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At least 667 records · Page 37Linked to original sources
PubMed1999

Exchange nailing for femoral shaft aseptic non-union.

Although rare, non-union of femoral shaft fractures is a cause of significant morbidity. In aseptic non-union, excellent union rates have historically been reported following reamed exchange femoral nailing. However, recently, a high incidence of failure requiring additional procedures has been reported. In light of these concerns and a recent change in our practice to the use of thin solid nails we undertook a retrospective study to determine the efficacy of exchange nailing with these modern nails in our hands. We reviewed records and radiographs of 25 patients who had a reamed exchange femoral nailing for established aseptic non-union. 24 patients (96%) united after exchange without the need for an additional procedure. The mean time to union was 29.75 weeks. Patients who had open bone grafting performed at the same procedure tended to unite quicker, but this did not achieve statistical significance (p = 0.14). Union times were not affected by smoking habits or nail type. This study demonstrates that reamed exchange nailing for aseptic femoral non-union remains an effective treatment. We believe that the nail type is less important than the biological effects of reaming, bone grafting and dynamization.

Adolescent↗
PubMed1997

The deformation of small diameter solid tibial nails with unreamed intramedullary insertion.

'Radiation-independent' aiming systems for the placement of interlocking screws in intramedullary tibial nails have failed because of insertional related nail deformation. Prior to the development of these distal aiming systems, the variable position of the nails' interlocking holes after insertion must be known. In this study, the amount and direction of implant deformation of solid stainless-steel tibial nails (diameters of 8 and 9 mm, n = 20) were analyzed. Measurement of implant deflection (three translations, three angles) in the center of distal transverse locking hole was performed with a three-dimensional-magnetic motion tracker system after nail insertion in paired human cadaver tibiae. The results showed combined mean lateral translation of the 8 and 9 mm nails (n = 20) of -4.5 +/- 3.5 mm (range: 14.3 mm) and dorsal translation -7.8 +/- 5.8 mm (range: 19.2 mm). The combined mean rotational deformation about the longitudinal axis of the nail was 0.3 +/- 0.7 degree (range: 2.4 degrees). The authors conclude that a simple aiming arm, mounted on the proximal nail end alone, is not sufficient to provide accurate distal aiming.

Bone Nails↗
PubMed2004

[Elastic sliding central medullary nailing with osteogenesis imperfecta. Fourteen cases at eight years follow-up].

PURPOSE OF THE STUDY: Elastic sliding centromedullary nailing (ESCN) proposed by Métaizeau in 1987 for the prevention and treatment of limb fractures in osteogenesis imperfecta has never been evaluated. A multicentric serie was studied in order to evaluate results of these procedure. MATERIAL AND METHODS: Thirty-six ESCN procedures were performed in fourteen patients. Percutaneous pinning was used for the femur and distal tibia and arthrotomy for the distal femur as needed and in all cases for the proximal tibia. The pins were bent in compliance with the principles of the ESCN system. The ends of the pins were bent back to form a U pushed into the epiphysis. Reaxing osteotomies required minimal incisions. Age at the first procedure, the number of procedures and complications, and time between procedures were recorded. Pin overlap and the angle formed were also recorded. Pin gliding was evaluated. Ability to walk with or without assistance was noted. RESULTS: The medullary canal measured 4 to 10 mm. The first procedure was performed at a mean age of four years (range 15 days to 10 years). Follow-up was eight years (range 1-12). There were 2.5 procedures per patient (range 1-5). Pins had to be changed in 75% of the bone segments. Mean time between two procedures was 3.2 years. There were no cases of defective sliding or infection. There were four cases of secondary fracture with a mean 30% pin overlap, two pin migrations, one nonunion, and one shortening. The majority of the complications occurred after the age of five years. At last follow-up, three patients could not walk, four walked with aids, and eight without aids. DISCUSSION: The advantages of the technique (size of the pins, nailing without reaming, pin sliding in all cases, low cost) must not overshadow the drawbacks (risk of pin deformation and migration, secondary fracture). Secondary fractures might be limited by discrete valgus of the femoral shaft and preventive pin change when the angle formed approaches 30 degrees and when there is only 30% overlap left. Use of telescopic nails before the age of five years increases the risk of complications while most of the complications observed with ESCN occur after the age of five years. Twenty-five percent of the ESCN complications involved only the femur. The percent of secondary fractures was less than with telescopic nailing (3.6% versus 11%) but there were more cases of nail migration. All pins slid, compared with 6% failure of elongation with telescopic nails. Although proof is not available, surgical treatment of osteogenesis imperfecta before the age of five years appears to provide more rapid functional progress. CONCLUSION: Sliding centromedulary nailing is an attractive alternative before the age of five years. In older children and to the end of growth, telescopic nail or pinning should be discussed although pinning may permit more secondary fractures which can be limited by rigorous surveillance of pin position.

