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PubMed2000

Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis.

OBJECTIVE: To determine the effect of reamed versus nonreamed intramedullary (IM) nailing of lower extremity long bone fractures on the rates of nonunion, implant failure, malunion, compartment syndrome, pulmonary embolus, and infection. DESIGN: Quantitative systematic review of prospective, randomized controlled trials. DATA IDENTIFICATION: MEDLINE and SCISEARCH computer searches provided lists of published randomized clinical trials from 1969 to 1998. Extensive hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files identified additional studies. STUDY SELECTION AND DATA EXTRACTION: Of 676 citations initially identified, sixty proved potentially eligible, of which four published and five unpublished randomized trials met all eligibility criteria. Each of three investigators assessed study quality and abstracted relevant data. RESULTS: The pooled relative risk of reamed versus nonreamed nails (nine trials, n = 646 patients) was 0.33 [95% confidence interval (CI), 0.16 to 0.68; p = 0.004]. The absolute risk difference in nonunion rates with reamed IM nailing was 7.0 percent (95% CI, 1 to 11 percent). Thus, one nonunion could be prevented for every fourteen patients treated with reamed IM nailing [number needed to treat (NNT) = 14.28]. The risk ratios for secondary outcome measures were: implant failure, 0.30 (95% CI, 0.16 to 0.58; p < 0.001); malunion, 1.06 (95% CI, 0.32 to 3.57); pulmonary embolus, 1.10 (95% CI, 0.26 to 4.76); compartment syndrome, 0.45 (95% CI, 0.13 to 1.56); and infection, 0.98 (95% CI, 0.21 to 4.76). Sensitivity analyses suggested that reported rates of nonunion and implant failure were higher in studies of lower quality. The type of long bone fractured (tibia or femur), the degree of soft tissue injury (open or closed), study quality, and whether a study was published or unpublished did not significantly alter the relative risk of nonunion between reamed and nonreamed IM nailing. CONCLUSIONS: There is evidence from a pooled analysis of randomized trials that reamed IM nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing.

Bone Nails↗
PubMed2000

Osteosynthesis of metastatic lesions of the proximal femur with a solid femoral nail and interlocking spiral blade inserted without reaming.

OBJECTIVES: To evaluate the efficiency of a solid femoral nail and interlocking spiral-blade, inserted without reaming (UFN/ spiral blade, Synthes-Stratec, Oberdorf, Switzerland), for the fixation of pathologic and impending pathologic fractures of the proximal femur, particularly those involving the subtrochanteric area. DESIGN: Retrospective, consecutive series. SETTING AND PATIENTS: All patients treated for pathologic and impending pathologic fractures of the trochanteric or subtrochanteric area, stabilized using a UFN/spiral blade, inserted without reaming, from June 1994 to June 1997. INTERVENTION: Femoral intramedullary nailing was performed without reaming on a radiolucent operating room table. The nail was inserted through a five-centimeter supratrochanteric approach, and the interlocking spiral-blade device was introduced percutaneously. METHODS: The following parameters were assessed: pathology reports, location of bone lesions, patient survival, pain relief, ambulation, hardware failure on successive radiographs, and intraoperative complications. RESULTS: Twelve pathologic and impending pathologic fractures were stabilized in ten patients. Two patients required bilateral nailing that was staged with intervals of two and three weeks, respectively. The average postsurgical survival was six and one-half months. No implant failure was noted, and no surgical revision was performed. One intraoperative death occurred during surgery and was documented on autopsy as massive pulmonary fat embolization. Neither patient with bilateral nailing suffered from fat embolism syndrome. CONCLUSIONS: Femoral nail insertion without reaming using an interlocking spiral blade provides appropriate stabilization of the proximal femur in case of metastatic lesions, even with extensive subtrochanteric involvement. Although the nails were inserted without reaming, this did not avoid the risk of fat embolization syndrome. This study only addressed results in patients with short-term survival.

Activities of Daily Living↗
PubMed2000

Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study.

