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PubMed2003

Treatment of pathological fractures of the humerus with a locked intramedullary nail.

OBJECTIVE: The humerus is a common site for metastasis. Intramedullary nail fixation has been reported to be the best form of fixation for this disease but complications occur. This study aimed to assess the use of a new humeral nail to treat pathological fractures and impending pathological fractures of the humerus. METHODS: 29 patients received 31 Austofix locked intramedullary humeral nails: 25 for pathological fractures and 6 for impending fractures; 24 nails were inserted anterograde and 7 retrograde. Cement augmentation was applied in 4 patients, and adjuvant therapy was used in 28 patients. Complications occurred in 12 patients. RESULTS: Fixation failed in 6 patients: 2 due to intraoperative fractures during retrograde nailing, one due to a fracture through screw holes postoperatively, and 3 due to local progression of disease. Difficulty in distal locking of the nail was encountered in 4 patients. Locked intramedullary nailing resulted in a stable humerus in 80% of patients. CONCLUSION: Retrograde insertion of the nail is associated with an increased risk of intra-operative fracture, and disease progression can occur, despite the administration of adjuvant therapy.

Adult↗
PubMed2004

Unreamed interlocking nailing in open fractures of tibia.

PURPOSE: To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the unreamed intramedullary nailing. METHODS: Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at Safdarjung Hospital, New Delhi, India. Records of 56 patients (4 women and 52 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures in all patients. All fractures were classified according to Gustilo and Anderson system for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted with assistance by an image intensifier. All nails were statically locked with one screw each proximally and distally. RESULTS: The patients were followed up for a mean period of 20 months (range, 18-24 months) and were evaluated according to the modified Ketenjian's criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Two of 4 type-IIIA and all 4 type-IIIB fractures had chronic osteomyelitis. Of 56 patients, 6 had early infection, 6 had delayed union, 6 had infected non-union, 2 had nail breakage, 8 had screw breakage, and 10 had anterior knee pain. CONCLUSION: Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in those type-III fractures with delayed presentation was not recommended, because of high incidence of complications.

Adolescent↗
PubMed1992

Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients.

The Gamma nail was introduced for the treatment of peritrochanteric fractures with the theoretical advantage of a load-sharing femoral component which could be implanted by a closed procedure. We report a randomised prospective study of 186 fractures treated by either the Gamma nail or a dynamic hip screw. Gamma nails were implanted with significantly shorter screening times, smaller incisions, and less intraoperative bleeding. The Gamma nail group had a shorter convalescence and earlier full weight-bearing, but there was no significant difference in mortality within six months, postoperative mobility, or hip function at review. More intra-operative complications were recorded in the Gamma nail group, mainly due to the mismatching of the femoral component of the nail to the small femurs of Chinese people. Use of a smaller modified nail reduced these complications. We conclude that with careful surgical technique and the modified femoral component, the Gamma nail is an advance in the treatment of peritrochanteric fractures.

Aged↗
PubMed1997

Recurrent rotational deformity of the femur after static locking of intramedullary nails: case reports.

Rotational deformity following intramedullary nailing may cause symptoms and require surgical correction by osteotomy. Reamed, locked intramedullary nailing may be performed, but concern about cortical blood supply and potential pulmonary dysfunction from reaming have led many surgeons to limit this and use smaller diameter nails. Slotted nails are commonly used but are less stiff in torsion than the newer unslotted nails, particularly at the lower diameters. We report two cases of recurrent femoral rotational deformity after using statically interlocked slotted intramedullary nails to correct existing femoral rotational deformities. These patients show that small diameter statically interlocked femoral nails with diminished bone-nail contact must be stiff enough in rotation to avoid potential recurrence.

Adult↗
PubMed1997

Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients.

