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PubMed1989

Nail infections.

Nail infections are and will continue to be a diagnostic and therapeutic challenge to all foot physicians. Attention to basic concepts of accurate detailed history and physical examination will aid in the determination of the etiology of these infections. Following basic guidelines of incision and drainage, gram stain, soaks, and antibiotics will be the cornerstone of initial treatment of pyogenic infections. Upon resolution of the acute infection a permanent treatment plan can be constituted based on the etiology. Nail infections of mycotic nature require an understanding by both patient and doctor as to the difficulty and resistance to treatment of this problem. It is the authors' opinion that aggressive persistent treatment will provide the best long-term result when dealing with mycotic infections. This may require nail removal, local and systemic treatment as well as change in shoe environment. As we have seen and is stated throughout this text, the nail and its pathologic processes can be a mirror of systemic disease. Many times a dystrophic infected nail may be the initial clinical presentation of a much more involved disease process. It is the responsibility and duty of all foot physicians to have a total understanding of knowledge of normal and pathologic process that affect the nail plates, nail bed, and surrounding nail proper. I hope this article will stimulate the foot physician to approach the disease of the nail with a high index of suspicion and respect.

Bacterial Infections↗

PubMed1989

Porosity of rat femora following intramedullary reaming and nailing.

The present study evaluated cortical porosity and thickness of intact rat femora 12 weeks after intramedullary reaming and nailing. The right femora were reamed and received either flexible polyacetal nails or rigid stainless steel nails. A third group was reamed but not nailed. The left femora were used as controls. The anterior cortical wall was analyzed at the mid-diaphyseal level. Neither reaming nor reaming combined with nailing influenced porosities with a diameter less than 10 microns. For larger pores, polyacetal nailing doubled the porosity, whereas steel nails increased porosity by a factor of 4.5. A slightly increased porosity was observed for the reamed group. Reduced cortical thickness was found in both nailed groups, whereas cortical thickness was increased in the reamed group compared with the control side. Implantation of rigid and flexible intramedullary nails in rat femora increased porosity along the anterior cortical wall.

Acetals↗

PubMed1986

Biomechanical effects of intramedullary reaming and nailing on intact femora in rats.

In order to study the effects of intramedullary reaming and nailing on bone mechanics, the left femur of male Wistar rats was reamed after circular periosteal stripping of the middle part as if for osteotomy. Osteotomy was, however, not performed. The rats were allocated into three groups: the first group had no nailing, the second group received flexible intramedullary polyacetal nails, and the third group was nailed with solid stainless-steel nails. Ten animals from the first group were sacrificed on the day of surgery. At four, eight, 16, and 24 weeks after operation, ten animals from each of the three groups were sacrificed. Both femora were tested mechanically and examined histologically. Intramedullary reaming resulted in the following immediate reductions in mechanical properties compared to the unoperated right femur: strength, 15%; stiffness, 20%; toughness, 7%; and resilience, 15%. From four weeks on, strength and energy absorption values were always lowest in the group with steel nails. The differences between groups were significant at four, 16, and 24 weeks. The lower values for mechanical properties of the femora with steel nails is interpreted as a result of stress shielding by the rigid nails. Flexible nails did not interfere with the ultimate restoration of mechanical properties of bones initially weakened by reaming.

Acetals↗

PubMed1995

Proximal third tibial shaft fractures. Should they be nailed?

Thirty-two extraarticular fractures of the proximal third of the tibia were treated with locked intramedullary nails. There were 10 closed and 22 open injuries. Treatment consisted of a reamed nail in each of the 5 closed fractures, and an unreamed nail in the remaining 27 fractures. Thirty of the 32 fractures eventually healed; however, 9 (28%) underwent exchange nailing and 4 (13%) required bone grafting. At final followup, 27 of 32 fractures (84%) had angulation of 5 degrees or greater in the frontal or sagittal plane. Nineteen of the 32 fractures (59%) had 1 cm or more of displacement at the fracture site. In 8 fractures (25%), there was loss of fixation, most commonly associated with placement of a single proximal locking screw. Fractures of the proximal third of the tibial shaft do not appear to respond as favorably to intramedullary nailing as do fractures in the distal 2/3 of the tibia. Valgus, apex anterior angulation, and residual displacement at the fracture site are common after nailing. Surgical errors of a medialized nail entry point and a posteriorly and laterally directed nail insertion angle contributed to malalignment. Based on their findings, the authors have limited the use of intramedullary nailing for proximal third tibial shaft fracture and consider alternate forms of fixation (plate or external fixation).