OBJECTIVE: To compare anterior and deep posterior compartment pressures during reamed and unreamed intramedullary nailing of displaced, closed tibial shaft fractures. DESIGN: Randomized prospective study. SETTING: University Hospital/Level I trauma center. PATIENTS: Forty-eight adults with forty-nine fractures treated with intramedullary nailing within three days of injury. INTERVENTION: After intraoperative placement of compartment pressure monitors, the tibia fractures were treated by either unreamed intramedullary nailing or reamed intramedullary nailing. A fracture table and skeletal traction were not used in any of these procedures. MAIN OUTCOME MEASUREMENTS: Compartment pressures and deltaP ([diastolic blood pressure] - [compartment pressure]) were measured immediately preoperatively, intraoperatively, and for twenty-four hours postoperatively. RESULTS: Compartment syndrome did not occur in any patient. Peak average pressures were obtained during reaming in the reamed group (30.0 millimeters of mercury anterior compartment, 34.7 millimeters of mercury deep posterior compartment) and during nail insertion in the unreamed group (33.9 millimeters of mercury anterior compartment, 35.2 millimeters of mercury deep posterior compartment). The average pressures quickly returned to less than thirty millimeters of mercury and remained there for the duration of the study. The deep posterior compartment pressures were lower in the reamed group than in the unreamed group at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours postoperatively (p < 0.05 at each of these times. A statistically significant difference between anterior compartment pressures could not be shown with the numbers available. The deltaP values were greater than thirty millimeters of mercury at all times after nail insertion in both the reamed and unreamed groups. CONCLUSION: These data support acute (within three days of injury) reamed intramedullary nailing of closed, displaced tibial shaft fractures without the use of a fracture table.

Adolescent↗
PubMed2001

Prospective randomized comparison between a dynamic hip screw and a mini-invasive static nail in fractures of the trochanteric area: preliminary results.

OBJECTIVES: This study aimed at comparing the results obtained with a sliding screw plate and an experimental device including a small-diameter nail that can be placed with a mini-invasive approach and provides a stable fixation. DESIGN: Randomized prospective study. SETTING: University hospital. PATIENTS: The study included two groups with thirty fractures of the trochanteric area. INTERVENTIONS: In both groups, the surgical procedure was carried out on patients placed on a traction table in a supine position, under an x-ray amplifier. Sliding screw plates (THS) were set in place according to the usual open technique. Nails were placed through a twenty-millimeter supratrochanteric cutaneous incision. This experimental system comprised a locked intramedullary nail with two nonparallel seven-millimeter cervicocephalic screws. MAIN OUTCOME MEASURES: The comparison between the two groups was based on the surgical procedure (time, duration of x-ray irradiation, and total blood loss); the initial postoperative period (complications, duration of hospital stay, and the time before returning home); the time before full weight bearing became effective; the functional and social recovery; mortality; and the quality of immediate and final anatomic restitution and healing. RESULTS: Operating time (p < 0.001) and blood loss (p < 0.001) were lower in the nail group, and no blood transfusion was required. Postoperative pain (p < 0.01), time necessary to support full weight bearing (p < 0.02), and time before returning home (p < 0.05) were reduced in the nail group. All fractures healed in the same amount of time, with good anatomic results in the nail group, whereas ten impactions beyond ten millimeters occurred in the plate group. No difference was found between the two groups in walking ability and autonomy recovery, but hip function (p < 0.05) was better in the nail group. CONCLUSION: This preliminary clinical study has shown the advantages of this mini-invasive technique. It could not evaluate all the possible disadvantages inherent in the method. These points will be evaluated in a multicenter study justified by these preliminary results.

Aged↗
PubMed2001

Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases.

OBJECTIVE: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. DESIGN: Retrospective. SETTING: Four Level I trauma centers. PATIENTS: Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. OUTCOME MEASUREMENTS: Clinical and radiographic analysis. METHODS: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. RESULTS: Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). CONCLUSIONS: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.

Bone Nails↗
PubMed2002

Anatomic assessment of the proper insertion site for a tibial intramedullary nail.

OBJECTIVES: To locate the proper insertion point for a tibial intramedullary nail in the coronal plane. DESIGN: Fifty-seven cadaveric lower legs were disarticulated at the knee and ankle and stripped of their soft tissue. Each tibia was nailed in a retrograde fashion through the center of the tibial plafond with a seven-millimeter sharp-tipped rod through the proximal tibia. The exit point of the nail was measured in the coronal plane in relation to the tibial tubercle. RESULTS: Except for one tibia, the intramedullary nail exit point was always located medial to the center of the tibial tubercle with the average being eight millimeters +/- six millimeters medial to the center of the tibial tubercle. Forty-six percent of the nails exited medial to the whole tibial tubercle. CONCLUSIONS: The insertion point of a tibial nail should be over the medial aspect of the tibial tubercle in the coronal plane. Our data supports using a medial or patellar splitting approach for nail insertion. Insertion sites lateral to the tibial tubercle should be avoided.

Aged↗
PubMed1991

A prospective evaluation of the AO/ASIF universal femoral nail in the treatment of traumatic and reconstructive problems of the femur.

