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PubMed2001

Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws.

OBJECTIVES: To describe the technique and results of using blocking screws and intramedullary nails to treat patients with fractures of the proximal third of the tibial shaft. DESIGN: Prospective. SETTING: Level I trauma centers. PATIENTS: Twelve consecutive patients treated with intramedullary nailing and blocking screws for fractures of the proximal third of the tibial shaft. INTERVENTION: Patients were treated with intramedullary nails and blocking screws. MAIN OUTCOME MEASURE: The alignment of fractures was determined using standard anteroposterior and lateral radiographs after surgery and at each follow-up examination. One patient was lost to follow-up. All other patients were followed at regular intervals until union or establishment of a nonunion. Changes in alignment and complications were noted. RESULTS: Postoperatively, all patients had less than 5 degrees of angular deformity in the planes in which blocking screws were used to control alignment. One patient had postoperative malalignment (6 degrees of valgus), but a lateral blocking screw to control valgus deformity was not used in this patient. One patient was lost to follow-up. Eleven patients were followed up to union (n = 10) or establishment of a nonunion (n = 1). Ten of eleven patients maintained their postoperative fracture alignment at their last follow-up examination (average follow-up of thirty-three weeks). One patient progressed from 6 degrees of valgus immediately after surgery to 10 degrees of valgus at union. This patient did not have a blocking screw to control valgus angulation. CONCLUSIONS: Blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.

Adolescent↗
PubMed1982

Nonunion of the tibia treated with Küntscher intramedullary nailing.

Nonunion of the tibia was treated by Küntscher intramedullary nailing un 48 patients. Thirty patients were treated with a completely closed intramedullary nailing and 18 required an open tibial osteotomy to realign the fracture. Bone grafting was not performed. The average time elapsed from injury to surgery was 15 months and the average healing time, as determined roentgenographically, was nine months following surgery. Three postoperative infections cleared with debridement and antibiotic therapy and subsequently united. There were two failures with persistent nonunion. Closed intramedullary nailing is an effective method of managing nonunion of the tibia in properly selected cases.

Adolescent↗
PubMed2004

Pressurization of the metastatic femur during prophylactic intramedullary nail fixation.

BACKGROUND: Venting during prophylactic nailing of metastatic femoral lesions may decrease intramedullary pressures and the risk of fat and tumor embolization. This study aimed to quantify maximum intramedullary pressure levels and durations, and to examine tumor displacement during prophylactic reamed intramedullary nailing of vented and nonvented metastatically involved femora. METHODS: Proximal metastatic defects were simulated in six pairs of cadaveric femora and prophylactically treated using reamed intramedullary nailing with or without proximal and distal vents. Maximum pressures, durations of pressure exceeding embolic threshold levels (25 and 200 mm Hg), and tumor displacement were recorded. RESULTS: Maximum pressures and durations of pressure exceeding embolic thresholds decreased more than 50% with venting (p < 0.05). Distal pressures surpassed the 25-mm Hg threshold even with venting. Post-test sectioning showed increased tumor disbursement in vented specimens. CONCLUSIONS: Venting reduces pressurization during prophylactic reamed intramedullary nailing of femoral metastases, but may increase the spread of tumor to extraskeletal tissue if vented tissue is not contained.

Air Pressure↗
PubMed1998

Intramedullary fibular graft for supracondylar fracture of the femur following total knee arthroplasty.

We describe a successful treatment, intramedullary fibular grafting, for a patient with a supracondylar fracture of the femur following total knee arthroplasty in which the fracture region was comminuted and a segmental large bone defect was present. Free autogenous fibular was inserted into the medullary cavity from the intercondylar region and fixed to the proximal fragment of the femur with augmented fixation using a small plate and screws. Our procedure makes it easy to perform large segmental bone grafting and internal fixation at the same time for such a condition.

Aged↗
PubMed1998

Use of an elastic intramedullary nail in difficult humeral fractures.

Debate continues over implant selection when surgical intervention is deemed necessary in the management of diaphyseal fractures of the humerus. We present a series of patients in which we used an elastic intramedullary nail to manage a variety of difficult humeral fractures and discuss the theoretical advantages which we feel this method offers.

Adolescent↗
PubMed1997

Decision making errors in the use of interlocking tibial nails.

Seventy-one fractures of the tibial shaft were treated with interlocking intramedullary nails. None of the fractures were treated with static locking of the intramedullary nails. These 71 fractures were studied to determine whether certain fracture patterns are prone to loss of alignment when static interlocking is not used. Loss of alignment was defined as shortening of 1 cm or more and/or change in angulation of at least 5 degrees. Loss of alignment occurred in eight of the 71 (11%) fractures. Shortening and/or angulation occurred in seven of 22 spiral and short oblique fractures, and in none of 27 transverse fracture patterns. It was concluded that the dynamically locked and nonlocked modes of intramedullary nailing should not be used in the stabilization of spiral and oblique fractures of the tibial shaft.

Adolescent↗
PubMed1978

A fluted femoral intramedullary rod. Biomechanical analysis and preliminary clinical results.