Adolescent↗

PubMed1994

[Gamma nail osteosynthesis of per- and subtrochanteric femoral fractures. 4 years experiences and their consequences for further implant development].

The Gamma nail can be used in all types of per- and subtrochanteric fractures because of its biomechanical characteristics. In this prospective evaluation of our 330 patients treated between November 1989 and November 1993 the usefulness of the Gamma nail for the osteosynthesis of all types of fracture was evaluated. The rate of intraoperative and postoperative complications but also gait function, postoperative weight bearing, general complications, and survival were analysed. We compared the results of four therapy periods to evaluate the importance of the expertise of the surgeon and the 'learning curve'. The Gamma nail osteosynthesis was performed in 72-98% in unstable per- and subtrochanteric fractures. The nail diameters used shifted to the 12 mm nail (99%) and the 130 degrees angle (93%) in the fourth examination period. The intraoperative complication rate is highly dependent from the expertise of the surgeon and the experience with the system. The rate decreased from 42.2% in the first to 17.2% in the fourth examination period. The most important complications were: additional fractures (1.7%), distal locking screw problems (7%), femoral head rotation (2,4%), and not sufficient fracture reduction (4.1%). Whereas in general these did not influence the postoperative management the use of a too short femoral neck screw lead to instability. Postoperative local complications were: rotation of the femoral head and neck (0.6-5.5%), related to the gliding of the neck screw (0.6-4%), fracture at the end of the nail (1.8-4%), fatigue break of the nail (1 case) and hematoma (1.2-8.3%). In all these cases reoperation was needed. To reduce the rate of intra- and postoperative complications a new gliding nail (GN) is presented. Due to the double T-profile of the femoral neck blade the implant is stable for neck rotation. The blade has a collar which makes it impossible to implant the blade to deep in the femoral neck. The larger nail profile at the femoral neck perforation reduces the risk of implant failure. The implant can be used as dynamic compression as well as static implant both in the direction of femoral neck and shaft.

Aged↗

PubMed1997

The effect of acrylic nails on the measurement of oxygen saturation as determined by pulse oximetry.

Pulse oximetry (Spo2) is a simple, noninvasive method that is widely used to determine oxygen saturation in patients undergoing surgical procedures. Artificial acrylic nails have recently become fashionable to strengthen and lengthen nails. This study investigates the effect of unpolished acrylic nails on the measurement of oxygen saturation by pulse oximetry. Data were collected during a 3-month period. Thirty women, average age 32 years (range 18 to 61 years), were recruited at a high-volume nail salon in northwestern Pennsylvania. A baseline pulse oximetry reading was obtained on each subject's natural, unpolished fingernail using a Nellcor N-20/N-20P portable pulse oximeter (Nellcor Incorporated, Hayward, California). A licensed nail technician applied the acrylic compound to the same finger. After the compound had hardened in approximately 5 minutes, a second reading was obtained on the unpolished acrylic nail. The mean pulse oximetry reading at baseline was 97.33% and after acrylic nail application, 97.58%. Using a paired Student's t test, no statistically significant differences existed between readings. This study demonstrates that unpolished acrylic nails do not affect pulse oximetry measurements of oxygen saturation. Patients may not need to remove unpolished acrylic nails before surgery.

Acrylates↗

PubMed1997

[Locked nail plate: a new treatment for unstable pertrochanteric fractures].

PURPOSE OF THE STUDY: This work is the outcome of a preliminary study on pertrochanteric fractures which showed that impaction with simple nail plates (SNP) was lead by hypercorrection in valgus demineralization and malposition of the nail in the femoral neck. To improve anchoring of the nail in the cervico-cephalic part, the authors propose to use a locked nail-plate (LNP), an innovative device based on the addition to the normal nail plate, of a screw securing neck and nail. MECHANICAL STUDY: Mechanical flexion and compression tests carried out on 8 pairs of femurs of fresh cadavers showed comparable rigidity for the two mounting, SNP and LNP. The difference became apparent at an equivalent load through a perforation in the SNP across the femoral head and by separation of the head from the LNP without any perforation. CLINICAL STUDY: 56 patients operated on between June 1994 and June 1996 were included 30 cases could be followed. There was only one complication: one dismantling of the plate from the diaphysis. The other 29 cases consolidated within an average of 8 weeks without any complications. Locking of the nail was effective and there was never cutting out the head by the nail nor any impaction in the focus of the fracture site. This was despite the fact that, in 12 cases there was advanced demineralization, in 8 cases hypercorrection in valgus, and in 13 cases of misalignment of the nail in the neck, all three of these being recognized as causes of articular deterioration. DISCUSSION: Pertrochanteric fractures currently represent a serious public health problem for which costs are definitely going to grow in the near future. We need a method for solid osteosynthesis simple and relatively inexpensive, but which also avoids the common mechanical complications. The LNP seems to correct SNP problems. This modification represents an improvement and should be used for any unstable pertrochanteric fracture.

