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PubMedDate not supplied

A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft.

OBJECTIVES: To determine if there are differences in healing, complications, or number of procedures required to obtain union among open and closed tibia fractures treated with intramedullary (IM) nails inserted with and without reaming. DESIGN: Prospective, surgeon-randomized comparative study. SETTING: Level One trauma center. PATIENTS: Ninety-four consecutive patients with unstable closed and open (excluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997. INTERVENTION: Interlocked IM nail insertion with and without medullary canal reaming. MAIN OUTCOME MEASURES: Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union. RESULTS: For open fractures, there were no significant differences in the time to union or number of additional procedures performed to obtain union in patients with reamed nail insertion compared with those without reamed insertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary procedures were needed to obtain union after unreamed nail insertion for the treatment of closed tibia fractures, but the difference was not statistically significant given the limited power of our study (p = 0.155). Broken screws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncompliant with weight-bearing restrictions. There were no differences in rates of infection or compartment syndrome. CONCLUSION: Our findings support the use of reamed insertion of IM nails for the treatment of closed tibia fractures, which led to earlier time to union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.

Adolescent↗
PubMed2002

Second generation intramedullary nailing of subtrochanteric femur fractures: a biomechanical study of fracture site motion.

OBJECTIVES: To compare fracture site motion between different second-generation intramedullary nails used to fix subtrochanteric fractures of the proximal femur with and without femoral neck fractures. DESIGN: Nondestructive mechanical testing of four types of femoral intramedullary nails was undertaken to evaluate fracture site motion using a model that simulated single-leg and double-leg stance. METHODS: Three types of reconstruction nails (the Russell-Taylor Delta [Smith & Nephew, Memphis, TN], the Uniflex [Biomet, Warsaw, IN], Alta CFX [Howmedica-Osteonics, Rutherford, NJ]) and the Long Gamma nail (Howmedica-Osteonics, Rutherford, NJ), each measuring 11 x 380 mm, were inserted in fiberglass composite femurs. Four fracture patterns were studied (transverse subtrochanteric, subtrochanteric with posteromedial wedge comminution, subtrochanteric with one-centimeter gap, and a one-centimeter gap with a subcapital neck fracture). Single-and double-leg stance loading was simulated using a servohydraulic load frame (MTS, Eden Prairie, MN). Two-way analysis of variance and post hoc t tests were used to determine any statistically significant differences between groups. RESULTS: In single-leg stance there were significant differences in coronal plane rotation, shear, and axial translation across the subtrochanteric fracture site between the different nail types and the different fracture patterns (p < 0.001). In double-leg stance there were significant differences in coronal plane rotation and femoral head vertical motion between the different nail types and the different fracture patterns (p < 0.001), and there were significant differences in shear and axial translation between the different fracture patterns (p < 0.001) but not the different nail types (p > 0.05). CONCLUSIONS: For simple, well-reduced fractures the choice of implant is not critical. As fracture severity increased (comminution, gap, and combined neck fracture), the choice of implant, particularly with reference to proximal nail dimensions and implant materials, was a significant factor in reducing fracture site motion. Therefore, our laboratory data suggest that when subtrochanteric fractures are unstable (e.g., comminution, segmental bone loss) and early weight bearing is desirable, the choice of implant is critical and should be restricted to implants that allow minimal fracture site motion (Long Gamma and Russell-Taylor).

Biomechanical Phenomena↗
PubMed2003

Optimal entry point for retrograde femoral nailing.

OBJECTIVE: The purpose of this study is to identify the optimum entry point for retrograde femoral nailing, defined as that point which will provide adequate fracture alignment while minimizing soft-tissue and articular cartilage injury. DESIGN: Cadaveric study. SETTING: Biomechanics laboratory. MAIN OUTCOME MEASURE: Anatomic relationships and fracture reduction. METHODS Eleven cadaveric femori with attached knee joints underwent retrograde femoral nailing with a Synthes femoral nail (Synthes, Paoli, PA, U.S.A.). After placement of the nail, the specimens underwent an osteotomy 3 inches proximal to the articular surface. Multiple entry points were tested to determine fracture alignment and extent of articular cartilage injury. Medial-lateral and anterior-posterior displacements, in addition to any soft-tissue or articular surface trauma, were recorded for these various points of entry. RESULTS: An entry point of 1.2 cm anterior to the femoral origin of the posterior cruciate ligament resulted in the least anterior-posterior displacement of the femoral shaft following fracture. In the coronal plane, an entry point at the midpoint of the intercondylar sulcus was identified as minimizing the displacement following fracture. This ideal position allows for proper seating of the nail within the intercondylar sulcus, resulting in minimal damage to the articular cartilage and posterior cruciate ligament and minimal disruption of the patella femoral joint. CONCLUSION: Retrograde femoral nailing should be used cautiously in select patients, when conventional antegrade nailing cannot be used, due to the unavoidable injury to the knee articular surface associated with this technique. The optimum entry point of 1.2 cm anterior to the femoral posterior cruciate ligament origin and centered in the intercondylar sulcus provides the optimal balance of fracture reduction and knee joint sparing. It may be difficult to target this site with a percutaneous technique and may require direct visualization of the intercondylar sulcus for ideal nail placement.