Age Factors↗
PubMed2005

[Centromedullary nailing of the femur for bone metastasis: clinical and radiological evaluation using the Tokuhashi score in 24 patients].

PURPOSE OF THE STUDY: Pluridisciplinary management of patients with metastasis to the femur is well defined, but the choice between palliative surgery or abstention must be decided on the basis of a few evaluated prognostic criteria. We report a series of 24 cases of metastasis to the weakened or fractured femur which was evaluated with the Tokuhashi score and treated by surgery. MATERIAL AND METHODS: Sixteen women and eight men, mean age 71 years (58-89) underwent centromedullary nailing of the femur. These patients had metastases from breast cancer (n = 13 of the 16 women). Twenty of the 24 patients also had other metastases. The Tokuhasi score was > 6 in 16/24 patients. Fourteen patients had pain which did not respond to morphine. Thirteen had fractures and eleven weakened femurs. Time to surgery was six days (1-15). A full nail was inserted in four patients and a reconstruction nail in twenty. RESULTS: Operative time was 93 minutes (57-123). Blood loss was 200 ml (150-350). There were no intraoperative complications (fat embolism) excepting increased comminution. Hospital stay was 23 days (8-55). Survival was 148 days (8-510) for patients with fractures and 272 days (12-730) for patients with weakened femurs. Eight patients with a fractured femur died (six within the first three postoperative weeks), two among those with preventive nailing. On average, weight bearing among the surviving patients with nailing for fracture was achieved on the 57th postoperative day (30-90). Only six patients required morphine early after surgery. Centromedullary nailing successfully relieved pain in all patients with an isolated metastasis. Mean survival in patients with a Tokuhashi score < 3 was 2.1 months. It was 17 months in those whose score was > 6. CONCLUSION: Centromedullary nailing for fractured or weakened femur due to metastasis is a useful therapeutic solution for patients with short life expectancy. With this technique, antalgesics can be reduced while preserving independence as long as possible. The Tokuhashi score is easy to establish. If it is less than 3, centromedullary nailing should not be attempted due to the short expected survival.

Aged↗
PubMed2002

Nail morphology studies as assessments for onychomycosis treatment modalities.

The purpose of this investigation was to study the morphology of the human nail treated with chemical penetration enhancers (CPE), bioadhesives and surface modifiers for assessment of topical treatment modalities for onychomycosis. CPEs, including dimethyl sulfoxide (DMSO) and urea were applied to human nail samples. Additional samples were treated with surface modifiers, tartaric acid (TTA) and phosphoric acid gel (PA). Other nail specimens were subjected to the bioadhesive polymers Carbopol 971P and Klucel MF. Atomic force microscopy (AFM), scanning electron microscopy (SEM) and polarized light microscopy (PLM) were utilized to visualize nail morphology and topographical changes of the human nail samples subjected to the various chemical agents. AFM, SEM and PLM micrographs revealed changes in topography to the dorsal layer when CPEs and surface modifiers were applied. Roughness scores as determined by NANOSCOPE IIIA software indicated a 2-fold increase when the dorsal nail layer was subjected to PA versus the control (147.8 vs. 85.0 nm, respectively). In contrast, when carbomer 971P was applied to the dorsal surface, roughness scores decreased significantly (44.6 vs. 85.0 nm, respectively). AFM, SEM and PLM studies of the human nail subjected to various chemical agents may be useful in the design and formulation of novel drug delivery systems for the topical treatment of onychomycosis. The AFM studies offer both a qualitative and quantitative assessment for nail treatment opportunities.

