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PubMed1996

Biomechanics of rigid tibial nail insertion sites.

The use of a very proximal insertion site for rigid intramedullary nailing was evaluated in a biomechanical study. The purpose of this study was to compare the bursting strains generated in a proximal tibia fracture fragment during rigid nailing, using the recommended insertion sites versus a more proximal site just anterior to the tibial plateau in the midline. Proximal one-third tibia fractures were created in 12 pairs of fresh cadaver specimens. Strain gauges were applied to the medial and lateral cortices of the proximal fragments. Lottes nails, Grosse-Kempf nails, and unreamed Russell-Taylor nails were inserted in four successive pairs of specimens. In each pair, one side used the recommended starting point, and the other side used the proximal insertion site. The strain was recorded at successive 2- to 4-cm depth intervals during nail insertion. In the Lottes group, much larger bursting strains were generated in the lateral cortex when using a distal starting point (P < 0.05). In the unreamed Russell-Taylor group, the anteromedial surface strains were significantly increased using a distal starting point (P < 0.05). The Grosse-Kempf group showed no significant difference in strains associated with any insertion point during tibial intramedullary nailing.

Adult↗
PubMed1997

Treatment of humeral shaft fractures by retrograde locked nailing.

From 1992 to 1994, 29 middle and 19 distal humeral shaft fractures (39 acute fractures, six nonunions, and three pathologic fractures) in 48 patients were treated by retrograde locked nailing. The first eight acute fractures were treated with Seidel nails, the other 40 fractures with specially designed humeral locked nails. Nails were inserted from the supracondylar (6) or the olecranon fossa (42) entry portal. With a single operation, all acute fractures and nonunions achieved osseous union without serious complications. The average time to union was 8.2 weeks for acute fractures and 14.2 weeks for nonunions. Recovery of shoulder function was complete. Elbow motion was excellent in all but one nonunion that resulted from a Type IIIB open fracture. Two patients with supracondylar entry had apex to posterior angular malunion. One patient with a distal comminuted fracture had varus malunion. Three patients had an iatrogenic bony split, but healing was unaffected. Patients with pathologic fractures maintained satisfactory arm function postoperatively. Given the few complications and good functional recovery seen in this study, retrograde locked nailing appears to be a good alternative treatment in middle and distal humeral shaft fractures. The olecranon fossa approach, with more linearity to the humerus, is preferred. In the authors' experience, humeral locked nails are inserted more easily and are associated with fewer complications than are Seidel nails.

Adolescent↗
PubMed1997

Comparison of compression hip screw and gamma nail for treatment of peritrochanteric fractures.

Twenty-seven peritrochanteric fractures in 27 patients were evaluated and treated prospectively. Ten fractures were internally fixed with compression hip screws (CHS) (Omega Howmedica, Rutherford, NJ) and 135 degrees, four-hole side plates. Internal fixation of the posteromedial fragment was not done. Eleven fractures were internally fixed with Gamma nails with distal screws. Six fractures were internally fixed with Gamma nails without distal screws. Each group was evaluated for surgical time, blood loss, hospital days, collapse of the fracture, infections, cut out of the lag screw from the femoral head, fracture healing, perioperative femoral shaft fractures, and implant failure. Surgery time did not differ significantly in either group. Blood loss and hospital days were less in the Gamma nail group. There were no infections, cut out of the lag screw, implant fractures, or pulmonary complications in either group. Fracture healing was the same in both groups. Those fractures treated with Gamma nails, both with and without distal screws, had 50% less collapse than those treated with CHS. There were two femoral shaft fractures in the Gamma nail group (11.76%). There were no femoral shaft fractures in the CHS group. Fractures of the femoral shaft were believed to be caused by two factors: a mismatch of the nail design and the normal geometry of the proximal femur and stress risers in the femoral shaft caused by repeatedly missing the screw hole with the drill bit. Although the Gamma nail is an excellent device for stabilizing and preventing collapse of unstable peritrochanteric fractures, the learning curve is high, and femoral shaft fractures can occur. We believe precautions outlined in this report are helpful in preventing these complications.

Aged↗
PubMed1997

[Sub-trochanteric fractures. A comparative study between gamma nail and angular osteosynthesis with lateral cortical support].