Anterior Cruciate Ligament↗
PubMed2004

Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up.

OBJECTIVE: To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures. DESIGN: Prospective, randomized. SETTING: Level 1 trauma center. PATIENTS: Forty-five patients with displaced closed and open Gustilo type I-IIIA fractures of the central two thirds of the tibia. INTERVENTION: Stabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail. MAIN OUTCOME MEASUREMENTS: Nonunions, time to fracture healing, and rate of malunions. RESULTS: The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements. CONCLUSION: Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails.

Adolescent↗
PubMed1984

Immediate closed antegrade Ender nailing of femoral fractures in polytrauma patients.

Fifty-four trauma patients with 61 femoral fractures stabilized within the first 24 hours of admission by closed antegrade Ender nailing were included in this study. This technique involves the insertion of Ender nails from a portal at the proximal end of the femur through the piriformis fossa. The curved distal ends of the nails were distributed throughout the distal femur to achieve greater purchase in the enlarged medullary canal of the distal fragment. This technique was used in one proximal, 20 midshaft, 37 distal, and three segmental fractures. There were 51 closed fractures, eight Grade I open, and two Grade II open fractures. The average age of the patient was 26 years, and the majority had polytrauma. The operative procedure was well tolerated by this group of patients. Pulmonary care was improved by avoidance of traction and enhanced capability for mobilization. Forty-two patients with 49 femoral fractures were available for complete follow-up. Forty-five fractures healed with the average time to appearance of bridging callus being 33 days, and average time to full union remodeled callus being 5.9 months. There were four nonunions, one delayed union, and eight malunions. There were nail protrusions in 22 cases (19 proximal and three distal). Fourteen patients required a second operation for reimpaction of the protruding nails or premature nail removal. These results were inferior to those obtained with the use of the retrograde Ender nailing technique or the Kuntscher nail. This technique should be used only if other techniques are unavailable or inappropriate, and only for stable, noncomminuted fractures.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma.

We investigated the effects of primary (< or = 24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in patients with multiple trauma. Two groups were separated: the group with primary femoral nailing with reaming (group RFN) was submitted to femoral nailing after reaming of the medullary canal; in the group with unreamed femoral nailing (group UFN) a small-diameter solid nail was inserted without reaming. Lung function was assessed by oxygenation ratio (PaO2/FIO2), and pulmonary hemodynamics by intraoperative pulmonary artery catheter measurements. Central venous blood concentrations of elastase and the platelet count were determined during and 3 days after surgery. Lung function was stable in UFN patients (n = 14), but deteriorated in RFN patients (n = 17) from 353 +/- 24 (PaO2/FIO2 preoperatively) to 260 +/- 28 (PaO2/FIO2 postoperatively) (p < 0.05) and improved only after 48 hours. Pulmonary artery pressure (PAP) did not change during surgery in UFN patients; in RFN patients PAP increased from 27.2 +/- 3.1 mm Hg (preoperatively) to 36.3 +/- 4.1 mm Hg (p < 0.05) upon reaming and normalized 1 hour after insertion of the nail. Femoral nailing after reaming represents a potential risk with respect to lung function disturbances. This might trigger the development of adult respiratory distress syndrome (ARDS), especially in patients at extra risk of this complication (additional lung contusion, "borderline patient"). In these cases unreamed femoral nailing might offer an alternative by allowing primary intramedullary stabilization without the risk of adverse effects to the lung.

Adult↗
PubMed1998

Muscle perfusion after intramedullary nailing of the canine tibia.