Analysis of Variance↗
PubMed2000

Development of small diameter intramedullary nails made from ISO 5832-9 stainless steel.

BACKGROUND: In order to improve strength in small diameter intramedullary nails, a system was designed in which the implants were manufactured from 30% coldworked ISO 5832-9 stainless steel. METHODS: Nail diameters were 9 and 10 mm for the femur, and 8 and 9 mm for the tibia. The nails were solid rods and the screws were partially threaded. Pre-clinical bending yield tests established that the 8-, 9- and 10-mm diameter rods had strengths comparable, respectively, with 10-, 12- and 14-mm diameter Grosse-Kempf nails. Forty-eight femoral and 98 tibial shaft acute fractures were treated with this system. Postoperatively, patients were allowed to gently bear weight as tolerated. RESULTS: There was one broken nail, occurring 10 months after femoral nailing. There were six broken screws, occurring between 3 and 6 months postoperatively in two patients and after more than 6 months in four patients. The broken screws had no adverse clinical effect. Five patients required late bone grafting or exchange nailing, and 15 patients required dynamization. CONCLUSION: This design of small diameter locked intramedullary nails was strong enough to allow early weightbearing.

Adolescent↗
PubMed1999

The surface anatomy of the germinal matrix of the nail bed in the finger.

Nail spicules result from incomplete excision of the nail matrix of the finger. We report a histological study to delineate the surface anatomy of the nail matrix. Sections were cut longitudinally and transversely in 19 fingertips. The proximal midline extent of the nail matrix was measured and expressed as a ratio of the distance from the nail fold to the distal interphalangeal joint. In the lateral sections, the angle subtended between the midline vertical and the lateral extent of the nail matrix was measured. The mean ratio of the proximal extent was 0.55 in the midline and the lateral angular extent was 66 degrees. The authors recommend that excision of the nail matrix should be rectangular, extending to the midlateral lines and proximally to a point three-quarters of the distance from the nail fold to the distal interphalangeal joint crease.

Adult↗
PubMed2000

Nail involvement in pemphigus vulgaris.

Nail involvement in pemphigus vulgaris is relatively rare. We describe a case of severe pemphigus involving both the skin and oral mucosa in which an acute exacerbation was preceded by the onset of nail involvement of all 4 extremities. Nail involvement occurred in the form of hemorrhagic paronychia of multiple digits. Oral, cutaneous, and nail manifestations of the disease were all well controlled by systemic therapy. A review of the literature on nail involvement in pemphigus reveals that this involvement may be manifested in multiple ways, with chronic paronychia and onychomadesis being the most common. Involvement of the nail occurs most frequently either as part of the initial presentation, or just before or concurrent with a flare of pre-existing disease. Nail involvement, when it occurs, is usually present when the disease is severe. Topical therapy is insufficient, and systemic therapy is warranted. In the majority of cases, nail recovery is complete, with no residual damage.

Foot↗
PubMed2000

Dermatopharmacology of ciclopirox nail lacquer topical solution 8% in the treatment of onychomycosis.

Ciclopirox is a synthetic hydroxypyridone antifungal agent. In contrast to the azoles, glucuronidation is the main metabolic pathway of ciclopirox; therefore interactions with drugs metabolized via the cytochrome P450 system are unlikely Ciclopirox is also distinct from the common systemic agents, which interfere with sterol biosynthesis. In fact, ciclopirox chelates trivalent cations (such as Fe3+), inhibits metal-dependent enzymes that are responsible for degradation of toxic metabolites in the fungal cells, and targets diverse metabolic (eg, respiratory) and energy producing processes in microbial cells. Ciclopirox is a broad spectrum antimicrobial with activity against all the usual dermatophytes as well as yeast and nondermatophyte molds. It has demonstrated activity against gram positive and negative bacteria, including resistant strains of Staphlococcus aureus. Ciclopirox exhibits fungal inhibitory activity (minimum inhibitory concentration < 4 microg/mL for dermatophytes) as well as fungicidal activity; to date resistance to the drug has not been identified. Ciclopirox has been formulated in a nail lacquer delivery system. After evaporation of volatile solvents in the lacquer, the concentration of ciclopirox in the remaining lacquer film reaches approximately 35%, providing a high concentration gradient for penetration into the nail. Radiolabel data demonstrate penetration into infected nails after only 1 application of the lacquer. Ciclopirox nail lacquer is a topical product that provides an active fungicidal agent in a delivery system capable of promoting nail penetration. With repeated applications, the antifungal agent is homogeneously distributed through all layers of the toenail achieving concentrations of ciclopirox in excess of inhibitory and fungicidal concentrations for most pathogens. Although ciclopirox readily penetrates nails, very low levels of ciclopirox are recoverable systemically, even after chronic use. Ciclopirox nail lacquer 8% is a topical product that provides an active fungicidal agent in a delivery system capable of penetrating nails.