PURPOSE OF THE STUDY: Treatment and outcome of sub-trochanteric fractures are at the origin of many problems. The aim of this study was to evaluate the superiority of the "Gamma Nail". MATERIAL AND METHODS: Two homogenous groups of patients were studied. Each group had 40 patients. The osteosynthesis performed in the first group (Group I) was an "angular" type with lateral cortical support (Nail plate, blade plate, dynamic screw). The second group (Group II) received the "Gamma Nail" implant. The 4 criteria employed to compare the 2 groups were: operatory (duration, blood loss, support-free walking); clinical (walking, pain, anatomy); radiological (reduction and healing); and finally complications and failures. RESULTS: The average operative duration in group I was 3 hrs vs 1 hr in group II. 90 per cent of group I received transfusions with 3 bloods units vs 40 per cent of group II, received 1 blood unit. Support-free walking was authorized 3 months later in group I, and immediately in group II. The results were identical for clinical criteria. The average time for radiological bone healing was 3.5 months in group 1 and 2 months in Group II. 12 complications occurred in group I and 3 in group II: 7 cases of dismantling, 4 non unions and 1 serious deep infection in Group I. In group II: 2 cases of dismantling and a diaphysis fracture beneath the nail. These complications were found in the beginning of our experience with the Gamma Nail. DISCUSSION: 30 per cent of patients in Group I were affected by complications vs 7.5 per cent in group II (with p = 0.01). The duration of surgery, blood loss, and support-free walking delay demonstrated the superiority of the Gamma nail technique. CONCLUSION: This study confirms the superiority of the Gamma nail for the treatment of sub-trochanteric fractures.

Adolescent↗
PubMed1998

The femoral supracondylar nail: preliminary experience.

The treatment of supracondylar fractures of the femur with an intramedullary nail presents some theoretical advantages. Compared to plate osteosynthesis, intramedullary fixation requires less extensive dissection and is biomechanically more favorable. In the elderly patient, these characteristics seem important since bone quality, extensive procedures and bone grafting remain problematic. Since August 1994 we have treated 16 consecutive closed fractures of the distal femur (A.O. type: 7 A.1, 2 A.3, 4 C.1, and 3 C.2) with the Green-Seligson-Henry intramedullary retrograde supracondylar nail. Twelve elderly and osteoporotic patients had suffered low-energy trauma, three young patients had been involved in a traffic accident and one other young patient had attempted suicide. The operative technique, complications and results are described. All fractures healed within a few months (2 to 7) without bone grafting. No failure of the fixation material and no deep infection were encountered. With most elderly patients the functional result was judged satisfactory, considering the population studied. Intraoperative determination of alignment and avoiding shortening were the major difficulties, especially with long oblique or comminuted fractures. Two major complications were encountered in the young population. In one instance nail protrusion in the intercondylar notch caused a deep patellar cartilage erosion and sympathetic distrophy leading to a 15 degrees flexion deformity. Another young patient needed a quadriceps release at the fracture site and subsequently a femoral valgus osteotomy in order to achieve an acceptable final result. In elderly osteoporotic patients presenting an isolated supracondylar fracture, antegrade nailing remains the "safest" technique by avoiding an unnecessary arthrotomy. When previous hip or knee surgery precludes the use of antegrade nailing techniques or when the fracture extends into the intercondylar region, retrograde supracondylar nailing offers some advantages compared to conservative treatment or plate osteosynthesis. On the other hand in young patients, anatomic reduction and alignment should be the goal, and open reduction with plate osteosynthesis, supplemented by bone grafting if needed, should remain the gold standard. When this seems technically impossible, the antegrade or retrograde insertion of an intramedullary nail with intraoperative assessment of length and fracture alignment is an interesting alternative.

Adult↗
PubMedDate not supplied

Nail changes in genodermatoses.

Nail changes may be marker lesions for complex systemic disorders and herald associated syndromes. Knowledge of the anatomy, embryology and biochemical properties of the nail apparatus is essential for understanding the pathogenesis of hereditary nail disorders. In the last few years significant progress has been made in the field of clinical and molecular pathology of human diseases. A considerable number of the genes responsible for genodermatoses have been identified. The homeobox master control genes, genes encoding for transcription factors, genes encoding for the maintenance of telomeres, or for structural molecules, such as the similarly evolutionary highly conserved a-helical rod domains of keratins, are involved in the embryogenesis and normal functioning of nails. Using nail changes in selected genodermatoses with a known genetic background, we try to elucidate the genesis of inherited nail disorders and review the resultant clinical manifestations.

Abnormalities, Multiple↗
PubMed1990

[Surgical interventions of the nail organ].