BACKGROUND: Intramedullary nailing with and without reaming leads to a reduction in cortical bone blood flow. The repair of the devascularized bone is mediated principally by the surrounding soft-tissue envelope. The objective of this study was to determine the effect on muscle blood flow of reamed and unreamed intramedullary nailing techniques. METHODS: Midshaft tibial osteotomies to create a 2.5-cm segment of devascularized tibial cortex were performed in 19 adult canines. The tibia was stabilized with a locked intramedullary nail without reaming in 9 animals and with intramedullary reaming in 10 animals. In the unreamed group, the tibia was stabilized with a loosely fitting (n = 4) or a tightly fitting (n = 5) locked nail. In the reamed group, limited reaming (n = 5) or standard reaming (n = 5) was performed. Muscle perfusion was measured in the anterior compartment musculature of the hind-limb using laser Doppler flowmetry. RESULTS: Overall muscle perfusion was greater in the reamed group than in the unreamed group at the conclusion of the nailing procedure (p = 0.0001) and at 5 weeks (p = 0.0008) and 11 weeks after nailing (p = 0.001). The degree of canal fit of the intramedullary nails and the extent of reaming before nail insertion did not further influence muscle circulation. CONCLUSION: The results of this study demonstrate that in the presence of an intact soft-tissue envelope, intramedullary reaming of the canine tibia has a major effect on increasing the circulation to the surrounding muscles. The increased extraosseous circulation may have implications for fracture healing.

Animals↗
PubMed2000

Correction of pincer-nail deformity using dermal grafting.

Pincer-nail syndrome has been described as distortion in the shape of the nails with excessive transverse curvature of the plate that increases from proximal to distal, leading to pinching and loss of soft tissue in the affected digit, resulting in severe pain. Many treatments have been recommended, but an effective long-term method that preserves the nail matrix has not been described. A method of dermal grafting under the nail matrix is described, and the results of treatment of six digits are reported. Five women and one man with an average age of 52 were treated. The affected digit was the thumb in four patients and the great toe in two patients. Follow-up averaged 25 1/2 months. The results were good in all cases with only one side of one nail remaining slightly curved. Pain was relieved in all cases, and complete adherence of the new nail plate occurred. Dermal grafting seems to provide excellent long-term treatment of the pincer-nail deformity with preservation of the nail matrix.

Adult↗
PubMed2004

Femoral nail removal should be restricted in asymptomatic patients.

Femoral nail removal has been suggested as a routine procedure for symptomatic and asymptomatic patients. The aim of this study was to evaluate whether asymptomatic patients have long-term complaints after femoral nail removal. Additionally, factors that might extend operation time and effect soft tissue healing negatively were analyzed. A retrospective study on the removal of 164 femoral nails after fracture consolidation was done. A review of the patient charts and radiographs was done. Neither the interval between nail implantation and nail removal or the use of an end-cap significantly influenced the operation time. The surgeon's qualification and nail depth were the only variables that influenced operation time. Neither operation time, nail depth, surgeon's qualification, nor the grade of heterotopic ossification significantly influenced the incidence of wound healing problems. One hundred nine patients (73%) were available for the followup interview. Preoperatively, 58 patients (53%) had local complaints. Of these 58 patients, 78% reported improvement and 7% reported an aggravation of their local complaints. Of the 51 patients who were asymptomatic before surgery, 20% reported long-term complaints at followup. Only symptomatic patients should be considered for femoral nail removal.

Adolescent↗
PubMed2005

Application of the palmar pocket method for total nail reconstruction without vascular anastomoses.

We present a case of a nail defect, which was reconstructed by free composite nail combined with the palmar pocket method without vascular anastomoses. A 40-year-old man lost his nail of the right middle finger by trauma 1 year ago. A total nail composite graft, composed of germinal and sterile matrices, and proximal nail fold, from which the nail plate was removed, was harvested from the ipsilateral first toe and was grafted on the right middle fingertip. The grafted nail was inserted into the palmar subcutaneous pocket. Fourteen days after the first operation, the grafted part was removed from the pocket, and active bleeding was noted on the sterile matrix. Seven months after the second surgery, the nail had grown and had an almost normal appearance. There was no conspicuous scar at either the recipient or the donor site.

Adult↗
PubMed1993

Coexpression of keratins characteristic of skin and hair differentiation in nail cells.

