nail group were considered to be independent of the choice of nail and did not affect the end result. Three splinterings of the distal fragment, one resulting in a change of the osteosynthesis implant to a condylar plate, were considered to result from the high stiffness of the non-slotted nail. Osteosynthesis of femoral shaft fractures using slotted nails has not resulted in healing disturbances, which could be accounted for by the high torsional elasticity of the nail; there seems to be no indication for high-stiffness nails in femoral fractures.
Adolescent↗
Psoriatic nails: a prospective clinical study.
BACKGROUND: Psoriasis is a widespread skin disorder in which nail involvement is a common symptom. Many psoriatic patients have nail changes morphologically resembling onychomycosis. OBJECTIVE: The present study was undertaken (1) to evaluate the frequency of nail involvement in psoriatic patients, (2) to assess the types of nail changes in psoriasis, (3) to find eventual relationships between nail involvement and some clinical parameters, and finally (4) to determine the prevalence of fungal nail infections in psoriatic individuals. MATERIAL AND METHODS: One hundred six patients hospitalized in our department due to exacerbation of psoriasis participated in the study. Each patient underwent dermatologic examination with special attention paid to the nail changes. In any case of abnormalities clinically suspected of fungal infection, further mycological investigations were performed. RESULTS: Nail changes were present in 83 patients (78.3%) with psoriasis. The most common nail abnormality observed on both fingernails and toenails was subungual hyperkeratosis. Hyperkeratosis, onychorrexis, and discoloration of nail plates were observed significantly more often on toenails. Pitting and longitudinal ridges were significantly more frequent on fingernails. Patients with psoriatic nail dystrophy were significantly older than psoriatic patients without nail abnormalities. Nails were involved statistically more often in patients with arthropathic psoriasis. Positive mycological cultures were obtained from 18% of patients with nail changes. The most commonly isolated fungi were molds. CONCLUSIONS: Dystrophic nails are frequently found in psoriatic individuals, especially those suffering from arthropathic psoriasis. Subungual hyperkeratosis and pitting are the most typical lesions. It is difficult to assess definitively whether psoriasis is a predisposing factor to the development of fungal infections of the nails.
Adolescent↗
Biomechanical study of nine different tibia locking nails.
We compared different nail types within the Bone/Implant-Complex to look for differences in stiffness for axial load, bending and torsion of the System. We simulated comminuted mid shaft fractures by a 2-cm defect osteotomy in paired human cadaver tibiae. We fixed tibiae with one of nine different interlocking nails [AO Unreamed Tibial Nail 9 mm (UTN9), AO Unreamed Tibial Nail 8 mm (UTN8), Russell & Taylor Delta Tibial Nail 9 mm (RTD), Russell & Taylor Reconstruction Tibial Nail 11 mm (RTR), Brooker & Wills Tibial Nail 11 mm (B&W), Grosse & Kempf Tibial Nail 11 mm (G&K), AO Universal Tibial Nail 11 mm (AOU), Klemm & Schellmann Tibial Nail 11 mm (K&S), and Börner & Mattheck Tibial Nail 11 mm (B-M)] according to the manufacturer's recommendations. In torque testing the unslotted nails (UTN9, UTN8, RTD, RTR, B&W) showed significantly higher stiffness compared to the slotted nails (G&K, AOU, K&S, B-M). Compared to intact bone, both groups of nails were significantly less stiff. In axial load testing large diameter nails interlocked by large diameter interlocking bolts (G&K, K&S, B-M) showed significantly higher stiffness. For A-P bending no significant differences between implants were found, but isolated bones showed significantly higher A-P bending stiffness. In varus-valgus bending large diameter nails (RTR, G&K, K&S, B-M) showed significantly higher bending stiffness compared to low diameter (UTN8, B&W) implants.
Adult↗
Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures.
OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).
Adolescent↗