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At least 595 records · Page 33Linked to original sources
PubMed2002

Locked nailing with interfragmentary wiring for humeral nonunions.

OBJECTIVE: Locked nailing for humeral nonunions is threatened by residual fracture gap and fracture motion. This article describes the clinical experience of using interfragmentary wiring to solve these problems. METHODS: Interfragmentary wiring was used in 21 consecutive humeral nonunions treated with humeral locked nails. The average age of patients was 49.5 years, with an average nonunion duration of 14.4 months. Eighteen patients had previous operations. Nonunions were located at the proximal third in 4, the middle third in 10, and the distal third in 7. Antegrade nailing was used in 11 and retrograde nailing in 10. Sixteen nonunions were nailed with 8-mm nails and five with 7-mm nails. Interfragmentary wiring was applied to either the posterior or the lateral cortex of humeri in a figure-of-eight configuration. Bone grafting was performed in all and average follow-up time was 22 months. RESULTS: With a single operation, all patients achieved osseous union in, on average, 18.3 weeks. One patient with segmental nonunion suffered acute renal failure 4 months after operation, but fracture healing was not affected. Wire infection occurred in one patient with preoperative infection at the nail entry site and was treated by implant removal. Other complications including two transient radial nerve palsies and one brachial artery injury did not affect the final outcome. At follow-up, all but four patients had complete recovery of shoulder flexion and abduction. The average postoperative Neer score (91.1 points) was significantly better than the average preoperative score (65.5 points). All but three patients had complete recovery of elbow motion. CONCLUSION: Interfragmentary wiring, a safe procedure if properly performed, could effectively decrease the residual fracture gap and fracture motion in locked nailing of humeral nonunions. Further biomechanical studies and prospective, randomized, controlled studies are warranted.

Adult↗
PubMed2005

Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures: a report of three cases.

Three cases of anterior distal femoral cortex penetration during intramedullary nailing for subtrochanteric fractures are documented. Case 1 involved a Zimmer (Warsaw, IN) M/DN antegrade femoral nail, case 2 a Howmedica (Allendale, NJ) long-stem Gamma nail, and case 3 a Synthes (Paoli, PA) titanium femoral nail with spiral blade locking. The anterior Zimmer nail penetration resulted in a displaced supracondylar fracture, which subsequently required revision. The Gamma nail as well as the Synthes nail were left impaled through the distal femoral cortex, and the subtrochanteric fractures went on to union. The anteroposterior radius of curvature for the Zimmer, the long Gamma, and the Synthes nail are 257 cm, 300 cm, and 150 cm, respectively. It has been estimated that the radius of curvature of the femoral diaphyseal canal is 114 to 120 cm. It appears that the difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.

Aged↗
PubMedDate not supplied

Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model.

There are several options available for surgical stabilization of pediatric femoral shaft fractures. The purpose of this study was to compare the stability afforded by Ender stainless steel nails, titanium elastic nails, and one-plane unilateral external fixators for the fixation using a synthetic adolescent midshaft femur fracture model. The anterior-posterior (sagittal plane) bending, lateral (coronal plane) bending, torsional, and axial stiffness values were calculated using 6 different fixation configurations. These included pairs of 3.5-mm-diameter Ender nails with and without distal locking, 3.5- and 4.0-mm-diameter titanium elastic nails as well as single- and double-stacked monolateral external fixators. Eight synthetic femur models, 4 each with simulated transverse and comminuted fracture patterns, were sequentially tested for stability afforded by the various fracture fixation configurations. External fixation exhibited significantly greater control of anterior-posterior angulation compared with all flexible-nailing systems. Although Ender nails were slightly superior to titanium nails in control of sagittal plane angulation, this was not statistically significant. Compared with the external fixation constructs, all 4 flexible nail constructs demonstrated higher torsional stability. For prevention of axial shortening, all fixation methods were similar for the transverse fracture pattern, whereas external fixation was superior to flexible nails in the comminuted fracture model. No significant benefit was demonstrated with double stacking of external fixators. These findings may help guide clinicians choose the optimal fixation method for treatment of pediatric femoral shaft fractures.

Biomechanical Phenomena↗
PubMed2003

Complications of locked nailing in humeral shaft fractures.

