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PubMed2005

Infection after reamed intramedullary nailing of the tibia: a case series review.

OBJECTIVE: We reviewed those patients who developed a postoperative infection after reamed intramedullary nailing of tibial shaft fractures to investigate the possible causes of infection, its effect on union time, and the requirement for reconstructive surgery. DESIGN: Retrospective review of patients who developed deep infection after reamed tibial nailing during a 15-year period. SETTING: University Level II Trauma Center. PATIENTS: Thirty-five with tibial diaphyseal fractures. INTERVENTION: All patients were treated with reamed intramedullary nailing. OUTCOME MEASURES: Union, union time, compartment syndrome, requirement for reconstructive procedures, and development of deep infection. RESULTS: In the closed-fracture group, 43.8% of patients were considered to have developed infection because of inappropriate fasciotomy closure, exchange nailing, and thermal necrosis. In the open-fracture group, 62.5% were considered to have developed infection attributable to late complications of plastic surgery. The most significant problem was marginal necrosis after flap cover. CONCLUSIONS: A number of deep infections after reamed intramedullary tibial nailing are avoidable. Particular attention must be paid to correct reaming, exchange nailing, and fasciotomy closure in closed fractures. In open fractures, marginal flap necrosis should be actively treated and not left to granulate.

Adolescent↗
PubMed1975

[Treatment of humeral fractures by intramedullary osteosynthesis].

Observations over 175 patients, treated for closed and open fractures of the brachial bone by intramedullary osteosynthesis with a metallic nail, are analysed. Among 175 patients 128 subjects were operated upon for closed brachial fractures, 26--for open fractures, and 21--for gunshot ones.

Adolescent↗
PubMed2000

Closed intramedullary tibial nailing using the Marchetti-Vicenzi nail.

We present the results of using the Marchetti-Vicenzi nail in the management of 41 closed and 16 type I-III open tibial fractures in 56 patients. The treatment goals were to achieve stability and fracture alignment allowing early functional treatment of the knee and ankle by immediate partial or full weight-bearing. Early callus formation and rapid mobilisation were obtained in 84% of the patients. The mean time to clinical union was 9.8 weeks (radiological union 28.4 weeks) for closed fractures and also 9.8 weeks for open fractures (radiological union 28.7 weeks). No late rotational deformities were observed. We argue that intramedullary nailing with a Marchetti-Vicenzi nail is a quick and excellent method of treating selected closed and open tibial fractures.

Adolescent↗
PubMed1996

The effect of single-pass reaming on tibial nail insertion load and stress.

This biomechanical study evaluated and compared the longitudinal and perpendicular stresses generated and the applied load required during the insertion of a tibial nail with three different insertion techniques. Insertion of a narrow-diameter nail using an unreamed technique generated significantly greater stress and required significantly greater applied load than either the single-pass reamed technique or a reamed technique. The single-pass reamed technique and the standard reamed technique were not significantly different from each other. This study biomechanically justifies the use of the single-pass reaming technique during the insertion of a narrow-diameter intramedullary nail in severe open tibial fractures. The use of this technique cannot be advocated until the biologic effect of single-pass reaming is more clearly defined.

Adult↗
PubMed1995

Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing.

We reviewed 63 patients with fractures of the distal tibial metaphysis, with or without minimally displaced extension into the ankle joint. The fractures had been caused by two distinct mechanisms, either a direct bending force or a twisting injury. This influenced the pattern of the fracture and its time to union. All fractures were managed by statically locked intramedullary nailing, with some modifications of the procedure used for diaphyseal fractures. There were few intra-operative complications. At a mean of 46 months, all but five patients had a satisfactory functional outcome. The poor outcomes were associated with either technical error or the presence of other injuries. We conclude that closed intramedullary nailing is a safe and effective method of managing these fractures.

Adolescent↗
PubMed1975

[Closed intramedullar osteosynthesis of diaphyseal fractures of the crural bones].

An experience with 137 operations of closed intramedullary osteosynthesis of tibial bones with Kuncher pins is analysed. Indications to surgery, technic of osteosynthesis and complications are described. Average terms of patients' incapacity were 130.7 plus or minus 14.4 days. Late results were studied in 118 patients. Good and satisfactory issues were gained in 117 patients, poor--in 1. It is the authors' opinion that closed osteosynthesis of crural diaphyseal fractures with Kuncher pins would provide solid fixation permitting to carry out functional therapy during the period of fracture consolidation.

Adolescent↗
PubMed2003

Open exchange locked nailing in humeral nonunions after intramedullary nailing.