Biomechanical Phenomena↗

PubMed1997

Nail abnormalities in rheumatoid arthritis.

Many nail abnormalities have traditionally been described in association with rheumatoid arthritis (RA), but their specificity has never been assessed in a controlled study. Our purpose was to evaluate the frequency and the specificity of nail changes associated with RA in a case-controlled study including 50 patients suffering from RA and 50 controls. For each patient, a general skin examination was performed and the 20 nails were examined. The nail features were noted and classified. A chi 2 test or a Fisher test was used to compare the two groups. The only nail abnormalities significantly associated with RA were longitudinal ridging on nine or 10 finger nails (29 patients in the RA group vs. three in the controls, chi 2: P < 0.001) and clubbing on at least one nail (24 patients vs. 10, chi 2: P < 0.01). Other nail changes were noticed but were not frequent enough to be significant. The presence of longitudinal ridging on the finger nails was significantly associated with RA.

Adolescent↗

PubMed2001

[Incidence of fungal involvement in nail psoriasis].

BACKGROUND AND OBJECTIVE: Because it is clinically so similar, onychomycosis is one of the most important differential diagnostic considerations in psoriatic nail changes. We determined the frequency of fungal involvement in nails of psoriatic patients. PATIENTS/METHODS: Fungal colonization of the nails of psoriatic patients with and without clinically obvious nail changes was investigated in a collective of 250 patients compared to a group of 102 non-psoriatic persons. RESULTS: There was no significant difference in the frequency of nail colonization with dermatophytes and moulds between healthy persons and psoriatics. Yeasts were more commonly found in psoriatic nails. CONCLUSIONS: Nail changes in psoriatic patients are mostly caused by psoriasis. However secondary colonization by yeasts is more common in psoriatic nails than in the general population. It remains to be clarified why dermatophytes are not more common in psoriatic nails.

Comorbidity↗

PubMed1996

[Results of primary unreamed tibial nailing of tibial fractures with severe open or closed soft tissue injuries].

Primary stabilization was performed in 72 tibial fractures with sever open (n = 37) or closed (n = 35) soft tissue injury using unreamed interlocking nails. In 60 (83%) cases the fractures healed without additional procedures. There were 2 cases of osteitis, but both these fractures healed after removal of the nail or after reamed nailing. In 9 patients with delayed union reamed nailing (n = 8) or bone grafting (n = 1) led to healing. In 1 patient with hypertrophic pseudarthrosis, union was achieved after substitution of a reamed nail for the anreamed nail. The infection rate was similar to that observed with external fixation. More secondary procedures, such as bone grafting or a change of the osteosynthesis technique, are necessary with external fixation than with unreamed nailing. Further advantages of unreamed nailing are the internal treatment of the fracture and the patient's greater comfort. Therefore, unreamed nailing can be recommended for the primary treatment of tibial fractures with severe open or closed soft tissue trauma.

Adolescent↗

PubMed2000

Ender nailing for tibial shaft fractures.

During the period from December 1980, when we began using Ender nails for the treatment of tibial shaft fractures, to December 1995, 274 unions of 280 fractures in 275 patients treated by Ender nailing were successfully achieved. Ender nailing for tibial shaft fractures can be classified into three methods A, B, and C, according to the insertion points of the nails. In method A, which is used for the proximal one-third fractures of the tibia, the nails are inserted from the distal tibia medially and laterally towards the proximal tibia. In method B, which is for middle or distal one-third fractures of the tibia, the nails are inserted from the proximal tibia medially and laterally directed distally. In method C, which is for long oblique or double fractures, one nail is inserted from a proximal site, and the other is inserted distally; these two nails must form an X-shape. Ender nailing is an excellent semiconservative treatment for tibial shaft fractures, maintaining adequate elasticity at the fracture sites where much callus is formed, leading to a good union.