BACKGROUND: The purpose of this study was to investigate the complications of humeral locked nailing. METHODS: Between 1994 and 2000, 161 humeral shaft fractures (98 acute fractures and 63 delayed unions or nonunions) in 159 patients treated with humeral locked nails were followed up for an average of 25.4 months. There were 89 men and 70 women, with an average age of 53.5 years. Acute fractures included 68 closed, 18 type I, 8 type II, 3 type IIIA, and 1 type IIIB open fractures. Thirty-six nonunions had previous operations. In general, acute fractures were treated with closed nailing and nonunions were treated with open nailing with bone grafting. Since 1998, interfragmentary wiring has been added in nonunions to compress the fracture. RESULTS: In total, 30 patients had 31 significant complications. Nine of them were persistent nonunions, six from acute fractures and three from nonunions. Fracture gap was associated with a significantly higher risk of nonunion. The risk of operative comminution was significantly higher in retrograde nailing, and operative comminution resulted in a significantly higher risk of nonunion. Seven of the nine nonunions underwent revisional nailing and achieved eventual union. Removal of the protruded screws was performed in two cases. Other complications included shoulder impairment, elbow impairment, angular malunion, and post-nailing radial nerve palsy. CONCLUSION: Many complications of humeral locked nailing can be prevented by improving the implant design or surgical techniques. The patients with persistent nonunion can be reliably treated by revisional nailing and bone grafting.

Adult↗
PubMed1994

Expression of integrins in human nail matrix.

The aim of this study was to characterize cell-cell and cell-matrix interaction by evaluating the expression of different integrins in the nail matrix. Nail biopsies were obtained from two cadaver fingers, and eight patients with ingrowing toenails. Frozen sections were stained by indirect immunofluorescence using anti-alpha 1, anti-alpha 2, anti-alpha 3, anti-alpha 4, anti-alpha 5, anti-alpha 6, anti-alpha v, anti-beta 1, anti-beta 4 and anti-ICAM-1 monoclonal antibodies. Biopsies from normal human foreskin were evaluated as controls. alpha 1, alpha 4 and alpha 5 subunits were absent from both nail matrix and normal human skin. alpha 2, alpha 3 and beta 1 subunits were expressed in the basal and suprabasal layers of nail matrix, but only in the basal layer of skin epidermis. alpha 6 and beta 4 subunits were strongly expressed in the basement membrane zone and in the basal layer of both nail matrix and epidermis. The alpha v subunit was expressed in the basal layer of nail matrix. ICAM-1 was not expressed in nail matrix epidermis. Our findings show that despite the distinctive features of the nail apparatus, compared with the epidermis, the pattern of integrin expression is similar, although some differences in the distribution of alpha 2, alpha 3 and beta 1 subunits are detectable. These are probably related to the peculiar differentiation and keratinization of the nail.

Basement Membrane↗
PubMed2004

Evaluation of nail involvement in patients with chronic cutaneous graft versus host disease: a single-center study from Turkey.

Although graft versus host disease (GVHD) is associated with a myriad of cutaneous signs, nail involvement is rarely mentioned in the literature. This study was conducted at the Department of Dermatology and The Bone Marrow Transplantation Unit of Hematology. All patients were examined clinically for presence of nail abnormalities. Severity of nail involvement was assessed as mild or severe. Of 28 patients diagnosed with chronic cutaneous GVHD, 14 had nail manifestations. Longitudinal ridging was the most frequently observed nail change on both the fingernails and the toenails. Severe nail changes such as ptergyium and onicoatrophy were noted in a few patients. As a result we could not find any relationship between nail changes and clinical severity but there was a relationship between nail changes and duration of disease. Nail manifestations could be responsible for considerable morbidity.

Adult↗
PubMed1993

Lichen planus limited to the nails in childhood: case report and literature review.

Although nail abnormalities have been reported to occur in 1% to 10% of patients with lichen planus, in children with lichen planus they are rarely mentioned in the literature. An 11-year-old boy had a two-month history of nail dystrophy affecting all the fingernails and the great toenails. The nail plates showed longitudinal ridging and thinning as well as onycholysis and distal splitting. There were no cutaneous or mucous membrane abnormalities. A nail biopsy specimen showed hyperkeratosis, hypergranulosis, and acanthosis in the ventral portion of the proximal nail fold and in the nail matrix. A band-like lymphocytic infiltrate was present in the superficial dermis, and the basal layer showed vacuolar alterations. A diagnosis of lichen planus was made. Treatment was intramuscular triamcinolone 20 mg once a month for six months. Since 1969 only 13 proved pediatric cases of lichen planus limited to the nails have been reported, including two children with 20-nail dystrophy and four with idiopathic atrophy of the nails.

Biopsy↗
PubMed1997

A biomechanical comparison of intramedullary nail and crossed lag screw fixation for tibiotalocalcaneal arthrodesis.

