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PubMed2002

Antegrade femoral nailing: an anatomical determination of the correct entry point.

Operative problems in the application of femoral locking nails are frequently related to an unfavourable entry point at the greater trochanter. Especially in more distally located fractures the nail is forced to follow the cortex abutted medullary canal. A wrong defined entry point either in the medio-lateral or dorso-ventral direction inevitably leads to tension between nail and femur. Forceful insertion in this situation may cause disastrous iatrogenic comminution at the fracture side or additional fractures at the proximal femur. To avoid tension between nail and femur the best suited entry point must be defined according to the natural medullary cavity. In 16 human cadaver femora, the natural medullary cavity was opened and after cleaning filled with a radio-opaque substance (barium sulphate). Twelve radiographs where taken from each bone starting with the anterior-posterior view and then turning the bone axially in steps of 15 degrees. From these radiographs, the ideal entry point at the greater trochanter was calculated. In 88% of the specimen the ideal entry point for a straight nail was found constantly at the medial border of the greater trochanter overlaying the tendinous insertion of the piriformis muscle. The axis of the medullary cavity was in average 2.1cm anterior to the dorsal border of the greater trochanter. In a second step the ideal entry point for bend nails was calculated. According to this calculation a bend nail with a radius of 100 cm needs an entry point 0.7 mm anterior to the dorsal edge of the greater trochanter. Overlaying the hook like shape of the posterior part of the trochanter.

Bone Nails↗
PubMed2004

Supracondylar Femoral Nail in the management of non-union of humeral shaft fractures.

We reviewed seven patients with established non-union of a shaft of humerus fracture, treated by locked intramedullary nailing using the Intramedullary Supracondylar Nail (IMSC Nail; Smith & Nephew Richards, Memphis TN). The mean age of the patients was 65 years (range 48-78 years). Three of the fractures involved the proximal third of the diaphysis while the remaining four involved the middle third. Six of the original fractures were closed and one was an open fracture. The time interval between the original injury and final surgery averaged 9.3 months. All the nailings were done by the ante-grade approach with static locking. Six of the patients had closed nailing and one had open nailing with bone grafting. The mean follow-up was 8 months and osseous union was achieved in all seven cases at a mean of 5.6 months. We conclude that the Supracondylar Femoral Nail is a useful alternative implant in the management of non-union of fractures of the humeral shaft with wide medullary canals.

Aged↗
PubMed1992

Femoral shaft fractures treated with plate fixation and interlocked nailing: a comparative retrospective study.

UNLABELLED: In a retrospective study, the results of 39 patients with fresh unilateral femoral shaft fractures were studied: 19 had been treated with an AO interlocking nail and 20 with an AO plate. The preoperative characteristics of both groups were similar. The interlocking nail procedure took significantly longer (P = 0.002, Wilcoxon's test) and was associated with technical faults in seven patients. Full weight-bearing was allowed significantly earlier (P = 0.001, Wilcoxon's) in the interlocking nail group. Delayed union was observed in three patients in the plate osteosynthesis group but was not encountered in the interlocking nail group. Cancellous autogenous bone grafting was performed seven times during or after plating, but was not necessary in the interlocking nail group. Two cases of osteitis arose after plating and none after interlocked nailing. At follow-up, one patient in each group was suffering from serious complaints. CONCLUSION: The interlocking nail procedure took longer than plating, but allowed earlier full weight-bearing. The final results were similar in both groups of patients.

Accidents, Traffic↗
PubMed1995

Injuries to the nail bed in childhood.

Many fingertip injuries in childhood involve the nail bed. Deformities of the nail are a frequent result of failure to repair the nail bed at the time of injury. Secondary correction of nail deformities seldom achieves good results. We present the results of our experience in the management of 19 children with 22 injuries involving the nail bed. All achieved normal nail growth and the overall result of the repair was good in 91%. Complications were few and parental satisfaction with the management was high. Every effort should be made to perform a meticulous primary repair of all nail bed injuries.

Amputation, Traumatic↗
PubMed1991

Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia.