Adolescent↗

PubMed2002

Comparison of the bone modeling effects caused by curved and straight nickel-titanium intramedullary nails.

Nitinol (NiTi) shape memory metal alloy makes it possible to prepare functional implants. A curved intramedullary NiTi nail has been shown to cause bending of the bone, bone thickening, increase in cortical area, and reduction in bone longitudinal growth. The purpose of the present study was to find out whether these changes are caused by the bending force of the curved nail or by the intramedullary nailing itself. Pre-shaped intramedullary NiTi nails were implanted in the cooled martensitic form into the medullary cavity of the right femur in 12 rats, where they started to restore their austenitic form, causing a bending force. Straight nails were used as controls in another 12 rats. After 12 weeks, the operated femurs were compared with their non-operated contralateral counterparts and the differences were compared between the groups. Anteroposterior radiographs demonstrated bone bowing only in the curved nail group. Retardation of longitudinal growth was observed in both groups, showing that the growth effect seems to be due to the intramedullary nailing itself. Increase in bone cross-sectional area and cortical thickness were found in both groups. However, this increase was more evident with the curved nail, indicating that the bending force of the functional nail seems to induce these changes.

Journal Article↗

PubMed2002

Nail beauty therapy: an attractive enhancement or a potential hazard?

Nail coatings which harden upon evaporation and coatings that polymerize may produce some reactions at the site of application to the nail itself, and distant reactions when small amounts of nail cosmetics are transferred by the hand to other areas of the skin. Nail cosmetic hazards may be occupational, or accidental, especially in children. Individuals wearing artificial nails tend to wear their nails longer, and are more careful about their nails when washing their hands. The sanitary conditions for the application of artificial nails are therefore paramount in preventing nail infections.

Journal Article↗

PubMed1986

Nail-gun injuries. Accident, homicide, or suicide?

It may be difficult to distinguish industrial accidents from suicide attempts or even assaults or homicide. Nail guns are relatively new industrial tools that can produce severe or fatal injuries. The configuration of the nail on patients' radiographs after such injuries can be helpful in determining the cause of injury. Steel nails that are bent are due to a ricochet and thus indicate accidental injury. Straight-nail injuries to the co-workers of nail-gun users are most likely due to over-penetration of the substance being nailed or accidental mid-air firing; however, intentional injury cannot be ruled out. Extremity injuries caused by straight steel nails in nail gun users are the result of carelessness or poor technique, but suicide should be considered when straight nails cause wounds to the chest, head, or abdomen.

Accidents, Occupational↗

PubMed2000

Interleukin-10 release and monocyte human leukocyte antigen-DR expression during femoral nailing.

This study determined the effect of femoral nailing on the expression of monocyte Class II antigens and interleukin-10 release and sought to differentiate any differences in the release of these elements of immune reactivity in patients undergoing reamed and unreamed nailing. Thirty-two patients presenting with an acute femoral fracture were studied. In 15 patients, the femoral fracture was stabilized with a reamed technique and in 17 patients with an unreamed technique. Venous blood samples were taken at presentation, at anesthetic induction, immediately after nail insertion, and subsequently at 1, 4, and 24 hours and at 3, 5, and 7 days after surgery. Serum interleukin-10 was measured by an enzyme-linked immunosorbent assay, and monocyte human leukocyte antigen-DR expression was quantified by flow cytometry. Serum interleukin-10 release and human leukocyte antigen-DR expression on monocytes showed a clear response to the nailing procedure. The group of patients undergoing a reamed femoral nailing procedure showed significantly higher interleukin-10 release and a significant depression in the expression of human leukocyte antigen-DR on monocytes compared with those whose nail had been inserted unreamed. One patient in the reamed femoral nailing group died of adult respiratory distress syndrome 3 days after injury. Reamed intramedullary nailing appears to be associated with greater impairment of immune reactivity than is the unreamed nailing technique.

Adolescent↗

PubMedDate not supplied

Tibial tubercle-medial malleolar distance in determining tibial nail length.