This study compared the mechanical bending and torsional properties of intramedullary nail fixation and lag screw fixation for tibiotalocalcaneal arthrodesis. Seven matched pairs of human cadaver lower extremities were studied, with one hindfoot in each pair stabilized with a 12 mm x 150 mm interlocked intramedullary nail inserted retrograde across the subtalar and ankle joints. The contralateral hindfoot was stabilized with two crossed 6.5 mm cannulated screws inserted across both the ankle and subtalar joints. Specimens were subjected to cantilever bending tests in plantarflexion, dorsiflexion, inversion, and eversion and to torsional tests in internal and external rotation. The intramedullary nail construct was significantly (P < 0.05) stiffer than the crossed lag screw construct in all four bending directions and both rotational directions: plantarflexion (nail, 42.8 N/mm; screws, 16.4 N/mm; P = 0.0003), dorsiflexion (nail, 43.0 N/mm; screws, 10.3 N/mm; P = 0.0005), inversion (nail, 37.7 N/mm; screws, 12.3 N/mm; P = 0.0024), eversion (nail, 35.4 N/mm; screws, 10.8 N/mm; P = 0.0004), internal rotation (nail, 1.29 N-m/degree; screws, 0.82 N-m/degree; P = 0.01), external rotation (nail, 1.35 N-m/degree; screws, 0.44 N-m/degree; P = 0.0001). Intramedullary fixation is biomechanically stiffer than crossed lag screws in all bending and torsional directions tested and therefore this construct may aid in maintaining alignment of the hindfoot during union and may help increase fusion rate through increased stability of the internal fixation.

Ankle Joint↗
PubMed2006

Mechanical failure in intramedullary interlocking nails.

PURPOSE: To study clinical and mechanical factors that predispose to failure of interlocking nails. METHODS: Between October 1996 and December 2002, 286 femoral fractures, 211 tibial fractures, and 47 humeral fractures were repaired using variously designed interlocking nails. Fracture pattern, level and site, nail size and type, weight bearing after nailing, and union status were reviewed after a mean follow-up of 22 months. RESULTS: Nail failure occurred in 27 fracture repairs (17 femoral, 9 tibial, and one humeral; 13 from our institution and 14 referred from elsewhere). In 55% of failed repairs, the fracture was distal. A high rate of tibial nail failure was noted. CONCLUSION: Distal fractures and stress concentration at the distal screws predispose to interlocking nail failure and can be prevented by protected weight bearing combined with the use of longer and larger nails. Routine supplementary cancellous bone grafting is unnecessary during renailing surgery when adequate reaming and a larger nail are used.

Adolescent↗
PubMed1998

Enhancing effect of N-acetyl-l-cysteine or 2-mercaptoethanol on the in vitro permeation of 5-fluorouracil or tolnaftate through the human nail plate.

The enhancing effects of various vehicles on the in vitro permeation of a hydrophilic model drug, 5-fluorouracil (5-FU), or a lipophilic model drug, tolnaftate (TN), through human nail plates were investigated using a modified side-by-side diffusion cell. Tip pieces from the 5th finger-nail, clipped from healthy volunteers, were used in this permeation study. The swelling and softening properties of the nail pieces were also measured in each vehicle. The weights and stresses of the nail pieces were dramatically changed after immersion in aqueous solvents containing N-acetyl-L-cysteine (AC) or 2-mercaptoethanol (ME). However, no significant change in the physicochemical properties of the nail pieces was found in the lipophilic vehicles. Thus, the water content in the nail plates absorbed from vehicles may relate to their physicochemical properties. Although keratin-softening agents and new skin permeation enhancers did not significantly promote 5-FU permeation compared with water alone, the flux from solvent systems containing AC or ME was substantially higher. In addition, TN permeation from solvents containing AC or ME could be measured, whereas that from other solvents was undetectable. When the AC concentration was increased, the 5-FU permeation and the nail weight increased and the stress of each nail piece decreased. It is concluded from these experimental results that AC and ME may be useful as enhancers for increasing drug permeation through the human nail plate.

Absorption↗
PubMed2007

Exchange nailing of ununited fractures.

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

Ankle Injuries↗
PubMed2000

Drugs in nails: physiology, pharmacokinetics and forensic toxicology.