Beginning in October 1986, we prospectively evaluated the AO/ASIF Universal Femoral Nail in the treatment of traumatic (89 nails) and reconstructive (11 nails) problems of the femur. For treatment of isolated femoral fractures, the mean time of patient positioning and nail insertion was 2.4 hours with a mean blood loss of 389 ml. Seventy-eight per cent of the patients were followed for a minimum of 12 months. There were no infections, one case of nail failure, two cases of screw fracture, and three nonunions. Sixteen nails have been uneventfully removed. The AO/ASIF femoral nail provides results comparable to other intramedullary interlocking devices.

Adolescent↗
PubMed1995

Unreamed intramedullary nailing of femoral fractures.

Seventy-five patients with 81 femoral shaft fractures were treated with unreamed antegrade intramedullary nailing using a titanium alloy implant (AIM femoral nail, ACE Medical) with static interlocking. There were 73 closed fractures and 8 open fractures. Six patients had bilateral femoral shaft fractures. In two cases there was an ipsilateral fracture of the femoral neck, two patients had an ipsilateral intertrochanteric fracture, in one case there was a concomitant subtrochanteric fracture, and four patients had sustained an ipsilateral fracture of the acetabulum in addition to their femoral shaft fractures. In 43 cases (53%) the fracture of the femoral shaft was a comminuted type fracture. Thirty-nine patients (52%) had suffered multiple injuries; the mean Injury Severity Score was 41.2. Sixty-nine fractures were stabilized primarily within 8 hours after admission and 12 fractures were treated secondarily, in a mean of 5.8 days after injury. Closed intramedullary nailing was performed in 73 femora and open nailing with cerclage wiring was done in 8. All 81 nails were implanted unreamed and static was used in every case. The diameters of the nails used were 9 mm (n = 68) and 10 mm (n = 13). Proximal interlocking was distally directed in 76 cases and proximally directed in 5 cases. Two patients died of severe head injuries and one patient died of multiple organ failure. The infection rate was 0%, and uneventful consolidation of the fractures was seen in all cases within a mean of 3.8 months. Neither in the case of nails nor in the case of interlocking bolts did an implant failure occur.

Adolescent↗
PubMed1996

Nailing versus plating in thoracic trauma: an experimental study in sheep.

In this study, femoral intramedullary pressure, fat embolization, and pulmonary response were measured during reamed and unreamed nailing and plating of femoral fractures after blunt thoracic trauma. Intramedullary peak pressures of 425 mm Hg (mean 205 mm Hg) occurred in the reamed nail group (group I) during reaming with the 9-mm reamer, while in the unreamed nail group (group II) peak values were seen during nail insertion (330 mm Hg) with a mean of 203 mm Hg. Plating never led to a pressure rise over 67 mm Hg (mean 37 mm Hg). In reamed nailing, the most intense embolism was identified under ultrasound imaging with the large awl and with the 9.0-mm reamer (mean 2.2) and in the unreamed nail group during nail insertion (mean 2.8). Minimal echoes appeared during plating. The pulmonary arterial pressure did not vary significantly postoperatively between the three groups (p < 0.08). Our findings indicate that intramedullary fracture fixation causes a higher increase of intramedullary pressure and more fat and bone marrow embolization than extramedullary ones. Nevertheless, only minimal differences in the pulmonary hemodynamic response (pulmonary arterial pressure) were noted even in the presence of thoracic trauma.

Animals↗
PubMed2003

Locked-nail treatment of humeral surgical neck nonunions.

OBJECTIVE: The authors' purpose was to report their experience with the use of locked nails in treating humeral surgical neck nonunions. Locked nailing has the advantages of minimal soft tissue trauma, automatic fracture reduction, and stable fracture fixation. METHODS: Excluding 3 patients with severe medical illness, a total of 15 consecutive patients with 15 nonunions were treated by humeral locked nailing and bone grafting. Delay from trauma to surgery averaged 13.8 months, and 10 patients had previous operations. The average age of patients was 55.1 years; average follow-up time was 22.4 months. There were two hypertrophic and 13 atrophic nonunions. The average preoperative Neer score for shoulder joints was 53.5. All but three cases had varus deformity, with an average angle of 32.3 degrees. RESULTS: Seven nonunions were nailed with 8-mm nails and eight with 7-mm nails. With a single operation, all but one patient achieved osseous union in an average of 5.4 months. This one patient, who had a Neer score of 72, refused further surgery. At follow-up, 13 of the 15 patients had excellent or good functional recovery of shoulder joints, with an average Neer score of 86.7. Four patients had residual varus angulation averaging 15.5 degrees. For patients with solid union, the average range of shoulder motion was 152.3 degrees in flexion and 146.4 degrees in abduction. No patients had significant limitation of elbow motion. Three patients had occasional shoulder pain and no patients had evident shoulder impingement. CONCLUSION: For humeral surgical neck nonunions in which the head fragment still preserves the greater tuberosity, locked nailing with transfixing screws appeared to be a useful alternative, especially in fractures with osteoporosis, severe varus deformity, or severe soft tissue scarring.