A long-term retrospective study of patients with chronic paronychia treated by eponychial marsupialization with or without nail removal is presented. Twenty-eight consecutive fingers with chronic paronychia in twenty-five patients were surgically treated. Symptoms had been present for 28 +/- 7 weeks. Twenty-three of these had nail irregularities. Of this group, the first seven fingers were treated with marsupialization alone. Recurrences developed in two of these. The next sixteen patients with nail irregularities were treated with marsupialization plus nail removal, and there were no recurrences (p less than 0.05). Furthermore, when the two recurrent paronychia were treated with both procedures, one healed completely and the other was markedly improved. All fingers without nail irregularities healed with marsupialization alone. These results confirm that eponychial marsupialization is an effective means of treating chronic paronychia and suggest that nail removal should be done when concurrent nail irregularities are seen.

Adult↗
PubMed2002

Matricectomy and nail ablation.

Matricectomy refers to the complete extirpation of the nail matrix, resulting in permanent nail loss. Usually however, matricectomy is only partial, restricted to one or both lateral horns of the matrix. Nail ablation is the definitive removal of the entire nail organ. The most important common denominator in the successful matricectomy is the total removal or destruction of the matrix tissue. Matricectomy may be indicated for the management of onychauxis, onychogryphosis, congenital nail dystrophies, and chronic painful nail, such as recalcitrant ingrown toenail or split within the medial or lateral one-third of the nail.

Caustics↗
PubMed2002

Docetaxel-induced nail dystrophy.

A 73-year-old man with metastatic prostate cancer treated with weekly docetaxel chemotherapy for 5 months developed an acute nail dystrophy restricted to the fingernails. This was characterized by onycholysis, subungual haemorrhage and acute paronychia, progressing to a subungual abscess of the right index finger. Nail bed hyperaemia and haemosiderin-like nail bed discoloration were present. Nail plate avulsion was performed to decompress the acutely painful subungual abscess. The right thumb, middle finger and left index finger demonstrated early, proximal white subungual collections of pus obscuring the lunula (onychophosis). Central nail plate fenestrations with a surgical drill led to exudation of purulent material. Cultures of the subungual abscess material yielded mixed organisms, possibly related to administration of flucloxacillin for 1 week prior to presentation. The patient completed a further two courses of docetaxel without sequelae, and the nail dystrophy appears to be resolving. Docetaxel-induced nail changes are a common adverse effect, occurring in 30-40% of patients. Mild changes do not usually warrant the discontinuation of treatment.

Acute Disease↗
PubMed1998

Structure of water, proteins, and lipids in intact human skin, hair, and nail.

Raman spectroscopy is a nondestructive analytical method for determining the structure and conformation of molecular compounds. It does not require sample preparation or pretreatment. Recently, near-infrared Fourier transform Raman spectroscopy has emerged as being specially suited for investigations of biologic material. In this study, we obtained near-infrared Fourier transform Raman spectra of intact human skin, hair, nail, and stratum corneum. We disclosed major spectral differences in conformational behavior of lipids and proteins between normal skin, hair, and nail. The amide I and III band location indicated that the majority of proteins in all samples have the same secondary alpha-helix structure. Positions of (S-S) stretching bands of proteins revealed a higher stability of the disulfide bonds in the hair and the nail. Analysis of vibrations of protein -CH groups showed that in the hair and the nail the proteins are apparently highly folded, interacting with the surroundings only to a small degree. The position of lipid specific peaks in spectra of hair, nail, and stratum corneum suggested a highly ordered, lamellar crystalline lipid structure. A greater lipid fluidity was found in whole skin. Assessment of the structure of water clusters revealed that mainly bound water is present in the human skin, stratum corneum, and nail. In conclusion, structural changes of water, proteins, and lipids in intact skin and skin appendages may be analyzed by Raman spectroscopy. This technique may be used in the future in a noninvasive analysis of structural changes in molecular compounds in the skin, hair, and nail associated with different dermatologic diseases.

Adolescent↗
PubMedDate not supplied

An in vitro biomechanical investigation of an intramedullary nailing technique for repair of third metacarpal and metatarsal fractures in neonates and foals.