The nails are the largest appendage of the skin. They provide protection of the tactile regions of the fingers; moreover, well cared-for nails are an attribute of beauty. Operations of the nails should, therefore, regard both functional and cosmetic aspects. Surgical procedures are indicated in the case of nail deformities, bacterial or mycotic infections, as well as pigmentation of the nail wall or plate, and periungual or subungual tumors, which are always suspicious of malignant melanoma. All operations of the nail region can be performed in Oberst's anesthesia. We recommend the preoperative application of a tourniquet to stop the blood flow.

Humans↗
PubMed1998

How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data.

OBJECTIVE: To analyze studies on oral treatment of toenail onychomycosis so as to aid clinicians and patients in making informed decisions. DATA SOURCES: Studies dealing with treatment of toenail onychomycosis were identified by means of 2 MEDLINE search strategies. One was a title search using the word "toenail"; the other search used the combined Medical Subject Headings "onychomycosis" and "therapy". STUDY SELECTION: Articles were read to ascertain that they (1) described results in toenails, (2) used both culture and microscopy, and (3) included a clinical evaluation. Not included were case reports, series of fewer than 15 subjects, reports that combined fingernail onychomycosis and toenail onychomycosis in their statistics, and articles reporting only the total number of toenails cured without providing data as to how many subjects were cured. DATA EXTRACTION: This elimination process left 26 articles, which were then analyzed by means of a checklist that included a morphologically normal nail, mycological findings, and methodological items including recurrence rate, intent-to-treat analysis, placebo group, and whether terms were defined. DATA SYNTHESIS: When there was sufficient data, the frequency with which the treatment achieved normal mycological results, a clinically normal nail, and a disease-free nail (normal-appearing nail plus normal mycological results) was calculated. Confidence intervals were calculated for disease-free nail results. CONCLUSIONS: Standard courses of terbinafine achieved a disease-free nail in approximately 35% to 50% of patients. For itraconazole, the relevant disease-free nail rate was about 25% to 40%. Disease reappearance is an important issue; unfortunately data are lacking as to its frequency.

Antifungal Agents↗
PubMed1995

Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia.

This study was performed to compare the effects of reamed and unreamed locked intramedullary nailing on blood flow in the callus and early strength of union in a fractured sheep tibia model. After the creation of a standardized short spiral fracture by three-point bending with torsion, each tibia was stabilized by the insertion of a locked intramedullary nail. Ten animals were allocated randomly into two groups: one that had reaming prior to nail insertion and one that did not. Blood flow was measured in real time with use of laser Doppler flowmetry. Endosteal perfusion was determined at the fracture site before and after nail insertion. Perfusion of the callus was measured at three locations (proximal diaphysis, fracture site, and distal diaphysis) and at three time intervals (2, 6, and 12 week follow-up). All animals were killed 12 weeks postoperatively, and the tibiae were tested to failure in four-point bending. Nailing with reaming resulted in a larger decrease in overall endosteal perfusion than nailing without reaming (p < 0.015). The presence or absence of reaming did not affect blood flow within fracture callus. Perfusion of callus was greatest at 6 weeks of follow-up. Bending strength and stiffness were the same in both groups at 12 weeks. The study demonstrated that perfusion of callus and early strength of union are similar following intramedullary nailing with or without reaming.

Animals↗
PubMed2002

["Biorigid" interlocking after unreamed intramedullary nailing of tibial shaft fractures].

Between April 1996 and December 1999, 76 tibial shaft fractures were treated at the Department of Trauma Surgery of the Justus-Liebig-University in Giessen, Germany and the Department of Orthopedic Surgery of the University of Louisville, USA with a newly developed, unreamed, solid, small diameter tibial nail interlocked "biorigidly" with screws in grooves of the nail. 69 Patients were reviewed with a minimal follow-up period of 16 months. In 65 patients, the fractures united without exchange nailing, although four of these fractures showed a delay of healing. In further four cases, non-union occurred, one of which was associated with the only break of a nail located at a distal interlocking groove of the nail. In one patient, a late medullary infection so far has not recurred following treatment. In 358 implanted interlocking screws, no implant failure was observed. First clinical experience suggests that, especially due to the low rate of material fatigue, the biorigid nail is an alternative to other implants for unreamed intramedullary nailing of the tibia.

Adolescent↗
PubMed1999

Bone growth is induced by nail transplantation in amputated proximal phalanges.