Administration, Topical↗
PubMed1990

Effect of various dietary factors on the deposition of selenium in the hair and nails of rats.

Noninvasive techniques to monitor selenium (Se) status at higher intake levels should be developed if Se supplements are to be given to human subjects as possible anti-cancer agents. Hair and nails have been suggested as indices of Se status because they are easily obtained, transported and stored. However, there has been little research on the potential influence of such factors as dietary Se intake or nutritional status on the levels of Se in hair and nails. Here we report the effects of chemical form of dietary Se and of methionine (Met) status on the Se content of rat hair and nails. Rats were fed diets containing 0.5, 1.5 or 2.5 micrograms/g of Se as sodium selenate (Na2SeO4) or L-selenomethionine (SeMet) for 8 wk. Hair and nail Se retention was two- to threefold greater when dietary SeMet was fed. Hair and nail Se levels increased as liver and muscle Se retention increased in rats fed SeMet, whereas in rats fed Na2SeO4, hair, nails and liver accumulated Se but muscle Se levels remained relatively unchanged. In a second experiment, rats were fed diets containing 0.1, 0.5 or 2.5 micrograms/g of Se as Na2SeO4 or SeMet, +/- added Met (0.3%) for 6 (+Met) or 7 (-Met) wk. Hair and nail Se retention was greater when Met was deficient than when this amino acid was not limiting. These results suggest that factors other than dietary Se intake affect hair and nail Se content and that these tissues should be used with caution for Se status assessment purposes.

Animals↗
PubMed2006

The relationship between the extensor tendon enthesis and the nail in distal interphalangeal joint disease in psoriatic arthritis--a high-resolution MRI and histological study.

OBJECTIVES: Diffuse swelling of the distal interphalangeal (DIP) joint beyond the joint margin is a common feature of arthritis in psoriatic arthritis (PsA). The purpose of this study was to explore the microanatomical basis for the inflammation and nail disease in PsA using a combined high-resolution magnetic resonance imaging (MRI) and histological studies. METHODS: High-resolution MRIs of the DIP joint were obtained in 30 subjects [10 PsA, 10 osteoarthritis (OA) and 10 normal volunteers]. The relationship between the DIP joint capsule and associated tendon enthesis and the nail bed and root were evaluated. Histological studies to define the relationship between the normal cadaveric DIP joint capsule and the nail root were performed on the middle and ring fingers of 10 dissecting room cadavers. RESULTS: On MRI, the dorsal capsular enthesis was the epicentre of an inflammatory reaction. This extended to involve the soft tissues adjacent to the nail in 8 of 10 cases in PsA, but only 4 of 10 cases in OA where the inflammation is less intense and in none of the normal fingers. The DIP joint capsule was intimately linked with the nail complex on histology, with the dorsal, volar and lateral aspects of the nail bed being ensheathed in fibres extending from the entheses. CONCLUSION: The study suggests that the extended nature of the enthesis organ associated with the DIP joint may explain the diffuse nature of the inflammatory response around the nail in PsA. Therefore the nail is as much an integral part of the enthesis organ as it is of the skin, which has implications for a better understanding of the disease.

Adolescent↗
PubMed1998

The effect of reamed and nonreamed intramedullary nailing on fracture healing.