An intramedullary rod for the femur was designed and compared with rods commonly used. Its bending strength was increased 40 to 80 per cent and its torsional rigidity was increased 230 to 3,000 per cent compared with the other devices tested. In forty patients with traumatic and pathological fractures and osteotomies of the femur, excellent fixation was achieved and very early weight-bearing was possible. In all fresh fractures and non-infected non-unions, union occurred very promptly and bone-grafting was not required in most instances. The stregth and rigidity of the device made it exceptionally useful for non-unions, pathological fractures of the femur, and resection-fusions of the knee.

Adolescent↗
PubMed2006

Closed, locked intramedullary nailing of pediatric femoral shaft fractures through the tip of the greater trochanter.

BACKGROUND: Closed femoral nailing is universally accepted as the treatment of choice in almost all diaphyseal femoral fractures in adults. Numerous authors reported favorable results applying the same surgical technique in the adolescent patient group. Nevertheless, reports of complications such as avascular necrosis and alteration of the proximal femoral anatomy have dampened the initial enthusiasm. The purpose of this paper was to evaluate the possible effect of closed intramedullary nailing through the greater trochanter on the proximal femoral anatomy. METHODS: We report the results of intramedullary nailing in 20 skeletally immature patients (13 men and 7 women) with a mean age of 14.4 years (range, 11-16 years). All were treated with closed, reamed, percutaneously performed nailing, using the tip of the greater trochanter as the nail insertion point. The patients were followed for 29 months in average (range, 19-37 months). RESULTS: No major complication (limb length discrepancy, avascular necrosis, coxa valga) occurred during the observation period. All fractures healed clinically and radiographically within 9 weeks in average (8-13 weeks) and all patients returned to the preinjury activity level. The mean ATD difference was 1.10 +/- 3.51 (range, -5-7 mm, 95% CI -0,54/2,74, p = 0.177). The mean LTA distance difference was 0.3 mm (range, -6-5 mm, p = 0.158), the mean femoral length difference was 1.9 mm (-9-12 mm, p = 0.122) and the overall limb length difference was 1.4 mm (-25-20 mm, p = 0.178). The mean neck-shaft angle difference was 0.20 +/- 1.74 (range, -3-4, p = 0.612) and the mean neck width was 0.60 +/- 1.50 (range, -3-3, p = 0.09). Fourteen nails (70%) were removed within 13 months in average (range, 10-18 months) without any complications. CONCLUSION: This study showed that with strict adherence to a surgical technique that respects the growing proximal femur and its vascular anatomy, using the tip of the greater trochanter as an entry point to the femoral canal, the proven advantages of closed, intramedullary nailing can safely be offered to the adolescent patient population as well.

Adolescent↗
PubMed1979

A review of fractures in the proximal femur treated with the Zickel nail.

The Zickel intramedullary fixation device was used to treat 26 patients with subtrochanteric or impending subtrochanteric fractures. The use of this device has advantages over traditional traction methods as well as nail plate fixation. Twenty-two patients were ambulatory within one month following surgery. Healing of the fracture by roentenogram required an average of 4.9 months and had a high union rate, 17 out of 18 patients was apparent with the use of the Zickel device. There is no classification of fractures at present which has a prognostic value when intramedullary fixation is used. Traumatic and pathologic fractures were treated with similar results. There was no appliance failure in this series.

Aged↗
PubMed2005

The use of elastic intramedullary nailing in the stabilisation of paediatric fractures.

UNLABELLED: The treatment of paediatric long-bone fractures remains controversial. Elastic intramedullary nailing has been proposed as an alternative for the treatment of paediatric long-bone fractures. PATIENTS: We treated 68 children in a time span of 9 years with 32 fractures of the forearm, 27 fractures of the femur and nine fractures of the tibia. The mean age was 8.3 years and the mean admission time 2.6 days. RESULTS: Mean consolidation time was 7.9 weeks for the forearm fractures, 11.9 weeks for the femur fractures and 10.6 weeks for the tibial fractures. Full weight bearing for the latter two fracture types was allowed within the first week. There were no major complications. The complications encountered were three hydrops of the knee, four low-grade infections and one delayed union. Leg length discrepancy was only seen in five patients (18%) and was less than 2 cm. DISCUSSION: In femur fractures, we let the parents decide between skeletal traction and intramedullary rods. When confronted with the possible complications (operation-related complications and infection) compared to the advantages (early weight bearing and short admission time), they almost always choose the operative approach. In our opinion, elastic intramedullary nailing is an excellent treatment option for diaphyseal fractures in children with skeletal immaturity, especially of the femur.

Bone Nails↗
PubMed1992

[Treatment civilian gunshot fractures of the femur shaft].