OBJECTIVE: To evaluate a dorsoproximal extra-articular approach for insertion of 8.25-mm, solid-titanium, intramedullary (IM) interlocking nails into ostectomized foal third metacarpal (MC3) and third metatarsal (MT3) bones; to compare the monotonic mechanical properties of IM nail constructs with paired intact bones; and to determine the effects of age, body weight, fore- or hindlimb, and left or right limb on the mechanical testing variables. ANIMAL OR SAMPLE POPULATION: Twenty bone pairs (10 MC3, 10 MT3) collected from 10 foals of various weights and ages. METHODS: One bone from each pair was randomly selected to be ostectomized and stabilized using an 8.25-mm, solid-titanium IM nail, and four 3.7-mm titanium interlocking screws (construct). Constructs and contralateral intact bone specimens were tested in axial compression and palmaro-/plantarodorsal (PD) 4-point bending. Monotonic mechanical properties were compared between intact specimens and constructs with an ANOVA; significance was set at P <.05. RESULTS: Nail insertion caused bone failure in 6 MC3 and 2 MT3. In general, mean mechanical testing values indicated that intact specimens were significantly stronger and stiffer than constructs for all age and weight ranges when tested in compression and PD 4-point bending (P <.05). Bone strength and stiffness of intact specimens tested in compression and bending tended to increase linearly with age and weight. CONCLUSION: IM interlocking nail fixation of gap-ostectomized MC3 and MT3 with 8.25-mm IM nails and 3.7-mm interlocking screws did not achieve sufficient strength or stiffness to be recommended as the sole means of repair for comminuted MC3 and MT3 fractures in young foals. CLINICAL RELEVANCE: IM interlocking nail fixation of foal cannon bone fractures may be useful to decrease soft-tissue disruption at the fracture site; however, there is a risk of bone failure associated with extra-articular insertion. This method should be combined with other forms of external coaptation for added stability in axial compression and PD bending.

Animals↗
PubMed1997

Mechanical characterization of a totally intramedullary gradual elongation nail.

An intramedullary gradual elongation nail (Albizzia) capable of fulfilling the function of traditional intramedullary nails while providing the gradual, controlled distraction of an external fixator was designed for progressive lengthening of lower limbs. In this study, the biomechanics of the gradual elongation nail were compared with several intramedullary nails: Grosse & Kempf, Russell-Taylor, AO, and Laffay. Bending stiffness, torsional stiffness, ultimate bending strength, and torsional strength were determined using the American Society for Testing and Materials standard F383-73 as a guide. The results show that in unextended and elongated conditions, the gradual elongation nail has torsional stiffness (1-5 Nm2) comparable with the AO nail (2 Nm2) and bending stiffness (41-89 Nm2), ultimate bending (246 Nm), and torsional (28-37 Nm) strengths within the ranges obtained for other intramedullary nails (27-105 Nm2, 167-298 Nm, and 2-100 Nm, respectively). Additionally, the low torque required to lengthen the device under a 500 N load (3 Nm) and the low longitudinal stiffness because of the active dynamization system with bimodal load deformation characteristics (80-120 N/mm initial, 600-800 N/mm secondary) produce a device with almost no torsional and longitudinal stress shielding. From a biomechanical point of view, this single, completely implantable device is a safe, viable, and efficacious alternative to external fixation for progressive lengthening of lower limbs.

Biomechanical Phenomena↗
PubMed1997

Difficulty in removal of certain intramedullary nails.

Intramedullary nailing is the most common treatment for displaced diaphyseal fractures of the femur and tibia. Gerhard Küntscher introduced the technique of intramedullary nailing to clinical practice in the 1940s, and this method has been the focus of many authors with regard to indications, technique, complications, and outcome. The five cases presented here represent a complication not often reported in recent years: the difficulty in removing an intact intramedullary nail. Inspection of the interlocking nails in four of the cases presented reveals a specific design characteristic: the cross sectional design of the nail prevents the distal, unslotted end of the nail from being extracted from the medullary cavity. This problem is preventable by a change in nail design or the development of absorbable implants.

Adolescent↗
PubMed1990

What's in a nail?

To determine the incidence of subclinical infection using routine swab methods in asymptomatic patients, 30 consecutive hollow intramedullary nails were studied. Variables identified were leukocyte count and differential, patient complaints, time elapsed from injury to nail implantation, duration of nail implantation, and the size of the nail. Specimens were gathered from the lumen of intramedullary nails using the routine swab method for bacterial culture as well as fungal and acid-fast growth. This material was also subjected to pathologic review with routine hematoxylin and eosin staining. There were no significant positive cultures in this study. The pathologic review indicated that the material in the canal of an intramedullary nail was either granulation tissue, fibrous tissue, or osseous tissue. No patient had a deep or superficial wound infection after implant removal. The results of this study indicate that the material in the lumen of the hollow intramedullary nail will fail to grew organisms when the swab method is used in gathering the specimen or the material is sent for quantitative bacteriology.