A study of ninety-nine patients who had a unilateral, displaced, isolated closed fracture of the tibial shaft was performed to determine the effect of the type of treatment on the clinical outcome. Forty-seven patients were managed with closed intramedullary nailing with reaming, and fifty-two were managed with closed reduction and a cast. The two groups were comparable with regard to the ages of the patients, the locations and amounts of displacement of the fractures, and the number of patients who had a history of smoking. The time to union was shorter in the patients who had been managed with intramedullary nailing than in those who had been managed with a cast (mean, eighteen compared with twenty-six weeks; p = 0.02). A non-union occurred in one patient (2 per cent) who had been managed with nailing and in five patients (10 per cent) who had been managed with a cast. There were no infections in either group. Removal of the nail was performed electively in twenty-six patients. Twenty-five patients who had been managed with nailing and twenty-five who had been managed with a cast were followed for a mean of 4.4 years. With use of the Iowa Knee Evaluation and the Ankle-Evaluation Rating System, the patients who had had nailing had mean scores of 96 points (range, 68 to 100 points) and 97 points (range, 74 to 100 points) for the knee and the ankle, respectively, compared with 89 points (range, 62 to 100 points) and 84 points (range, 62 to 100 points) for those who had been managed with a cast (p < 0.05). Administration of the Medical Outcomes Study Short Form-36 Health Survey to the twenty-five matched pairs of patients yielded scores that were significantly better after nailing than after treatment with a cast (a mean of 85 points [range, 27 to 99 points] compared with a mean of 74 points [range, 20 to 97 points]; p < 0.05). We concluded that the treatment of displaced closed fractures of the tibial shaft with closed intramedullary nailing with reaming provides functional results that are superior to those obtained with use of a cast.

Adolescent↗
PubMed1999

Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail.

BACKGROUND: The purpose of this two-part investigation was to test the feasibility, safety, and efficacy of immediate weight-bearing after treatment of fractures of the shaft of the femur with a statically locked intramedullary nail. METHODS: In the first part of the investigation, a biomechanical study was performed to determine the fatigue strength of eleven different statically locked intramedullary nail constructs. Segmentally comminuted midisthmal fractures were simulated with use of sections of polyvinyl chloride pipe; each construct was cyclically loaded in compression with use of physiologically relevant loads in a materials testing machine at eight hertz. The fatigue tests were conducted according to the so-called staircase method, and the construct was considered to have run out (exceeded its anticipated service life) if it had not failed after 500,000 cycles. In the second part of the study, a clinical investigation of immediate weight-bearing after treatment of comminuted fractures of the femoral shaft with a Russell-Taylor (RT-2) construct was performed. Complete follow-up data were available for twenty-eight of the thirty-five patients (thirty-six fractures) entered into the study. RESULTS: In Part I of the study, two constructs, a statically locked twelve-millimeter-diameter Russell-Taylor femoral nail with two distal locking screws (RT-2) and a statically locked twelve-millimeter-diameter Zimmer femoral nail with two distal locking screws (Z-2), had significantly higher mean fatigue strengths (2171 and 2113 newtons, respectively) than all other constructs tested (p<0.001), but the strengths of these two constructs were not significantly different from each other. Constructs with only one distal locking screw demonstrated significantly lower (p<0.05) fatigue strengths than the two-screw constructs. These results suggest that full weight-bearing during the weeks immediately after insertion of the nail may be possible, even for patients who have a comminuted fracture of the femoral shaft. In Part II of the study, twenty-six of the twenty-eight patients were bearing full weight on the fractured limb or limbs at the six-week follow-up visit. All fractures united; only one of these needed an additional procedure (the removal of the screws five months after the insertion of the nail) to stimulate union. No loss of fixation, such as back-out or breakage of a locking screw or breakage or bending of the intramedullary nail, occurred. CONCLUSIONS: We concluded from this two-part investigation that immediate weight-bearing after stabilization of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail is safe when the construct has a relatively high fatigue strength. Immediate weight-bearing after stabilization of a fracture of the femoral shaft permits patients who have multiple fractures of the extremity to walk and to participate in physical therapy earlier, possibly decreasing the duration of the hospital stay or reducing the need for prolonged rehabilitation on an inpatient basis.

Adolescent↗
PubMed2004

Allergic contact dermatitis from acrylates in artificial nails.

Artificial nails are an increasingly popular cosmetic enhancement to the natural nail. Several forms are available, including sculptured nails, photobonded nails, and preformed nails. Reactions to artificial nails have included paronychia, onychodystrophies, and dermatitis at contact areas and at sites distant to the contactant. We present a patient who developed erythema and painful pruritic vesicles of the paronychial tissue several hours after the application of sculptured nails. A strong reaction of erythema and edema occurred at the site of methyl methacrylate and ethylene glycol dimethacrylate testing. Removal of the artificial nails resulted in resolution of the reaction.