Adult↗
PubMed2004

Exchange reamed nailing for aseptic nonunion of the tibia.

BACKGROUND: Exchange reamed nailing of the tibia is a common procedure in the treatment of an aseptic tibial nonunion. However, reports in the literature supporting this technique are limited. METHODS: Forty patients with a tibial nonunion after initial unreamed intramedullary nailing were retrospectively assessed after an exchange reamed nailing. The main outcome measurements included radiographic and clinical union as well as time from exchange reamed nailing to union. RESULTS: Thirty-eight patients achieved union of their fracture (95%). The average time from exchange nailing to union was 29 +/- 21 weeks. Complications included one deep vein thrombosis (2.5%) and two hardware failures (5%). CONCLUSION: Exchange reamed nailing for nonunions of the tibia results in a high union rate and is associated with a low complication rate. This technique is recommended as a standard procedure for aseptic tibial nonunions after initial unreamed intramedullary nailing.

Adolescent↗
PubMed2006

Limb malalignment and functional outcome after antegrade versus retrograde intramedullary nailing in distal femoral fractures.

BACKGROUND: Torsional malalignment and mechanical axis deviation (MAD) are worrisome complications after nailing of distal femoral fractures. Variable, sometimes contradictory, reports about these problems have been published. METHODS: In a retrospective nonrandomized study, 41 patients (mean age, 44.5 years) with distal third femoral fractures that were operatively treated using either antegrade (20 cases) or retrograde (21 cases) intramedullary nailing during a period of 2 years have been reviewed. Goniometric measurement was done using a navigated ultrasound examination whereas functional evaluation and return to sports were assessed using Merle d'Aubigné functional grading system and Tegner and Lysholm activity score. RESULTS: There was no difference in femoral length, torsion, or MAD between patients treated using antegrade nails and those treated with a retrograde nail. There was a greater limitation of knee motion with retrograde nailing and of hip motion with antegrade nailing. The functional grading and activity evaluation showed, however, no difference between both groups. CONCLUSIONS: The study cohort showed that no treatment method had proved an advantage over the other regarding limb geometry or the functional outcome. The proper operative indication, intraoperative control, and the surgeon's experience seem to be more important in this regard than the nailing technique.

Adolescent↗
PubMed1994

Variation of differentiation in nail and bovine hoof cells.

Human nail plate contains two distinct types of keratins, skin-type and hair-type keratins. To elucidate that nature of the differentiation pathway of nail, we examined the expression of these keratins in human nail as well as in cultured cells taken from bovine hoof matrix. In this study we succeeded in showing that human nail matrix is characterized by the segregated localization of skin- and hair-type keratins except for the apical matrix in which both types of keratins are co-expressed. These results allow us to infer that some of the nail cells possibly divert the pattern of keratin expression during differentiation in vivo. Cultured cells taken from the ventral matrix of bovine hoof, which undergo the pathway of hair-type differentiation in vivo, expressed skin-type keratins together with hair-type keratins, thereby indicating that these cells develop into another pathway of differentiation (skin-type differentiation) from hair-type differentiation developed in vivo. These results provide us with a further insight into nail differentiation under which nail cells develop into multiple patterns of differentiation in vivo and in vitro.

Animals↗
PubMed2005

A nail drilling method suitable for the diagnosis of onychomycosis.

We describe a nail drilling method suitable for the diagnosis of onychomycosis. Thirty-three patients with onychomycosis in which the big toenail had a white band or spike were enrolled in this study. We drilled a hole about 3-mm-wide in the most proximal part of the white band or spike using a ball-shaped metal file and then, through the hole, sampled the underlying nail material softened by fungi after removing the superficial hard nail plate. Fungi in 32 (97.0%) of the nail samples were detected by direct KOH examination. When incubated on Sabouraud's dextrose agar slant with chloramphenicol and cycloheximide, fungal cultures were obtained from 27 (81.8%) of the 33 nail samples. Fourteen of the fungal isolates were identified as T. rubrum, 11 as T. mentagrophytes, and 2 as Acremonium sp. The nail drilling method is suitable for diagnosing onychomycosis with a white band or spike, because it gives a high isolation rate and leaves the patients' nail relatively more intact compared with other methods.

Acremonium↗
PubMed1994

The basement membrane zone of the nail.