Adolescent↗
PubMed1993

Comparison of reamed and nonreamed solid core nailing of the tibial diaphysis after external fixation: a preliminary report.

From July 1982 to March 1990, 32 patients had an external fixator applied to treat a tibial diaphyseal fracture and subsequently underwent intramedullary nailing: 16 with reamed and 16 with nonreamed solid core nails. Indications for surgery were 12 atrophic and 1 hypertrophic nonunion in each group. The balance were either planned conversions or inadequate external fixators due to head injuries. All but one were seen by an author at a minimum of 1 year. Among the reamed nails, 3 fractures were grade III B. Two patients had pin tract infections, and there were no prenail wound infections. All infections were clinically inactive at the time of nail insertion. Postnail, 7 patients became infected, requiring 12 debridements and 2 procedures to achieve union. One patient had a plate applied 44 weeks postnail and was lost 48 weeks postnail with a persistent infected nonunion. The average time to union was 26 weeks. In the nonreamed solid core group, 2 fractures were grade III A and 5 grade III B. There were 2 pin and 5 prenail wound infections. One nail was inserted across an active pin tract infection. One tibia became infected postnail (p = .04). The fractures united at an average of 14 weeks postnail (p = .036). Two debridements to control infection but no further procedures to achieve union were necessary (p = .003). When tibial reconstructions following external fixation are required, nonreamed solid core nails are efficacious and may be preferable to reamed nails.

Adolescent↗
PubMed1996

Distal femoral fixation: a laboratory comparison of the 95 degrees plate, antegrade and retrograde inserted reamed intramedullary nails.

A biomechanical cadaver study was performed to compare the stability of three standard distal femoral fixation techniques. Eighteen mildly osteoporotic femurs were selected, based on a dual-energy x-ray absorption scanning bone density of 0.3-0.5 g/cm2 and a Singh index of III-IV. After initial mechanical characterization of these intact femurs, a distal femoral osteotomy was created, reduced, and stabilized under compression using random assignment to one of three methods of fixation: (a) six-hole 95 degrees supracondylar plate, (b) retrograde inserted statically locked supracondylar intramedullary nail, and (c) antegrade inserted statically locked Russell-Taylor nail. The instrumented femurs were mechanically tested, a 1-cm gap created, and the femurs retested. The specimens were finally loaded to failure in A-P three-point bending. The 95 degrees plate provided significantly stiffer fixation than the supracondylar intramedullary nail or Russell-Taylor nail in both a compressed transverse and gap distal femoral osteotomy model. The Russell-Taylor nail provided the least rigid fixation. The 95 degrees plate and Russell-Taylor nail had statistically significant greater loads to failure than the supracondylar intramedullary nail. These results support the use of a 95 degrees plate when maximum rigidity of fixation or maximum compression is desired.

Biomechanical Phenomena↗
PubMed1996

Removal of intramedullary nails from the femur: a review of 45 cases.

The excellent biocompatibility of titanium and its alloys may result in osseointegration. In order to determine if this presents an obstacle to removal of intramedullary nails, we retrospectively reviewed a series of 45 cases of isolated removal of a femoral nail. Indications for removal were persistent pain and discomfort, request of an asymptomatic patient, or skeletal immaturity. Twenty-three nails were titanium, and 22 were stainless steel. Although removal of the titanium nails had a significantly longer operative time (110 vs. 84 min), analysis of variance indicated that this was due to a greater number of crosslocking screws in the titanium nails (2.2 vs. 0.6) and a tendency to set the titanium nails deeper in the femur. The use of the titanium material per se did not pose a risk factor for difficulty in late removal of an intramedullary nail.

Adult↗
PubMed1997

Comparative biomechanical analysis of supracondylar femur fracture fixation: locked intramedullary nail versus 95-degree angled plate.