Humeral nonunions after cannulated intramedullary nailing have been difficult to reconstruct. In the current study, 23 consecutive patients were treated by open exchange locked nailing with bone grafting. There were 16 men and seven women with a mean age of 46.2 years. The nonunions followed humeral locked nailing in eight patients, Seidel nailing in 13, and Küntscher nailing in two. The average nonunion time was 14.7 months. The nonunions, located at the proximal (1/3) in four humeri, middle (1/3) in 15, and distal (1/3) in four, were antegrade nailed in 10 and retrograde nailed in 13. Nineteen had 8-mm nails and four had 7-mm nails. Supplementary wiring was used in 19 patients. The average followup was 21.4 months. With one surgery, all but one patient (96%) achieved osseous union in, on average, 16.3 weeks. One patient with chronic renal dialysis had persistent nonunion and an osteolytic supracondylar fracture. Other complications included one postoperative radial nerve palsy, one brachial artery injury, and one wire infection. At followup, all patients with solid union had excellent or satisfactory recovery of shoulder function. The average postoperative Neer score (90.7) was significantly better than the average preoperative score (68.5). Two patients had losses of elbow motion of 10 degrees and 20 degrees, respectively. This study shows that humeral nonunion after cannulated intramedullary nailing can be treated effectively by open exchange locked nailing with bone grafting. Supplementary wiring can compress the nonunion and facilitate bone healing.

Adult↗
PubMed1997

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

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

Adolescent↗
PubMed1998

Muscle perfusion after intramedullary nailing of the canine tibia.

BACKGROUND: Intramedullary nailing with and without reaming leads to a reduction in cortical bone blood flow. The repair of the devascularized bone is mediated principally by the surrounding soft-tissue envelope. The objective of this study was to determine the effect on muscle blood flow of reamed and unreamed intramedullary nailing techniques. METHODS: Midshaft tibial osteotomies to create a 2.5-cm segment of devascularized tibial cortex were performed in 19 adult canines. The tibia was stabilized with a locked intramedullary nail without reaming in 9 animals and with intramedullary reaming in 10 animals. In the unreamed group, the tibia was stabilized with a loosely fitting (n = 4) or a tightly fitting (n = 5) locked nail. In the reamed group, limited reaming (n = 5) or standard reaming (n = 5) was performed. Muscle perfusion was measured in the anterior compartment musculature of the hind-limb using laser Doppler flowmetry. RESULTS: Overall muscle perfusion was greater in the reamed group than in the unreamed group at the conclusion of the nailing procedure (p = 0.0001) and at 5 weeks (p = 0.0008) and 11 weeks after nailing (p = 0.001). The degree of canal fit of the intramedullary nails and the extent of reaming before nail insertion did not further influence muscle circulation. CONCLUSION: The results of this study demonstrate that in the presence of an intact soft-tissue envelope, intramedullary reaming of the canine tibia has a major effect on increasing the circulation to the surrounding muscles. The increased extraosseous circulation may have implications for fracture healing.

Animals↗
PubMed1996

Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus.

We performed a retrospective study of thirteen patients who had had sixteen pathological fractures of the shaft of the humerus secondary to metastatic disease. All but one fracture was stabilized with interlocking intramedullary nailing with use of a closed technique. The mean operative time for the sixteen procedures was ninety-two minutes (range, fifty to 180 minutes), the mean blood loss was 116 milliliters (range, fifty to 200 milliliters), and the mean duration of hospitalization was five days (range, two to ten days). Fourteen extremities had a return to nearly normal function within three weeks after nailing. Relief of pain was rated as good or excellent in all but one patient. Eleven patients (fourteen humeri) received radiation therapy at a mean of seven days (range, three to fourteen days) after the operation. Nine patients died at a mean of four months (range, one to twelve months) postoperatively; the remaining four patients were still alive at a mean of ten months (range, nine to fifteen months). There were no problems related to the wound, deep infections, nerve palsies, or failures of the implant. The fracture was united in all seven of the eleven extremities in patients who survived for at least three months and had radiographs available. Interlocking intramedullary nailing of the humerus for pathological fractures provides immediate stability and can be accomplished with a closed technique, brief operative time, and minimum morbidity, with a resultant early return of function to the extremity.

Adult↗
PubMed1994

Intramedullary nailing technique and its effect on union rates of tibial shaft fractures.

Seventy tibial shaft fractures treated by intramedullary nailing using two different techniques were compared. The first group (35 cases) was treated with a Herzog intramedullary nail following hand reaming and minimal traction. The second group (35 cases) had a Grosse and Kempf or AO nail inserted following power reaming and skeletal traction. Fracture patterns were similar in both groups. In the hand-reamed group, the mean time to union was 15.2 weeks with two delayed unions and no non-unions. In the power-reamed group, the mean time to union was 19.9 weeks with 10 delayed unions and two non-unions. These differences were statistically significant. Complications in the hand-reamed group included a Sudecks atrophy and one mal-union. In the power-reamed group, there were three transient foot drops, two compartment syndromes and one pulmonary embolus. This difference was not statistically significant. Our findings suggest that surgical technique has an important effect on the healing rates of nailed tibial shaft fractures. When intramedullary nailing is performed, minimal reaming is required and skeletal traction should be avoided if possible.

Adolescent↗
PubMed2002

Insulin-like growth factor-1 and transforming growth factor-beta1 accelerates osteotomy healing using polylactide-coated implants as a delivery system: a biomechanical and histological study in minipigs.