Acrylates↗
PubMed1989

Immediate strain shielding after femoral reaming and nailing. An in vivo study in rat femora.

Following intramedullary reaming and nailing of rat femora, in vivo changes in dynamic strain were correlated with in vitro measurements of the bones. Reaming and nailing procedures were performed 2 days after implantation of unidirectional strain gauges at the anterior, mid-diaphyseal level of the femur. Structural stiffness of polyacetal nails were three times as stiff as intact bone. Reaming only decreased the median strain value by 26 percent, and this value was not reduced by insertion of polyacetal nails. Steel nailing reduced the strain by 74 percent. Tested by three-point bending, reaming increased stiffness by 5 percent at the anterior aspect. The presence of nails gave stiffness values that were 9 percent (polyacetal) and 56 percent (steel) higher than the reamed only condition. Our results indicate that steel nailing following reaming causes marked reduction in strain at the anterior, mid-diaphyseal surface, whereas reduction in strain caused by polyacetal nails is negligible.

Animals↗
PubMed1989

Strain shielding 12 weeks after femoral reaming and nailing in rats.

The purpose of this study was to investigate the in vivo strain-shielding in rat femora 12 weeks after intramedullary nailing with either flexible or rigid implants. Five days prior to death, unidirectional strain gauge units were implanted on the anterior bone surface bilaterally. Median strain values of reamed only and polyacetal-nailed femora ranged from 67 to 90 percent of the intact side. Removal of polyacetal nails and sham operations gave negligible changes in strain. Strain of the steel-nailed femora was 51 percent of the intact side. Removal of nails increased strain to 91 percent of the intact side. Testing of femora after removal of implants revealed stiffness of 116 and 103 percent of normal in reamed-only and polyacetal-nailed groups, respectively. Stiffness in the steel-nailed group was reduced to 85 percent of normal. None of these changes were statistically significant. This study indicates that rigid intramedullary nails cause strain shielding at the anterior, mid-diaphyseal surface of rat femora 12 weeks after insertion. Removal of rigid implants seems to restore the loading configuration immediately.

Animals↗
PubMed1994

Nailing and occlusion of the medullary cavity. Flow and mechanical changes in rat femora.

25 rats were bilaterally operated on and the femoral canal nailed, nailed and plugged with silicone or only plugged with silicone after intramedullary nailing. A fourth group was intramedullary reamed without any other intervention. The bones were evaluated after 12 weeks, including flow measurements, mechanical properties and bone dimensions. There were no differences between the groups in total bone or cortical bone blood flow. There were only marginal changes in outer and inner anteroposterior diameters and the area moment of inertia. The maximum bending stress in bones that had been both nailed and silicone-plugged was decreased compared to the other groups, except the nailed bones. In the silicone/nail group, energy absorption was less than in the other groups, except the nailed group. We conclude that modest intramedullary reaming, nailing or plugging of the femoral canal do not change the mechanical properties of the bone, nor do they induce chronic vascular changes in bone. However, when the medullary cavity is filled with both a nail and silicone, mechanical as well as structural changes may ensue.

Animals↗
PubMed2001

Exchange nailing for failure of initially rodded tibial shaft fractures.

This retrospective study evaluated 32 patients who underwent exchange nailing for initially rodded nonunited tibial shaft fractures during a 5-year period. High-energy trauma accounted for 22 fractures; 19 fractures were open. An unreamed nail was initially used to stabilize all but 2 fractures. Implant failure occurred in 31% of fractures, mostly in distal-third fractures, with a failure rate of 34%. Average time from injury to exchange nailing was 36 weeks (range: 6-148 weeks) and consisted of closed reamed nailing and fibulectomy in 27 cases. Healing occurred an average of 20 weeks (range: 6-47 weeks) after postexchange nailing in 27 (84%) fractures. Four (12.5%) fractures healed after additional procedures. There was 1 persistent nonunion. Factors leading to delay in union time included comminution, healed fibula, and proximal location. Multiple regression analysis using survival data at P<.05 showed a significant correlation between fracture configuration and fixation method (locked, dynamic, and unlocked) on time to union. Exchange nailing with closed reaming and fibulectomy is a viable option for treating failures of primarily nailed tibial fractures. Increased stability and stimulation of arrested bone healing may account for the good outcome. The advantages of repeat reamed nailings should be weighed against the possible adverse effect of reaming on bone vascularity.