To further investigate the differentiation of nail, this study examined the composition and expression patterns of nail keratin by using monoclonal antibodies specific for keratins characteristic of skin or hair differentiation. Immunoblotting studies revealed that bovine hoof plate contains skin and hair differentiation-specific keratins, whereas immunofluorescence staining also showed that both keratins were present in the suprabasal cells in the bovine nail matrix. Skin differentiation-specific keratins were found to be expressed in the apical and dorsal nail matrices, whereas the hair differentiation-specific keratins were expressed mainly in the ventral nail matrix and partially in the apical and dorsal nail matrices. Moreover, the localization of the two types of keratins partially overlapped. Double-label immunofluorescence showed that unusual keratinocytes that co-express skin and hair differentiation-specific keratins exist in the nail matrix. These results indicate that the nail matrix consists of both skin-type and hair-type differentiating cells and, additionally, intermediate keratinocytes that may be progressing the pathways of both skin and hair differentiation.

Animals↗
PubMed1995

Early events in the invasion of the human nail plate by Trichophyton mentagrophytes.

A new in vitro model for the study of nail invasion by dermatophyte fungi was developed. The dermatophyte Trichophyton mentagrophytes, and fragments of finger-nails and toe-nails were used. Arthroconidia were inoculated on the ventral surface of the nails. After 6 h, adherence and germination of arthroconidia was observed. By 16 h, small germ tubes with side branches were evident. At about 24 h, micro-colonies had become established. At 48 h, a mycelium had formed, and at about 72 h most of the nail fragment was covered with fungal growth. Nail penetration occurred from the ventral surface through the intercellular spaces, and with longer incubation all three layers were invaded by arthroconidia growing through channels. Nail invasion occurred in the absence of added nutrients. Dermatophyte fungi appeared to invade the nail by a combination of mechanical and chemical factors. The model provides a substrate to study the pharmacokinetics and bioavailability of new antifungal agents in situ.

Humans↗
PubMed2004

Bowen's disease of the nail bed.

A 77-year-old man presented with a 2-year history of left thumbnail dystrophy, purulent discharge and aching pain. There was no history of trauma. On examination there was a linear area of nail dystrophy and dyschromia of the nail bed. The nail plate was thinned proximally. No other digits were affected. There was no lymphadenopathy. X-ray of the digit was normal. Longitudinal nail biopsy revealed Bowen's disease along the length of the nail bed and nail matrix specimen. After avulsion of the nail plate, the nail matrix and tumour were fully excised. The defect was repaired with a split-skin graft. His symptoms were relieved.

Aged↗
PubMed1996

Treatment of humeral shaft fractures with the Seidel intramedullary nail.

BACKGROUND: The use of intremedullary nails for the management of humeral shaft fractures has been controversial. Recently, the Seidel nail has become available. The purpose of this study was to review our initial experience with the Seidel nail. METHODS: A retrospective clinical and radiographic review of 25 consecutive patients treated with Seidel intramedullary humeral nail was performed. The nail was used for non-union in 10 patients, delayed union in four, acute fracture in eight and pathological fracture in three. Eighteen of the 19 survivors were clinically reviewed at an average of 15 months (range 8-15). Pain, function, satisfaction, shoulder power, range of motion and clinical outcome were graded using the UCLA shoulder score. RESULTS: Pain was present at the shoulder in four patients and at the fracture site in nine. Average shoulder abduction was 99 degrees and nine patients could not abduct the shoulder past 90 degrees. Sixty-six percent of patients reviewed were graded as only fair or poor using the UCLA shoulder score. In three patients rotational control was not achieved with the distal locking device at the time of surgery. Complications included non-union in 10 patients and three intra-operative fractures. CONCLUSIONS: Non-union was more likely to occur if rotational control was not obtained, or if the patient had the nail inserted for a previous non-union. Use of the Seidel nail frequently leads to shoulder pain and dysfunction. The distal locking device is unreliable and predisposes to non-union. We do not recommend the continued use of the Seidel nail.

Adolescent↗
PubMedDate not supplied

Yellow nail syndrome in three siblings: a randomized double-blind trial of topical vitamin E.