In recent years, drug analysis in keratinised matrices, such as hair and nails, has received considerable attention because of several advantages over drug testing methodologies employing body fluids, such as urine or serum. For example, keratinic matrices, such as finger- and toenails, can accumulate drugs during long term exposure. Drugs are incorporated into nails by a double mechanism: (i) deposition into the root of the growing nail via the blood flow in the nail matrix; and (ii) incorporation via the nail bed during growth from the lunula to the beginning of the free margin. Together, these account for a wide retrospective window of drug detection. Nails can provide a good forensic matrix for the detection of drugs of abuse. Indeed, the international literature has reported the use of nail analysis in postmortem detection of drugs of abuse, drug testing in the workplace and drug screening to detect prenatal exposure, even though further studies are needed for correct interpretation of the data obtained. Another application of drug analysis in nails consists of the possibility of detecting the presence of an antimycotic at the site of action during antifungal therapy for patients with onychomycosis. When available, this evidence has permitted drug treatment of a shorter duration and reduced toxicity. However, so far the potential of drug monitoring in nails still lacks harmonisation and validation of analytical methodologies and a better comprehension of the possible correlation between drug concentrations in the matrix and period of exposure.

Forensic Medicine↗
PubMed1998

Attempted unreamed nailing in tibial fractures: a prospective consecutive series of 55 patients.

We evaluated the possibility of unreamed insertion of an intramedullary nail (IMN) in a consecutive series of 55 tibial shaft fractures in 55 patients (30 men). 43 fractures were closed and 12 fractures were open. All surgeons involved were instructed to try unreamed insertion primarily. Selection of nail diameter was based on measurements of the narrowest part of the medullary canal on preoperative AP- and lateral radiographs, with a millimeter-ruler. Of the 25 cases where a 9 mm nail was chosen, 10 were impossible to insert without reaming. An 8 mm nail was selected in the remaining 30 cases, and here 10 required reaming. Mean time-to-union was 4.2 months. Delayed union was noted in 9 patients of whom 6 had been stabilized with an unreamed nail. The concept of unreamed insertion must be questioned since this could be done in only 35 patients and, in addition, we were not able to demonstrate any significant differences in time-to-union in fractures stabilized with an unreamed or a reamed nail. Implant failures were seen in 5 patients, all stabilized with an 8 mm nail. Failure of interlocking screws did not affect the final outcome. However, a possible combination of screw breakage and healing disturbances may lead to the need for more complex surgical procedures. Due to these reasons and the fact that the 8 mm nail could not be inserted unreamed in 10 of 30 patients, we stopped using the 8 mm nail.

Adolescent↗
PubMedDate not supplied

Nail surgery.

Nail surgery is not particularly difficult but often delicate. Profound knowledge of the anatomy, physiology and pathology of the nail organ as well as surgical skills and atraumatic instruments are prerequisites for successful nail operations. Careful preoperative preparation of the patient as well as consistent post-operative care are necessary. The following article will give information about the essentials of nail surgery, such as adequate anaesthesia, instrumentation, and complications. The most frequently performed nail operations are described focussing on techniques proven to be safe and successful. Nail avulsions, ingrowing nail, myxoid pseudocysts and subungual exostoses as well as the treatment of haematomas and nail tumours are outlined. Ungual melanomas are the most frequent malignant tumours of the nail apparatus and deserve special attention. Some indications for cryosurgery, laser and electro-surgery are given.

Humans↗
PubMed2000

[Nail manifestations of systemic diseases].

General diseases-associated nail disorders may be classified into 5 types according to their clinical impact. Type I refers to nail disorders considered as peculiar features among the various symptoms of general disease such as peri-ungueal vascular dilatation, onycholysis, Beau lines, opaque nails or melanonychia. Type II refers to nail disorders with a strong clinical value such as Terry's nails, Muerhrcke's lines or koilonychia. Type III refers to nails disorders presenting as significant syndromes of several diseases such as yellow-nail syndrome of subungueal splinter haemorrhages, and type IV to specific disorders considered as true keys for diagnosis such as digital hippocratism, Bazex's acrokeratosis, Koenen's tumor, or nail hypoplasia. In type V are included drug-induced nails disorders especially after chemiotherapy or antiretroviral therapy.

Autoimmune Diseases↗
PubMed2001

[Unreamed locking intramedullary nailing of humeral fractures--basic evaluation of a patient group].