Mammals are able to regrow the tips of amputated fingers and toes. However, regrowth is limited to regions covered by, and is dependent upon, the presence of the nail organ. If the nail organ is responsible for bone growth in digit-tips, we reasoned that transplanted nail organ might also be able to induce outgrowth from other levels of the digit. Partial nail organ has been transplanted to amputated proximal phalanges of young rats. To date, six transplants have successfully produced outgrowth of nail. New bone growth, not seen in control amputated digits, was documented by x-ray and by alizarin red and calcein injections to be directed toward implanted nail organ. These results support an inductive role for nail organ epithelium in bone growth after amputation and provide encouragement for attempts to enhance a positive outcome after appendage amputation.

Amputation, Surgical↗
PubMed2004

External fixation versus locked intramedullary nailing in tibial shaft fractures: a prospective, randomised study of 78 patients.

INTRODUCTION: We performed a prospective, randomised study to compare the Ex-fi-re external fixator (EF) with locked intramedullary (IM) nailing in tibial fractures. Only fractures without soft-tissue problems of importance were included. MATERIALS AND METHODS: Ex-fi-re is a unilateral, dynamic axial fixator with fracture reduction capabilities. The Grosse-Kempf nail was used for nailing. A total of 78 patients with 79 fractures were entered in the study (41 Ex-fi-re, 38 IM nails). RESULTS: Time to radiographic union and full weight-bearing did not differ significantly, but unprotected weight-bearing was achieved earlier in the IM group (12 vs 20 weeks; p<0.001). There were more reoperations due to secondary dislocation in the EF group. There were no differences in final angulation or shortening. After 6 months and 1 year there were no differences in knee motion, ankle motion, fracture site pain or ankle pain. Some 64% of the nailed patients complained of anterior knee pain after 1 year. CONCLUSION: The results were comparable in most respects. Unprotected weight-bearing was achieved earlier after IM nailing. Anterior knee pain was frequent after nailing.

Adolescent↗
PubMed1998

Graded exchange reaming and nailing of non-unions. Strength and mineralisation in rat femoral bone.

The effect of graded exchange reaming and intramedullary nailing on a non-union model in the rat femur was studied by clinical, radiological, bone mineralisation and biomechanical methods. A standardised procedure was first developed to create a non-union that did not heal and in which non-union developed consistently. In 30 male Wistar rats a standardised osteotomy was produced in the left femur diaphysis. The fractures were reamed to 1.5 mm and nailed with a soft polyethylene nail for 12 weeks. After 1 week the fractures were manipulated in bending and rotation every 2nd day for 5 weeks. At 12 weeks radiographs demonstrated a hypertrophic non-union in all fractures, and the rats were randomly divided into three groups. In the control group no reoperation was performed (group C). In group 1.6 exchange reaming to 1.6 mm and medullary nailing were performed, and reaming and nailing to 2.0 mm in group 2.0. The effect of extensive versus modest reaming and nailing on bone repair was then assessed 12 weeks later. Physical examination, radiographs, bone mineralisation measurements by dual energy X-ray absorptiometry (DEXA) and biomechanical femurs evaluated by a three-point bending test in a Mini Bionix (MTS) testing system were employed. In the control group radiographs revealed a state of non-union in all fractures, and the mechanical strength was significantly reduced compared with both intervention groups. Bone mineral content (BMC) and bone mineral density (BMD) were reduced in the callus region compared with group 2.0. In the intervention groups radiographs showed various degrees of union. Mechanical testing showed that the fracture energy was significantly higher in group 2.0 than in group 1.6. The finding that extensive exchange reaming and nailing seems favourable in non-unions of diaphyseal fractures compared with modest reaming may have clinical implications.

Absorptiometry, Photon↗
PubMed1982

Ender's nails in femoral shaft fractures.

Thirty-five patients with uncomplicated fractures of the femoral shaft were treated by closed reduction and internal fixation with Ender's nails. Twenty-eight similar patients were treated by Küntscher's nailing. The average blood loss after Ender's fixation was 110 ml compared with 450 ml after Küntscher's nailing and the ranges of operative time were 9-30 minutes and 24-50 minutes respectively. Patients were mobilized on average 9 days after Ender's nailing and 75 per cent had a hospital stay of less than 3 weeks. The comparable figures after Küntscher's nailing were 13 days and 4 weeks. All patients regained 80-90 per cent of knee flexion by 4 months. Thus Ender's nails proved to be a reliable method of medullary fixation in young adults with femoral shaft fractures and caused less morbidity than Küntscher's nailing.