Stimulation of bone healing and bone formation through local application of growth factors from implants may improve the clinical outcome in fracture treatment. Previous studies demonstrated a high mechanical stability of a thin poly(D,L-lactide) (PDLLA) coating on metallic implants that can withstand the process of intramedullary insertion. Following an initial peak, 80% of incorporated insulin-like growth factor-1 (IGF-1) and transforming growth factor-beta1 (TGF-beta1) were released continuously, within 42 days. The goal of the present study is evaluation of the coated implants on fracture healing in a large animal model. A midshaft osteotomy (1 mm gap) of the right tibia of Yucatan minipigs was stabilized with uncoated vs. coated titanium interlocking nails (5 mm). X-ray examinations and blood analyses (including IGF-1 and IGF-binding proteins) were performed, and body weight and body temperature were taken throughout the experiment. After 28 days, both tibiae were dissected for mechanical torsional testing and histomorphometric analyses. No differences were found in the blood analyses, body weight, or temperature due to the coating or the incorporated growth factors between the groups. X-ray examinations revealed a faster consolidation of the osteotomy in the growth factor-treated group. Biomechanical testing showed a significantly higher torsional stiffness and maximum load. Progressive remodeling was observed in the histological and histomorphometric analyses with a larger callus volume in the growth factor group compared with the control groups. We conclude that local application of growth factors from a biodegradable PDLLA coating of intramedullary implants accelerates bone healing in a large animal model without systemic side effects.

Animals↗
PubMed1987

Management of malunion and nonunion of the tibia.

When treating acute tibial shaft fractures, every attempt should be made to prevent malunion or nonunion of the tibia. When these complications occur, tibial osteotomy and intramedullary nailing is a functional treatment alternative when infection is not present. Treatment of an infected nonunion usually requires staged protocol using several surgical procedures to effect an acceptable outcome.

Bone Lengthening↗
PubMed1989

[Osteopoikilosis--fracture healing].

Between 1956 and 1988 five cases of osteopoikilosis have been observed. All cases were found by chance. In two cases there were fractures: one of the femur shaft, which has been stabilized by intramedullary nailing, one of the fifth metacarpal bone which has been treated conservatively. In both cases no delay of bony union could be observed. Osteopoikilosis- as a mesenchymal lesion--seems to have no negative influence on fracture healing.

Bone and Bones↗
PubMed2005

[Retrograde intramedullary nailing for humeral shaft fractures in adults. Evaluation of anatomical and functional results in 63 cases].

PURPOSE OF THE STUDY: Many methods have been proposed for treatment of displaced humeral shaft fractures in adults. This study was designed to evaluate the anatomical and functional results of patients treated by retrograde intramedullary nailing through the lateral condyle. MATERIALS AND METHODS: Sixty-three fresh traumatic fractures of the humerus were treated between January 2000 and January 2003. Five patients were lost to follow-up. The AO classification and the Hackethal classification modified by De La Caffinière were used. Outcome was assessed according to the modified Stewart and Hundey classification. RESULTS: We had 23 very good results, 26 good results, five passable results and four bad results. The bad results were three cases of non-union and one case with poor function (stiffness of elbow and shoulder). Mean delay to union was ten weeks four days. There were no cases of iatrogenic radial nerve palsy or pin migration. CONCLUSION: Retrograde intramedullary nailing is a reliable method, easy to perform and of low economic cost. We propose it for all types of displaced shaft humeral fractures.

Adolescent↗
PubMedDate not supplied

Intramedullary nailing for chronic tibial stress fractures. A review of five cases.

Chronic tibial stress fracture is an unusual condition that is primarily seen in athletes and military personnel. Recurrent or recalcitrant stress fractures can be career-ending because they require lengthy nonoperative treatment. We performed a retrospective review of five patients who underwent intramedullary tibial nailing for recalcitrant stress fractures at Womack Army Medical Center, Ft. Bragg, North Carolina, from 1991 to 1994. Interviews were used to survey the patient's history and outcome. We reviewed each case regarding preoperative symptoms, preoperative treatment, surgery performed, radiographic findings, and functional outcome. In each case there were several similarities in symptoms and, most notably, radiographic findings and failure of nonoperative therapy for more than 1 year. Each patient had an unusually narrow medullary canal, a thickened anterior cortex, and a linear unicortical fracture line on the anterior or tension side. Although functional results varied, all patients reported improvement in their symptoms and could return to limited running. There were two excellent results (defined as unlimited pain-free running and resolved tibial pain) and three good results. We believe intramedullary tibial nailing should be considered for treating chronic stress fractures of the midanterior tibia that are recalcitrant to nonoperative therapy in a selected group of patients.

Adult↗
PubMed2000

Reamed nailing of Gustilo grade-IIIB tibial fractures.

Reamed intramedullary nailing was carried out on R57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis. Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures.

Accidents, Traffic↗