PURPOSE OF THE STUDY: The aim of the work is to provide an overview of the existing experience in Synthes unreamed humeral nail (UHN). MATERIAL: Between August 1996 and February 2000 we treated by means of UHN a group of 37 patients (12 men and 25 women), average age 55 years (range, 18-87 years) with a fracture of humeral shaft. According to AO classification in 10 patients it was a case of a fracture of proximal humerus involving the shaft (11B-3) and in 27 cases a fracture of the shaft (12 A, B, C). The whole group was operated on by 11 surgeons. METHOD: In 26 cases we used the antegrade method and in 11 cases the retrograde one, in dependence on the type and location of the fracture. The assessment was performed in the form of a prospective study. The follow-up including radiograph checks was carried out at the intervals of 6 weeks, 3, 6, 9 and 12 months after the operation or at another 6 weeks or 3 months after the extraction of the nail, if any. In addition we invited the whole group, i.e. 37 patients for the final control examination which all of them attended. This examination was performed by the first author of the work. The average follow-up was 38 months (range, 12-55 months). RESULTS: The average duration of the surgery in the whole group was 80 minutes, the average duration of x-ray exposure was 3.1 minutes. Peroperative complications occurred in total 42 times in 23 patients. Seven cases required a supplementary incision, i.e. open reduction of the fracture; insufficient nail placement (not into the proper depth) in the humeral head and its prominence into joint line evaluated on the post-operative radiograph) in antegrade nailing occurred 6 times. Problems with locking were encountered 15 times in 10 patients. Comminution of the fragments peroperatively during the insertion of the nail occurred 3 times, peroperative injury of the radial nerve was recorded in total 4 times, always in the antegrade method of the insertion during distal locking from the lateral side. A postoperative complication occurred 16 times in 12 patients, 6 times the radiograph showed penetration of the end of the nail into the shoulder and 6 times the locking screws loosened. No infect was recorded. The mentioned complications required in total 10 revision surgeries in 6 patients (5 of them were treated by the antegrade method). The fracture healed in a good anatomical position in 33 cases. In 4 cases there occurred non-union which was 3 times treated with a plate re-fixation and cancellous bone grafting of which twice successfully. In 2 cases the healing required another revision surgery. A good subjective as well as objective result was achieved almost in 90% of patients. A risk factor from the viewpoint of the limitation of the range of motion in the shoulder proved to be the fracture of 11B3 type and also the antegrade method of nailing, in case of the elbow the retrograde method of nailing. However, the greatest risk was posed by the necessity of a longer post-operative immobilisation of the limb in the case of a not quite stable internal fixation. DISCUSSION: A relatively high number of complications in our group results from strict criteria we have set. However, also literary data present a relatively high number of variously serious complications. Our results as well as the average duration of the surgery is comparable with other authors. CONCLUSION: The main indication of UHN are comminuted or multi-level fractures of humerus in the central three fifths of its length. If possible we prefer the retrograde method of nailing, in the antegrade method we recommend distal locking from the anterior aspect of the arm. Transverse or short oblique fractures can be successfully treated by a simpler Hackethal technique. Long spiral fractures are ideally treated conservatively or by plate fixation.

Adolescent↗
PubMed2003

Design concepts and early utilization of a new femoral interlocking nail.

Interlocking nails provide excellent stability and control of femoral fractures from the hip to the supracondylar regions, yielding excellent clinical results. Advances in femoral nail design have provided for increased variability in their applications, allowing surgeons to stabilize a wide variety of fractures through either antegrade or retrograde nail insertion methods. In the past, nails were manufactured to be implanted with a specified insertion technique, requiring the surgeon to become facile with multiple nail systems to care for the entire spectrum of femoral injuries. A new femoral intramedullary nail system is being introduced with the capability of stabilizing both right- and left-sided femoral fractures in all 3 modes of interlocking--that is, first-generation antegrade nailing, second-generation reconstruction nailing, and retrograde nailing. The design and rationale of this system are discussed, and clinical examples of use of this new device are provided.

Bone Nails↗
PubMed2004

[Biomechanical study on rotating-arm self-locking intramedullary nail in the treatment of tibial shaft fracture].

We have designed a new kind of self-locking intramedullary nail for the treatment of unstable fracture of the middle and distal tibial shaft and have compared it with the interlocking nail by means of biomechanical experiments. The data could be used as a basis for clinical application. Fourteen formalin-fixed tibials of adults were made into unstable fracture models with a 2cm bone defect each. They were divided into 2 groups. Group 1 was fixed with self-locking intramedullary nail and group 2 was fixed by interlocking nail. All specimens were submitted to biomechanical test. The data were analysed by t test. The results showed there is no difference in anti-bending stiffness between the self-locking intramedullary nail and the interlocking nail. The anti-rotating and anti-compressing stiffness of interlocking nail is slightly better than that of self-locking intramedullary nail, but still the firmmess of the self-locking intramedullary nail in resisting rotation can meet the requirement of biological fixation. Its structure is reasonable, simple, practical, and it can resist certain harmful stress.

Biomechanical Phenomena↗