Intramedullary nailing has revolutionized the treatment of fractures. It is important to be aware of the biological and mechanical effects of reaming and nailing on bone. Most nails are substantially stiffer than bone, but because of their location in the medullary canal do not have nearly as adverse an effect on callus strength as plates. Reaming and nailing embolizes marrow contents into the systemic circulation and reduces blood flow to the total bone and cortex by 30% to 80%. This results in a hyperemic reaction that revascularizes the cortex depending on the type of nail used. Preservation of the soft tissue envelope around the fracture enhances this response resulting in fracture healing ratio of 98% when closed nailing techniques are used. The primary advantage of nonreamed nailing is better preservation of the blood supply to the cortex whereas the major advantage of reamed nailing is a more rigid construction, stronger implants, and earlier fracture union.

Biomechanical Phenomena↗
PubMed2002

Biomechanical evaluation of the proximal femoral nail.

In 1997, the proximal femoral nail was introduced for treatment of peritrochanteric femoral fractures. Treatment results show a low complication rate. The most serious complication is cutout of the hip pin and femoral neck screw. Considerable load on the hip pin is thought to facilitate cutout. The biomechanical behavior of the hip pin and the femoral neck screw as part of the standard proximal femoral nail, and of an experimentally modified proximal femoral nail (in which the hole through the nail for the hip pin is modified to a slot) was studied. In the standard proximal femoral nail, the amount of the total load carried by the hip pin varies between 8% and 39% (mean, 21%). If the hip pin passes through a slot in the nail, it carries 2% to 8% (mean, 5%) of the load. The nonconstrained lateral end of the hip pin reduces the bending load applied to the implant. The slotted hole for the hip pin also allows the femur and the nail to medialize, even if the hip pin and femoral neck screw lose parallelism. The prevalence of cutout of the proximal femoral nail may be reduced by introduction of this mechanism.

Biomechanical Phenomena↗
PubMed1994

Nonunion of the tibia treated with a reamed intramedullary nail.

Forty-seven tibial nonunions were treated with a reamed intramedullary nail. Initially, there were 14 (30%) closed and 33 (70%) open tibial fractures. The initial fracture management consisted of casts in 12 (26%) patients, Ender or Lottes nails in nine (19%), and external fixation in 26 (55%). The time from injury to nailing averaged 31.5 weeks. All but one fracture was nailed using a closed technique (98%). Twenty-six patients were initially managed with external fixation. Duration of fixation averaged 11 weeks, and the time from fixator removal to nailing averaged 24 weeks. Patients were followed for an average of 18.7 months after nailing. Forty-two of the 47 (89%) nonunions united uneventfully. Infection developed in six (13%) patients, five of which occurred in previously open fractures treated with external fixation. After one or more procedures, these nonunions consolidated without apparent infection. Reamed intramedullary nailing is a safe and effective method of treatment for tibial nonunions of previously closed fractures and prior open fractures that have been treated with Ender or Lottes nails. Because of the risk of infection, we do not recommend its use after external fixation of open fractures.

Adult↗
PubMed1995

Nonreamed nailing of tibial diaphyseal fractures in blunt polytrauma patients.

The efficacy of nonreamed nailing as the treatment of choice of unstable blunt tibial diaphyseal fractures was studied. From March 1, 1990, through August 31, 1991, 72 patients with 74 fractures that required fixation were treated. One patient died and six were lost to follow-up, leaving 65 patients with 67 fractures. Follow-up averaged 21 months (range 5-43). Fisher's exact and logistic regression analyses were used to compare grades of open fractures, comminution as classified by Winquist, and dynamic and static nailings. The failure rates of 51 titanium and 16 stainless steel nails were compared. Times to union were compared by the log rank statistic method. The average time to union was 32 weeks with 26 (39%) additional operations required to achieve union; 13 dynamizations (12 successful), 12 exchange nailings (11 successful), and one plate and bone graft. The rate of reconstructive procedures to achieve union was a more sensitive indicator of difficulties achieving union than was time to union. Reoperation rates were 33% for closed or grade I and II fractures compared with 46% for grade III fractures (NS). Among closed grade I and II static versus dynamic nailing, times to union were 36 versus 25 weeks (p < 0.01), and the reoperation rates were 44% versus 13% (p < 0.04). Winquist I and II fractures required a 24% reoperation rate versus 53% for grade III and IV and segmental fractures (p < 0.01). Static locked fractures required a 48% reoperation rate versus 12% for dynamic locked fractures (p < 0.01). A logistic regression analysis demonstrated that locking mode was the most important factor in determining reoperation rates. Fifteen additional reoperations for infection, broken or painful implants, or to remodel bones that united with an incomplete circumference of cortex were performed. With an additional 12 elective nail removals, the total reoperations numbered 53 (79%). Titanium alloy nails had a 2% failure rate versus 25% for stainless steel nails (p < 0.01). Two of 28 (7%) grade III fractures became infected. All fractures united within 10 degrees of normal alignment and 1 cm of length. Nine (13%) united with an incomplete cortical circumference, refractory to dynamization and full weight bearing. Thirteen of the 58 (22%) fractures available for an evaluation of ankle motion were symptomatic, with < 10 degrees of dorsiflexion.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1995