Adolescent↗
PubMed1991

Open versus closed nailing of femoral fractures in the polytrauma patient.

Thirty-four patients with severe multiple injuries underwent either open or closed nailing of 35 femoral fractures. Open nailing was performed in 17 femurs and closed nailing in 18 femurs. The average abbreviated injury score was 27 in both the open group (range: 17-45) and closed group (range: 22-36). Soft tissue injuries were present in eight (47%) cases in the open group compared to three (16%) in the closed group. The treatment protocol was similar in both groups. Intramedullary nailing was delayed an average of 11 days in the closed group. This was significantly different than the open group where the average time to nailing was less than 24 hours (p less than 0.001). Reamed nails were used in all cases except for two in the closed group. The median time to fracture healing was 5.0 months in the open group and 4.1 months in the closed group, with an average follow-up of 18 months in both groups. Two cases required reoperation (one nonunion and one shortening at the fracture site). Both these cases were in the open group. There were no superficial or deep infections in either group. Closed reamed intramedullary nailing is recommended for treatment of diaphyseal femur fractures in patients with severe coexistent injuries. Open nailing should be reserved for cases in which an adequate reduction cannot be achieved by closed methods.

Adult↗
PubMed1999

[Glomus tumor of the nail area. Apropos of a series of 55 patients].

PURPOSE OF THE STUDY: Glomus tumors are infrequent in the hand. We have review 55 cases, localized in the nail area to discuss their diagnosis and surgical approach. MATERIAL AND METHODS: Out of 80 glomus tumors of the hand seen in two hand units, 55 were located around the nail area, 33 in the nail bed area, 8 at the nail root and 14 laterally. The population was predominantly female (42 cases) and the mean age 43 years. The mean delay before presentation was 37 months. Pain was the main symptom (97 per cent) increased by trauma and cold. A blue spot was visible in 15 cases and diagnosis was performed on clinical ground in all cases except two. A notch was present on X-ray in 16 cases. A prospective study with MRI allow a diagnosis in 18 of 21 cases. All tumors were removed through a lateral approach elevating the nail complex and confirmed histologically. RESULTS: The diagnosis was per-operatively confirmed in 53 cases and performed in one case. The last case of supposed hemangioma was modified at histological examination. No case of nail dystrophy (not existing pre-operatively) or residual pain was seen at the 81 months of follow up. Seven recurrences were observed, 4 of them having been operated initially in our units. DISCUSSION: Clinical diagnosis could be performed on clinical grounds. MRI is to be reserved to recurrences or multi-operated patients. Risk of recurrence has to be mentioned pre-operatively to the patient. CONCLUSION: Lateral approach with nail complex elevation is safe, allowing excision of the tumor without nail dystrophy.

Adolescent↗
PubMed2000

Reconstruction of a double nail deformity: a case report.

We report the successful reconstruction of a double nail deformity after fingertip injury. Double nail growth is rather rare. In our case it was not of congenital origin. Double nail deformity results from implantation of the nail matrix associated with damage to the finger tip. We excised the second nail and reconstructed the remaining nail bed using a part of the excised one. The vertical growth of the first nail was also corrected. Four months later, successful regeneration of the nail was observed.

Finger Injuries↗
PubMed2000

A pilot study on the role of intralesional triamcinolone acetonide in the treatment of pitted nails in children.

