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PubMed1995

Tibial fractures with bone loss treated by primary reamed intramedullary nailing.

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

Activities of Daily Living↗
PubMedDate not supplied

The treatment of femoral shaft fractures using intramedullary interlocked nails with and without intramedullary reaming: a preliminary report.

OBJECTIVE: To compare operative and postoperative variables in the treatment of femur fractures using interlocked intramedullary nails with and without reaming. DESIGN: Prospective and randomized. METHODS: 81 consecutive patients with femur fractures treated with a stainless steel statically locked intramedullary nail. Whether or not reaming was done was randomized. There were 42 nails placed without reaming and 39 placed with reaming. There were no demographic differences between the two groups. Intraoperative and postoperative variables were studied. Interval healing was assessed by one observer on bimonthly radiographs. RESULTS: There were more intraoperative technical complications in the group without reaming. There was no statistical difference in operative time, transfusion requirement, or time to union between the groups. In the reamed group callus formation occurred faster and there was slightly more blood loss (247 cc vs. 396 cc) (p < 0.05). However, when distal fractures were analyzed separately, the time to union was faster in the reamed group (< 0.05). Two patients in the unreamed group and none in the reamed group developed delayed unions. Pulmonary complications occurred in two patients, one in each group and did not appear to be related to the nailing. CONCLUSION: Reamed canal preparation led to faster healing of distal fractures treated with statically locked intramedullary nails. Blood loss was greater in the reamed group but this did not translate into increased transfusion requirements. In this series, there was no advantage to nail insertion without reaming.

Adolescent↗
PubMed2003

Distal interphalangeal joint arthrodesis with Herbert screw.

Fifteen patients underwent arthrodesis of finger distal interphalangeal joint (DIP) and/or thumb interphalangeal joint (IP). Only Herbert screw intramedullary compression fixation was used. There was one faulty proximal thread placement with some pain, but the patient refused further surgery. Full union was achieved in 14 of the cases, with prominent hardware in one and intolerance to cold in two.

Adolescent↗
PubMed2003

Retrograde interlocked intramedullary nailing of supracondylar distal femur fractures in an average 76-year-old patient population.

Twenty-seven fractures of the distal femur in 27 adult patients were treated with retrograde, interlocked, intramedullary nails after intercondylar fracture extension had been reduced and treated with lag screws. Postoperatively, early mobilization exercises began immediately, but weight bearing was not allowed until clinical union was achieved, after which full weight bearing was permitted. Retrograde, interlocked, intramedullary nailing provides an excellent technique to establish union of supracondylar and distal femoral shaft fractures with a low complication rate and opportunity to regain knee motion in the mentally competent, motivated patient.

Adult↗
PubMed1990

[The prevention and treatment of skeletal deformities in fibrous dysplasia].

Fibrous dysplasia generally leads to skeletal deformity over time, particularly when the lower extremities are affected. The authors describe their experience in this field, proposing mainly preventive treatment of progressive deformities and pathological fractures. They prefer intramedullary nailing, which by strengthening the affected bone allows free and early mobilization of the limb. Moreover, full weight-bearing prevents the onset of "ex non usu" osteoporosis, which is quite often responsible for pathological fractures.

Adolescent↗
PubMed1982

The influence of intramedullary nailing on the development of metastases in the treatment of an impending pathologic fracture: an experimental study.

An experimental model was developed to study the effects of a pathologic fracture and intramedullary nailing on metastatic spread. The end point used was the production of lung metastases in rats inoculated intracortically with a rat rhabdomyosarcoma. We found that a pathologic fracture markedly increases the incidence of lung metastases and that intramedullary nailing, by decreasing the incidence of fractures, decreases this incidence. The surgical procedure itself does not increase the incidence significantly. It is concluded that in metastatic disease prophylactic nailing of an impending pathologic fracture is the treatment of choice.

Animals↗
PubMed2004

Nonunions of the distal tibia treated by reamed intramedullary nailing.