Adolescent↗
PubMed1989

Penetrating knee injuries: the nail gun.

Since the development of the nail gun in the 1950s, various reports cite injuries to the head, chest, abdomen, and extremities. Few of these reports mention any nail gun injuries to the knee joint. A total of 33 patients with penetrating injuries to the knee was identified. Of these, 13 had penetrating wounds caused by power nail guns or staplers. The average age was 25 years (range, 17-40). In 10 of the 13 patients, bone involvement (femur in 6, patella in 2, tibia in 1, and both femur and patella in 1) occurred. Treatment consisted of arthroscopy with irrigation of the knee and nail removal in 10 patients. The other 3 patients underwent arthrotomy in conjunction with nail removal and irrigation. No drains were used postoperatively. I.v. cephalosporin antibiotics were given initially in all cases and were continued orally after hospital discharge. Immediate post injury follow-up varied from a few days to 3 months. Six of the 13 patients were found for follow-up 10-33 months (average 19 months) post injury. All of these returned to full duty in the home construction industry. None developed an infection or needed additional surgery. Based on this series, power nail gun knee joint wounds should have tetanus prophylaxis, arthroscopic evaluation, and irrigation of the knee joint in conjunction with nail removal, i.v. antibiotics for 12-48 h, followed by a 10-day course of oral antibiotics. Unless cultures indicate differently, a first-generation cephalosporin is recommended.

Adult↗
PubMed2004

Comparison of unreamed nailing and external fixation of tibial diastases--mechanical conditions during healing and biological outcome.

Locked intramedullary nailing and external fixation are alternatives for the stabilization of tibial shaft fractures. The goal of this study was to determine to what extent the mechanical conditions at the fracture site influence the healing process after unreamed tibial nailing compared to external fixation. A standardized tibial diastasis was stabilized with either a locked unreamed tibial nail or a monolateral fixator in a sheep model. Interfragmentary movements and ground reaction parameters were monitored in vivo throughout the healing period. After sacrifice, the tibiae were examined mechanically and histologically. Bending angles and axial torsion at the fracture site were larger in the nail group within the first five weeks post-operatively. Unlike the fixator group, the operated limb in the nail group did not return to full weight bearing during the treatment period. Mechanical and histomorphometrical observations showed significantly inferior bone healing in the nail group compared to the fixator group. In this study, unreamed nailing of a tibial diastasis did not provide rotational stability of the osteosynthesis and resulted in a significant delay in bone healing.

Animals↗
PubMed1996

Ocular nail gun injuries.

PURPOSE: Penetrating ocular trauma resulting from nails can have disastrous visual consequences. Ocular nail gun injuries occur when a nail propelled at high velocity penetrates the globe. The authors report four consecutive patients with ocular injuries resulting from nail guns. METHODS: Four patients with ocular nail gun injuries are described: one with scleral penetrating injury, one with corneal penetrating injury, and two with perforating (through- and-through) injuries of the globe. RESULTS: Three of the four patients recovered good visual acuity after surgical intervention. CONCLUSION: Although dependent on the site of impact, the visual prognosis may be less severe than expected because the nail penetrates the eye at a high velocity such that there are less contusive forces. Adherence to safety precautions involving the use of nail guns as well as the obligatory use of safety glasses should reduce the incidence of these injuries.

Accidents, Occupational↗
PubMed2004

Secondary intramedullary nailing after distraction osteogenesis: 30 patients followed for 2-12 years.

BACKGROUND: There is no consensus about replacement of an external fixator by reamed intramedullary nailing in fracture cases. PATIENTS AND METHODS: We evaluated the outcome in 30 patients (33 segments) of secondary intramedullary nailing during the consolidation phase after callus distraction using an external device. The main reasons for nailing were docking site nonunion (17 patients), angular deformity or fracture of the lengthened area (8 patients) or intolerance of the external device (5 patients), in 11 patients combined with a delayed distracted callus maturation. The average follow-up time was 4 (2-12) years. RESULTS: Intramedullary infection after nailing occurred in 1 case, and slight loss in callus length in 5 cases. Failure of union at the docking site with nail breakage occurred in 1 case. In the other patients, consolidation in the lengthened callus area and also union at the docking site were achieved on average 6 months after nailing. INTERPRETATION: We believe that intramedullary nailing during the consolidation phase after bone lengthening or bone transport is a treatment option for delayed callus maturation or docking site nonunion, reducing prolonged use of the external fixator.

Adolescent↗