Distal femoral nonunion: treatment with a retrograde inserted locked intramedullary nail.

Between March 1989 and August 1993, 16 distal femoral nonunions (16 patients) were treated using the supracondylar intramedullary nail. The time between the initial event and retrograde nailing averaged 33 months. The nonunion level was infraisthmal in four patients and supracondylar in 12. Operative technique involved retrograde insertion of a reamed supracondylar intramedullary nail through the intercondylar notch. Follow-up was available on all patients and averaged 20 months (range 9-46). Four nonunions (25%) united with a single surgery at an average of 17 months. A fifth nonunion united at 21 months after nail dynamization and subsequent nail breakage. The nonunions of two additional patients united after exchange of a broken retrograde nail. Additional surgical procedures were performed in six of the remaining nine patients in an attempt to gain union. At an average follow-up of 16 months (range 9-23), none of the nine had united. Nine nails fractured at an average of 11 months, all through a screw hole near the nonunion. Based on these results, we cannot recommend use of the supracondylar intramedullary nail in its present form for the treatment of distal femoral nonunions.

Adult↗
PubMed1996

Management of humeral nonunion after the failure of locking intramedullary nails.

We reviewed 21 cases of humeral nonunion following the failure of "locking" humeral nails. The nails had been inserted as the primary operative procedure following humeral fracture in fifteen cases or after the failure of closed treatment in six cases. Reconstruction after the failure of these implants was complicated by poor bone stock and difficulty in achieving union. Although technically difficult, open reduction and internal fixation with plating and bone grafting (successful in nine of nine cases) was more consistent than exchange nailing (successful in four of 10 cases) in achieving union (p = 0.01). Two patients refused further surgical intervention. The degree of bone loss associated with a loose nail, the lack of success of exchange nailing, and the insertion site morbidity associated with humeral nail removal differentiate these nonunions from similar lower extremity problems. The degree of bone loss following failed locking nailing of the humerus is a major concern, and exchange nailing alone may not be an acceptable option to deal with this problem.

Adolescent↗
PubMed1997

Compartment pressures during nonreamed tibial nailing without traction.

OBJECTIVE: To assess the intracompartmental pressure changes during the nailing of acute tibia fractures with the extrinsic factors of 90 degrees/90 degrees positioning, posterior thigh posts, continuous traction, and remaining removed. STUDY DESIGN: Prospective case control. METHODS: Fifty-eight acute tibia fractures were nailed using an unreamed technique without leg elevation, thigh post, or continuous traction. Two presented with compartment syndrome and had fasciotomy before nailing. Thirty of the remaining fifty-six tibias had continuous intracompartmental pressure monitoring of the anterior compartment. RESULTS: The highest pressures were routinely seen during manual reduction of the fracture (20-58mms Hg; avg = 34mm Hg) and during nail passage (15-56mms Hg; avg = 26mms Hg). In fifteen tibias, the pressure rose to within 30mmg Hg of the diastolic pressure and in 12 tibias the pressure exceeded 40mmg Hg. The pressures in all cases returned to baseline immediately following nail passage (avg = 13.8mms Hg). No sequelae of compartment syndrome was found in any of the 56 tibias presenting without compartment syndrome. There were no iatrogenic compartment syndromes in the series. CONCLUSION: When extrinsic factors that increase intramedullary pressures are avoided, then intramedullary nailing raises the intramedullary pressure only momentarily. The pressure peaks during manual reduction and nail passage, and then returns to normal before the patient is awakened. Intramedullary nailing performed without reaming or traction is safe with respect to compartment syndromes and continuous pressure is not required.

Adolescent↗