OBJECTIVE: The purpose of this study is to determine the efficacy of reamed intramedullary nailing in the treatment of nonunions of the distal one-fourth of the tibia. Nonunions of the distal tibia are particularly difficult to treat given the short distal segment, the proximity to the ankle joint, and the fragile soft-tissue envelope. Intramedullary nailing is an attractive solution to this problem because it avoids extensive dissection, and the implant remains intraosseous, posing minimal problem for the soft tissues. DESIGN: Retrospective review of patient charts and radiographs. SETTING: Tertiary care orthopaedic hospital. PATIENTS/PARTICIPANTS: Thirty-two patients with nonunions of the distal one-fourth of the tibia. Prior treatments included casting, internal fixation with plates and screws, intramedullary nailing, and external fixation. Seven patients had a history of infection, but no patient had signs of active infection at the time of surgery. INTERVENTION: Study patients were treated by reamed, locked intra-medullary nailing. MAIN OUTCOME MEASUREMENTS: Main outcome measurements included time to union, correction of deformity, and complications including infection and reoperation. RESULTS: Average length of follow-up was 25 months (range 4-81 months). Twenty-nine out of 32 patients achieved union at an average of 3.5 months after reamed, locked intramedullary nailing. Of the remaining three, 2 patients united after dynamization (one at 4 months after dynamization and the other at 7 months), and the third patient united 4 months after exchange nailing. Deformity was corrected to a maximum of 4 degrees in all planes. Four patients had positive intraoperative cultures, and only 2 required removal of the nail after achieving union to control infection. There were no signs of chronic osteomyelitis in these 2 patients at the date of the last follow-up visit; 5.5 years and 2 years following nail removal. CONCLUSIONS: Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-fourth of the tibia, even in the setting of prior infection or external fixation. It allows for excellent correction of deformity, which is an essential component of the procedure.

Adolescent↗
PubMed2004

Treatment of acute fractures of the femoral shaft with reamed intramedullary interlocking AO nails.

OBJECTIVE: To review and audit our experience with closed intramedullary interlocking nailing for acute femoral shaft fractures. METHODS: All patients admitted to The Aga Khan University Hospital, over the last six years and with a minimum follow-up of twelve months, with acute fractures of the femoral shaft were included in the study. All patients treated for established non-unions and infections or with pathological fractures were excluded from the study. RESULTS: There were 89 fractures, 74% of whom were closed and 50% were associated with other orthopedic injuries. Most of these were younger patients involved in high velocity road traffic accidents. The union rate was 88% with 4.4% of fractures going into non-union. The remaining 8% of the fractures went into a phase of delayed union, but ultimately united, making the overall success rate to be 95.6%. The mean time for union was 11.5 weeks. At the final clinical follow-up, 4% of the patients had minor pain, 7% had limp, 4% had leg length discrepancy of more than 2 cm and 4% had decreased range of motion at the hip or knee joints. We had a 4% rate of superficial infection. There were 3 cases of pudendal nerve neuropraxia and 2 cases of deep vein thrombosis. CONCLUSION: Intramedullary Interlocking nailing is a safe and effective treatment modality for acute fractures of the femoral shaft. Proper surgical decision making regarding static versus dynamic mode of locking can avoid problems of delayed union.

Acute Disease↗
PubMedDate not supplied

The influence of intramedullary nailing upon the development of metastases in the treatment of an impending pathological fracture: an experimental study.

An experimental model has been developed in which the effects of a pathological fracture and intramedullary nailing on metastatic spread have been investigated. The endpoint used was the production of lung metastases in rats inoculated intracortically with a rhabdomyosarcoma. We have found that a pathological fracture markedly increases the incidence of lung metastases and that intramedullary nailing, by decreasing the incidence of fractures, decreases the incidence of lung metastases. The surgical procedure itself does not increase the incidence significantly. It is concluded that in metastatic disease prophylactic nailing of an impending pathological fracture is the treatment of choice.

Animals↗
PubMed1993

[Tibial intramedullary nailing without open drilling].

By means on the basis of a prospective study of 33 osteosynthesis with the unreamed tibia nail (UTN) the following conclusions were found: 1. A technical simple, intramedullary solid strength bearing device in only two diameters is available, therefore costs for stock keeping are low. Systematic interlocking of the nail is necessary. Regarding the multiplicity of indication as well as the mechanical character the UTN is close to the principle of the internal fixator. 2. As a result of its solid constitution remarkable hollow cavities do not exist, so that retention of hematoma or secretions is limited (prophylaxis of infection). 3. In case of a closed nailing procedure the less rigid fracture fixation is favourable for the biology of the bone healing (fracture hematoma, less traumatic procedure without reaming of the medullary cavity, etc.). 4. The frequently observed breakage of interlocking bolts leads spontaneously to a dynamisation favourable as to time and therefore to a better bone healing process (callus formation). 5. Time intervals of bony fractures consolidation are significantly shorter compared to the exclusive osteosynthesis with the external fixator [3]. 6. The unreamed tibia nail is an implant for both primary stabilisation of closed diaphyseal fractures of the tibia with soft tissue injury and for secondary procedure/treatment for example after external fixator osteosynthesis or initial non-operative treatment. Early change of procedure seems to be of importance.