OBJECTIVES: To compare the initial stability of the genucephalic (GSH) intramedullary nail and the 95-degree condylar compression screw and side plate (DCS) for distal femur fractures. DESIGN: Human cadaveric biomechanical study. PARTICIPANTS: Twelve matched pairs of fresh frozen human cadaveric femurs. INTERVENTION: Genucephalic intramedullary nail device (Smith and Nephew Richards, Memphis, TN, U.S.A.) and the 95-degree DCS device (Synthes USA, Paoli, PA, U.S.A.) were compared. Grouped or dispersed screw constructs were tested for each fracture fixation system with progressively more severe simulated fracture patterns. MAIN OUTCOME MEASUREMENT: Axial and torsional stiffness values. RESULTS: The DCS plate with the dispersed screw configuration had the greatest torsional stiffness (p < 0.0011). The GSH nail with the grouped screw configuration absorbed more energy (work) during axial loading compared with the plate constructs (p < 0.0007). There were no significant differences in axial or torsional stiffness within treatment groups for fracture patterns of increasing severity. CONCLUSIONS: Based on the authors' results, the selection of a GSH nail or a DCS plate should not be determined by the severity of the fracture. If a DCS plate construct is selected, the authors recommend a dispersed screw configuration, including the most proximal hole in the plate, to provide superior stiffness in torsional loading and equal stiffness in axial loading when compared with the GSH nail constructs. If a GSH nail is selected, the authors recommend a grouped screw configuration, which absorbed more energy during axial loading compared with the DCS plate constructs and the nail with the dispersed screw configuration.

Adult↗
PubMedDate not supplied

Length of operative procedures: reamed femoral intramedullary nailing performed with and without a fracture table.

OBJECTIVES: To determine whether performing reamed intramedullary nailing of the femur without the use of a fracture table decreases the length of operation. DESIGN: Retrospective. SETTING: Level 1 trauma center, Nashville. Tennessee. PATIENTS/PARTICIPANTS: Consecutively treated patients with fractures of the femoral shaft were treated with intramedullary nails from June 1986 to March 1996. INTERVENTION: Reamed intramedullary nailing of the femoral shaft was performed with the use of a fracture table or with the leg draped free on a radiolucent table. MAIN OUTCOME MEASUREMENTS: Length of anesthesia time, prep and drape time (from the point the anesthetized patient is turned over to the surgeons until incision), and intramedullary nailing time (from incision until end of surgery) for reamed intramedullary nailing of the femoral shaft performed with and without the use of a fracture table were compared. RESULTS: Univariate analysis showed statistically significant decreases in the length of prep and drape time, operative time, and anesthetic time when fractures were treated without the use of a fracture table. Multivariate analysis showed that use of a fracture table prolongs prep and drape time (plus twenty minutes), operative time (plus seventeen minutes), and anesthesia time (plus seventy-three minutes) when the covariates of age, sex, fracture location, learning curve, position of the patient, nail brand, and number of distal bolts are controlled. CONCLUSIONS: Reamed intramedullary nailing of the femoral shaft performed without the use of a fracture table is significantly faster than when the procedure is performed with a fracture table.

Adolescent↗
PubMed1999

Early changes in nutrient artery blood flow following tibial nailing with and without reaming: a preliminary study.

OBJECTIVE: To quantify the changes in nutrient artery blood flow following reamed and unreamed nailing of intact canine tibias. DESIGN: In vivo animal study. INTERVENTION: Eighteen dogs underwent nutrient artery blood flow measurements over a fourteen-day period. The intervention groups consisted of controls (Group I), nailing without reaming (Group II), and nailing with reaming (Group III). MAIN OUTCOME MEASUREMENTS: Nutrient artery blood flow was measured through implantable ultrasonic blood flow probes placed around the nutrient artery of the tibia. RESULTS: Nutrient artery blood flow averaged 1.94 milliliters per minute over the fourteen-day period in Group I (no reaming or nailing performed). Nutrient artery blood flow following nailing without reaming (Group II) decreased to 44 percent of baseline values immediately after the procedure. By postoperative day 1, flow had decreased to 23 percent of baseline; over the fourteen-day period, nutrient artery blood flow recovered toward baseline values. Immediately following nailing with reaming (Group III), nutrient artery blood flow measured zero milliliters per minute. Over the fourteen-day period, nutrient artery blood flow in this group averaged 39 percent of the baseline level (range 19 to 58 percent). Whereas nutrient artery blood flow recovered toward baseline values (99 percent of baseline) by fourteen days in Group II, nutrient artery blood flow measured only 26 percent of the baseline level on postoperative day fourteen in Group III. CONCLUSIONS: The preliminary data suggest that nailing with reaming provides a double insult to the nutrient artery distribution.

Animals↗