The anatomy of the epidermis, dermis and subcutaneous tissues of the nail apparatus is distinct from that of non-appendageal skin. Apart from the demonstration of the longitudinal configuration of the dermal-epidermal junction of the nail bed, there have been no studies of the composition of the basement membrane zone of the nail apparatus. We obtained three human accessory digits, including one thumb, all of which had been amputated for cosmetic reasons, and were without known pathology. Specimens were stained with a battery of monoclonal and polyclonal antibodies which target normal basement membrane zone antigens, and studied by indirect immunofluorescence. This study demonstrated that the four distinct regions of the nail, namely the proximal nail fold, the nail matrix, the nail bed and the hyponychium expressed all the target antigens found in the normal non-appendageal basement membrane. In particular, there was normal expression of the epidermal-associated antigens, the 220- and 180-kDa bullous pemphigoid antigens, and the alpha 6 beta 4 integrin. There was also normal expression of the lamina lucida antigens LH39, GB3 and laminin. It is of interest that the dermal-associated components, namely the 285-kDa linear IgA antigen, the extracellular matrix glycoproteins chondroitin sulphate, type VII collagen and its closely associated proteins, and the poorly characterized antigen for LH24 and LH39 were all normally expressed. Fibronectin, which is not a normal basement membrane zone component, was diffusely expressed in the extracellular matrix, but did not accentuate the basement membrane zone.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibodies, Monoclonal↗
PubMed1992

Loceryl nail lacquer--realization of a new galenical approach to onychomycosis therapy.

Loceryl nail lacquer was developed to provide the effective antifungal drug, amorolfine, in a once-weekly dosage regimen combined with a convenient mode of application. Traditional formulations such as creams and nail solutions do not fulfil these requirements because they are wiped or washed off very rapidly. Amorolfine nail lacquer builds a non-water-soluble film on the nail plate, and this film remains in place for 1 week. The film contains a high concentration of amorolfine and forms a depot from which the drug is delivered and which allows the drug to permeate the nail plate. The film-forming polymer and the solvent were optimized for drug release, stability, and convenience of application (drying time, no gloss, transparency). In preclinical development, porcine hoof horn was used as a screening model to differentiate between formulations and dosage strengths with respect to the penetration rate. A high drug concentration of 11.72 micrograms/specimen (10 mm in diameter) was reached in the hoof horn after 6 h, increasing to 39.5 micrograms/specimen within 7 days, the maximum duration of the investigation. The drug concentration achieved was far above its minimum inhibitory concentration. Furthermore, the penetration model clearly indicated that amorolfine crossed the horn barrier and was found in the moistened gauze which simulated the nail bed. After a 7-day penetration period, 1.8% of the applied dose (500 micrograms) was available under the nail.

Administration, Topical↗
PubMed2005

A splint for pincer nail surgery: a convenient splinting device made of an aspiration tube.

BACKGROUND: To treat pincer nail, both conservative therapy and surgical therapy have been reported. However, there is no consensus about the best method of treatment. OBJECTIVE: The use of a splint prepared from an aspiration tube after pincer nail surgery is introduced. METHODS: Pincer nail was treated by surgery with splinting in seven patients (nine toes). RESULTS: Nine toes from seven patients were evaluated. The postoperative follow-up period ranged from 6 to 37 months (mean 17.7 months). An excellent result was obtained in eight toes, but ingrowth of the nail occurred in one toe. The cosmetic improvement was marked and satisfactory. CONCLUSION: This splint is cheap and easy to make, can prevent contracture of the nail matrix and nail bed, can reduce pain, and allows direct observation of the nail bed because it is transparent. Thus, this technique seems to be convenient and useful.

Adult↗
PubMed2006

How low should you go: novel device for nail trephination.

BACKGROUND: The most commonly used treatment for subungual hematomas is nail trephination, a technique that is not standardized and that poorly controls for trephination depth. OBJECTIVE: The objective was to test the safety and tolerance of a new device for nail trephination that uses innovative "mesoscission" or microcutting technology to create holes of specific depths in the nail plate without penetrating the nail bed. MATERIALS AND METHODS: Fourteen adult subjects with healthy toenails had five holes drilled in a random single-blind fashion at different test settings into their right great toenail with this device and were assessed for pain and pressure tolerance as well as perioperative and postoperative complications. RESULTS: Nail trephination with this device in this small pilot study was controlled and well tolerated. LIMITATIONS: The study population was small (n = 14) and the follow-up evaluation relied on patient self-report, which is not always reliable. The follow-up period was only 1 week and did not allow for evaluation of permanent nail plate deformity. CONCLUSION: Mesoscission may be a controlled and practical alternative to traditional nail trephining methods.

Adult↗