Yellow nail syndrome is an uncommon disorder characterized by dystrophic nails, lymphedema, and respiratory disease. It has rarely been reported in children and this is the first report of congenital yellow nails in siblings. The purpose of this study was to determine whether topical vitamin E applied to the nail plates and periungual skin would affect the growth rate or appearance of the fingernails in patients with congenital yellow nail syndrome. This study was the first trial of a treatment for this entity in children and the largest randomized double blind trial to date. We found that vitamin E solution had no significant effect (p = 0.84) on fingernail growth or the global appearance score (p = 1.0) when compared with placebo. The average growth rates and global assessment scores improved and onycholysis and onychomadesis decreased from baseline with both vitamin E and placebo treatment, although these were not primary end points of the study. Topical vitamin E did not result in a statistically significant improvement when compared with oil alone for the treatment of the nails in our three patients with yellow nail syndrome. However, it is interesting and perhaps clinically useful that both vitamin E and placebo oil improved the condition of the nails.

Administration, Topical↗
PubMedDate not supplied

An in vitro biomechanical investigation of an interlocking nail for fixation of diaphyseal tibial fractures in adult horses.

The compressive, bending and torsional mechanical properties of osteotomized adult equine tibiae stabilized with an interlocking intramedullary nail (nail-tibia composite) were compared with those of intact tibiae to determine the clinical applicability of the the nail for repair of tibial fractures in adult horses. The mean yield load, failure load, and stiffness for the nail-tibia composites were significantly less (P < .05) than those for the intact tibiae in all loading configurations. The mean compressive yield load for the nail-tibia composites was greater than the compressive load calculated from previously reported in vivo data for walking and trotting, and was equal to the load calculated for recovery from anesthesia. The mean yield bending moment for the nail-tibia composites was greater than the bending moment previously calculated for standing, walking, and recovery from anesthesia. The mean torsional yield load for the nail-tibia composites was less than the torsional load determined for the walk from another in vivo study. The design of the interlocking nail evaluated in the present study should be modified to increase torsional and compressive yield strengths and torsional stiffness before reasonable success could be expected for the treatment of adult equine tibial fractures.

Animals↗
PubMed2003

Treatment of psoriatic nails with topical cyclosporin: a prospective, randomized placebo-controlled study.

BACKGROUND: Nail involvement is a frequent event in the course of psoriasis causing severe distress. While systemic cyclosporin (CsA) represents a well-established therapy of psoriasis, its topical use is limited by the difficult penetration of the molecule through the skin and the nail because of its highly lipophilic nature. OBJECTIVES: We carried out a prospective randomized placebo-controlled study in order to analyze the effectiveness and tolerability of topical oil-dissolved 70% CsA solution in nail psoriasis. METHODS: Sixteen adult patients with nail psoriasis, divided randomly into two groups of 8 patients (group A and group B), were treated respectively with a 70% maize-oil-dissolved oral CsA solution and maize oil alone. To compare the therapeutic effectiveness, all patients were evaluated, before starting the treatment and after 12 weeks of therapy, by the same dermatologists. The patients were also asked to assess the severity of their nail involvement at baseline and at the end of the treatment. RESULTS: In group A, 3 patients came to a complete resolution of nail lesions and 5 showed a substantial improvement of the overall severity score. In group B, a slight improvement was noted in only 1 patient. All the patients of group A judged positively the results of the therapy, while in group B only 1 patient reported a moderate improvement. CONCLUSION: Our results show that topical therapy with oral CsA solution is a safe, effective and cosmetically highly acceptable treatment modality for nail psoriasis. The ability of CsA to influence keratinocyte proliferation and T-cell lymphokine release, reducing the cornification of the upper layers of the epidermis, may prevent the typical alterations observed in nail psoriasis.

Administration, Topical↗
PubMed1996

Psoriasis of the nails associated with disability in a large number of patients: results of a recent interview with 1,728 patients.

BACKGROUND AND OBJECTIVE: Occurrence rates of clinical features of nail psoriasis vary considerably in the literature. Little information is available on subjective complaints of patients affected by psoriasis of the nails. METHOD: Interviews with 1,728 psoriatic patients concerning their nail changes and complaints are reviewed. RESULTS: The results indicate that pitting and deformation are the most common clinical aberrations in psoriatic nails, with a positive association between the duration of skin lesions and nail psoriasis. No relation was found between age and nail psoriasis in this group. Remarkably, 51.8% of patients suffered from pain-caused by the nail changes, and a large group of patients was restricted in their daily activities, housekeeping and/or profession (58.9, 56.1, 47.9%). Treatment was disappointing: only 19.3% showed marked improvement during treatment. CONCLUSION: This indicates that psoriasis of the nails is a more important individual and social-economic problem than previously assumed and that development of new treatments is needed.

Adolescent↗