35 consecutive cases of fractures of the femoral diaphysis due to gunshot wounds (GSW) treated at Jackson Memorial Hospital of the University of Miami between January 1988 and February 1990 were reviewed. There were 32 low velocity and 3 high energy transfer wounds. The treatment protocol for low velocity GSW consisted of 3 days i.v. antibiotics, balanced skeletal traction (for logistic reasons) and delayed closed intramedullary nailing. There was no formal debridement performed. 3 out of 32 patients declined any operative intervention. The remaining 29 patients were treated according to the above protocol. 12 patients could be followed until complete osseous consolidation. In this group the only complication consisted of one late infection. 17 patients were lost to follow-up before complete consolidation. Out of this group, 8 showed advanced fracture callus formation on the last radiograph available, whereas 9 patients were lost to follow-up almost immediately after discharge. Since GSW victims were generally uninjured and treatment of indigent patients in the Miami area is declined by all other hospitals, we assume that there were non major complications even in the group of patients lost to follow-up. We therefore conclude, that intramedullary nailing of low velocity gunshot fractures of the femoral diaphysis without formal debridement is the treatment of choice under civilian circumstances.

Adult↗
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↗
PubMed1994

Initial experience with the treatment of supracondylar femoral fractures using the supracondylar intramedullary nail: a preliminary report.

Initial experience at a Level I Trauma Center with the use of a retrograde supracondylar intramedullary (IM) nail for the treatment of supracondylar and supracondylar-intercondylar intraarticular fractures of the distal femur is presented. Thirty-eight patients with 41 complex distal femur fractures were treated with this newly developed retrograde IM rod. These included 22 open fractures and 19 closed fractures. Four nonunions occurred, but all progressed to union after revision internal fixation and bone grafting. Two of five delayed unions required revision fixation. Two required screw renewal and dynamization. Thirty-five of 41 knees achieved at least 90 degrees of knee motion. There were no infections and no problems with wound healing. Four patients developed fatigue fractures of the rod. These mechanical failures occurred when 11- and 12-mm nails were used in conjunction with 6.4-mm interlocking screws. The rod system was therefore modified to include 12- and 13-mm diameter nails and smaller 5.0-mm interlocking screws. There have been no subsequent nail failures. We are cautiously optimistic that supracondylar IM rod fixation will contribute to the management of these difficult fractures. However, further clinical trials and additional biomechanical testing should be undertaken prior to widespread use of this device.

Adolescent↗
PubMed2006

Antegrade intramedullary splinting or percutaneous retrograde crossed pinning for displaced neck fractures of the fifth metacarpal?

INTRODUCTION: It is generally accepted that severely displaced or malrotated neck fractures of the fifth metacarpal should be treated by closed reduction and pinning. As antegrade intramedullary splinting avoids adhesions of the extensor hood and provides intramedullary stability this technique seems to be advantageous in comparison with traditional retrograde percutaneous crossed pinning. We raised the question whether the antegrade technique would give clinical and radiological results superior to the retrograde technique and investigated this within a comparative clinical study. MATERIALS AND METHODS: Thirty patients with displaced neck fractures of the fifth metacarpal who received operative treatment were included in a retrospective cohort study. Data was analysed from medical records and a clinical and radiological outcome evaluation was performed. Fifteen patients had antegrade intramedullary splinting and fifteen patients retrograde percutaneous pinning. Median time for follow-up was 17 and 18 months, respectively. RESULTS: A significantly better outcome was found after antegrade splinting for ROM restriction of the metacarpophalangeal joint (0 degrees vs. -15 degrees ; P = 0.016), shortening (P = 0.029), pain (0 vs. 5; VAS 0-100; P = 0.026), and overall assessment by the Steel score (400 vs. 357; P = 0.001). There was no statistical difference in grip strength and functional assessment by the DASH score. CONCLUSION: From our clinical and radiological data we conclude that antegrade intramedullary splinting is superior to retrograde percutaneous crossed pinning and thus should be preferentially considered for displaced neck fractures of the fifth metacarpal.

Adolescent↗
PubMed1975

[Osteosynthesis of trochantero-diaphyseal and sub-trochanteric fractures. (Apropos of 57 osteosyntheses)].

The authors report 57 cases of osteosynthesis for trochanterodiaphysial and subtrochanteric fractures. They analyse the types of fracture in relation to age, methods of treatment used and the results. They emphasize the poor prognosis after 70 years. They suggest close wound intramedullary nailing whenever possible and osteosynthesis on non-fractured metastasis in order to prevent fracture.

Adolescent↗
PubMed1984

[Disorders of fracture and osteotomy healing. An analysis of aseptic complications].

The analysis of aseptic complications of bone healing shows that after conservative treatment failures are based mainly on an inadequate indication (37 of 68 patients). An operative procedure would have been better in these cases. Insufficient and recurrent reductions (11 of 68 patients) as well as over-extension with diastasis (9 patients) were less frequent. Osteosyntheses without bone healing were very frequent after failures in the operative technique (92 of 219 patients) and when bone defects (56 patients) remained. It is generally noticed that there is a relatively small number of bone healing problems following intramedullary nailing (13 patients) compared with plate osteosynthesis (119 patients). Both techniques are separately analyzed concerning the kinds of complications. Therapeutic priorities for the treatment of fractures are derivated.

Bone Plates↗
PubMed1995

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

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

Adult↗