OBJECTIVE: To assess the accuracy of a previously undescribed method of determining tibial nail length based on anatomic landmarks. DESIGN: Cadaveric study. METHODS: Four methods of tibial nail length determination were compared. Nail lengths for each of fourteen cadaveric lower extremities were determined using full-length scanograms, spotograms, acrylic template overlays, and the distance between the tibial tubercle and the medial malleolus (TMD). Each tibia was then nailed. The accuracy of each method was then evaluated. RESULTS: The full-length scanogram method resulted in incorrect nail lengths in eleven of fourteen (79 percent) cases. Six of fourteen (43 percent) incorrect nail lengths resulted from the use of spotograms. All measurements made with the Template technique yielded nails that were too short (100 percent). The TMD method rendered four of fourteen (29 percent) nails of incorrect size. CONCLUSION: The tibial tubercle-medial distance (TMD) proved an easy, inexpensive, and accurate method of preoperative nail assessment.

Adult↗

PubMed2004

Nonunions of the distal tibia treated by reamed intramedullary nailing.

OBJECTIVE: The purpose of this study is to determine the efficacy of reamed intramedullary nailing in the treatment of nonunions of the distal one-fourth of the tibia. Nonunions of the distal tibia are particularly difficult to treat given the short distal segment, the proximity to the ankle joint, and the fragile soft-tissue envelope. Intramedullary nailing is an attractive solution to this problem because it avoids extensive dissection, and the implant remains intraosseous, posing minimal problem for the soft tissues. DESIGN: Retrospective review of patient charts and radiographs. SETTING: Tertiary care orthopaedic hospital. PATIENTS/PARTICIPANTS: Thirty-two patients with nonunions of the distal one-fourth of the tibia. Prior treatments included casting, internal fixation with plates and screws, intramedullary nailing, and external fixation. Seven patients had a history of infection, but no patient had signs of active infection at the time of surgery. INTERVENTION: Study patients were treated by reamed, locked intra-medullary nailing. MAIN OUTCOME MEASUREMENTS: Main outcome measurements included time to union, correction of deformity, and complications including infection and reoperation. RESULTS: Average length of follow-up was 25 months (range 4-81 months). Twenty-nine out of 32 patients achieved union at an average of 3.5 months after reamed, locked intramedullary nailing. Of the remaining three, 2 patients united after dynamization (one at 4 months after dynamization and the other at 7 months), and the third patient united 4 months after exchange nailing. Deformity was corrected to a maximum of 4 degrees in all planes. Four patients had positive intraoperative cultures, and only 2 required removal of the nail after achieving union to control infection. There were no signs of chronic osteomyelitis in these 2 patients at the date of the last follow-up visit; 5.5 years and 2 years following nail removal. CONCLUSIONS: Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-fourth of the tibia, even in the setting of prior infection or external fixation. It allows for excellent correction of deformity, which is an essential component of the procedure.

Adolescent↗

PubMed2006

Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients.

OBJECTIVE: To compare the rate of Acute Respiratory Distress Syndrome (ARDS) in multiply injured patients with femoral shaft fractures, treated with intramedullary femoral nails inserted with or without reaming. DESIGN: Prospective, randomized, multicenter, clinical trial. SETTING: Seven Level 1 trauma centers. PATIENTS: Three hundred fifteen patients with 322 femoral shaft fractures were stratified into 2 groups according to their estimated injury severity scores (ISS > or =18 vs. ISS<18) and then randomized to receive an IM nail with either reamed or unreamed insertion for primary stabilization of their femoral shaft fracture. One hundred forty seven patients with 151 fractures received an unreamed nail whereas 168 patients with 171 fractures, received a reamed nail. All fractures were nailed within 24 hours after their trauma. INTERVENTION: Closed intramedullary nailing for femoral shaft fractures. MAIN OUTCOME MEASUREMENTS: Determination of the rate of ARDS in patients undergoing intramedullary nailing of femoral shaft fractures. RESULTS: Three of the 63 multiply injured patients who received a reamed nail developed ARDS as compared with 2 out of 46 patients in the unreamed group. This difference was not statistically significant (P=0.42). (The power for this difference is only 5%. 39,817 patients are needed in each group to detect a difference that small.) This difference was not statistically significant. There were a total of 4 deaths, 2 each in both the reamed and unreamed group. No death resulted from ARDS. CONCLUSIONS: The overall incidence of ARDS was found to be low with primary stabilization of femoral shaft fractures with intramedullary nailing. There was no difference in the incidence of ARDS between the reamed and unreamed groups, given the sample size.

Adolescent↗