BACKGROUND: Pitted nails is a non-specific entity seen in children that is often associated with various underlying skin disorders such as atopic dermatitis, psoriasis, alopecia areata and lichen planus; and those without such associations are labelled as idiopathic pitted nails. Spontaneous resolution is common but may take several years. Treatment options so far have not been encouraging. This pilot study sought to determine the safety and efficacy of intralesional steroid in the treatment of pitted nails in children. METHOD: Children with pitted nails below the age of 12, seen between January 1994 and December 1997, were invited to participate in this study. Symmetrically affected fingernails were selected, topical anaesthetic cream applied and a single dose of triamcinolone acetonide was introduced intralesionally to the proximal nailfold while the contralateral nail acted as control. The degree of pitting of nail surface was documented at months 0, 2 and 4. RESULTS: Four children were enrolled, and their ages ranged from 4 to 9 years. The degree of pitting was reduced to a mean of 15% of the nail surface in the second month, and 42% in the fourth month. The procedure was fairly well tolerated and no adverse effects were noted. CONCLUSION: Intralesional steroid is a safe and acceptable method of treating pitted nails in children with a maximum effect seen in 2 months. In order to sustain a continuous therapeutic effect, a bimonthly treatment is suggested.

Child↗
PubMed2002

Intramedullary nailing of humeral shaft fractures.

The development of interlocking humeral nail systems has greatly broadened the indications for nailing of humeral shaft fracture. Rotational control is better than with earlier nail systems, and most nails have an oblong distal hole that allows axial loading of the fracture site with muscle contraction. When nailing is done with closed technique, loss of the fracture hematoma and periosteal stripping are avoided. Even when open reduction is required, periosteal stripping can be kept to a minimum. Surgical wounds are smaller, even when open reduction is necessary, and when closed nailing is done, bone grafting is unnecessary. Intramedullary nails are ideal for segmental fractures, pathologic fractures, and fractures in osteopenic bone. Because the arm usually is not a weight-bearing extremity, hardware failure is rare and union rates are equivalent to those of compression plate and screw fixation. Compression plates and external fixation certainly have their place for some fracture patterns and for severe wounds that are unsuitable for intramedullary nailing. The surgeon should be well versed in all three techniques and should be able to rapidly choose among these, depending upon the fracture pattern, skin wound, associated injuries, and overall condition of the patient.

Bone Nails↗
PubMedDate not supplied

Mechanical properties of different combinations of flexible nails in a model of a pediatric femoral fracture.

Flexible nailing of pediatric femoral shaft fractures is based on the principle of using two C-shaped nails to create six points of fixation. However, clinical studies using various nail combinations demonstrate similar outcomes. This study aimed to compare the mechanical properties of different nail combinations by testing them in a model of a child's midshaft femoral fracture. The two C-shaped nails were compared with two straight nails and with paired S- and C-shaped nails. The constructs were tested in four-point bending and torsion. Graphs of the data were produced, from which the bending and torsional stiffness of the constructs was calculated. The results showed that there was no significant difference between the mechanical properties of the three different constructs. The conclusion is that any of the tested nail combinations can be used to treat a midshaft fracture of the femur in a child.

Biomechanical Phenomena↗
PubMed2002

Aseptic nonunion of a femoral shaft treated using exchange nailing.

BACKGROUND: There are many methods for treating femoral shaft aseptic nonunions of which exchange nailing is the simplest technique. However, the reported success rate varies. Therefore, a prospective study was conducted to further clarify the role of exchange nailing. METHODS: From October 1994 through December 1999, 40 femoral shaft aseptic nonunions in 39 patients were treated using exchange nailing. The indications for this technique included a femoral shaft aseptic nonunion with a previously inserted intramedullary nail, less than 1 cm shortening, a radiolucent line of the nonunion, and no segmental bony defects. The surgical technique consisted of close removal of the previously inserted intramedullary nail, reaming the intramedullary canal as widely as possible (1 or 2 mm oversized), and re-insertion of a stable unlocked or locked intramedullary nail. RESULTS: Thirty-six femoral shaft aseptic nonunions in 35 patients were followed-up for at least 1 year (median, 2.9 years; range, 1.1-6.0 years) and 33 nonunions healed. The union rate was 91.7% (33/36) and the union period was median 4 months (range, 3-8 months). No major surgical complications were noted. The other three patients with persistent nonunions were continuously followed-up due to their reluctance for further operations. CONCLUSION: Although exchange nailing is a relatively simple surgical technique, it can still achieve a high union rate with a low complication rate. Despite that factors to induce a persistent nonunion are still unclear, clinically, exchange nailing should be used as the first choice in the treatment of an indicated femoral shaft aseptic nonunion.

Adolescent↗