Adult↗
PubMed2005

[ Intramedullary nailing (ESIN) in clavicular pseudoarthroses. Results of a prospective clinical trial].

This prospective clinical trial was performed to assess healing, clinical outcome and complications after intramedullary nailing of midshaft clavicular nonunions. Over 2.5 years, 14 patients were included. Exclusion criteria were pathological fractures, bony defects, previous operative therapy, atrophic and infection pseudarthrosis and the patient's age: <18 years or >70 years. Results were evaluated after 3, 6, 12 and 18 months. Beginning 3 months after the operation, pain (VAS), subjective satisfaction, Constant score and DASH score were significantly better than preoperatively during the follow-up period (p<0.001). There were no infections, no implant displacements or refractures.Intramedullary fixation of midshaft clavicular nonunions with an elastic titanium nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results without additional bone grafting.

Adult↗
PubMed2001

Focal osteolysis at the junctions of a modular stainless-steel femoral intramedullary nail.

BACKGROUND: During routine follow-up of patients treated with a three-piece stainless-steel modular femoral nail, osteolysis and periosteal reaction around the modular junctions of some of the nails were noted on radiographs. The purpose of this study was to evaluate the prevalence, etiology, and clinical relevance of these radiographic findings. METHODS: Forty-four femoral fractures or nonunions in forty-two patients were treated with a modular stainless-steel femoral intramedullary nail. Seventeen nails were excluded, leaving twenty-seven intramedullary nails in twenty-seven patients for this study. All patients had had a femoral diaphyseal fracture; nineteen had had an acute fracture and eight, a nonunion. These twenty-seven patients returned for radiographs, a physical examination, assessment of functional outcomes, assessment of thigh pain with a visual analog scale, determination of serum chromium levels, and nail removal if desired. A control group of sixteen patients treated with a one-piece stainless-steel femoral intramedullary nail was evaluated with use of the same outcome measures and was compared with the group treated with the modular femoral nail with regard to prevalence of thigh pain and serum chromium levels. Twelve modular femoral nails were removed according to the study protocol. The modular nail junctions were analyzed for corrosion products, and histopathologic analysis of tissue specimens from the femoral canal was performed. RESULTS: The twenty-seven patients were seen at a mean of twenty-one months after fracture fixation; twenty-six of the twenty-seven fractures healed. Twenty-three femora had at least one of three types of abnormalities-osteolysis, periosteal reaction, or cortical thickening--localized to one or both modular junctions. Eighteen patients had severe reactions, defined as osteolysis of > or =2 mm, cortical thickening of > or =5 mm, and/or a periosteal reaction (group 1). Nine patients had mild or no reactions (group 2). Serum chromium levels in group 1 (mean, 1.27 ng/ mL; range, 0.34 to 3.12 ng/mL) were twice as high as those in group 2 (mean, 0.53 ng/mL; range, 0.12 to 1.26 ng/mL). However, this difference did not reach significance with the numbers available. The differences in serum chromium levels between group 1 and the control group with a one-piece nail (mean, 0.26 ng/mL; range, 0.015 to 1.25 ng/mL) (p<0.01) and a control group without an implant (mean, 0.05 ng/mL; range, 0.015 to 0.25 ng/ mL) (p<0.01) were significant. The level of thigh pain recorded on the visual analog scale was also significantly different between group 1 and the control group with a one-piece implant (p = 0.03). Retrieved modular nails had signs of fretting corrosion as well as stainless-steel corrosion products adherent to the junction where the osteolysis occurred. Histologic and spectrographic analysis revealed two types of corrosion products that were consistent with stainless-steel within the peri-implant tissue and were associated with a foreign-body granulomatous response. CONCLUSIONS: The presence of corrosion products at the taper junctions suggests that particulate debris was a major factor in the etiology of the radiographic findings of osteolysis, periosteal reaction, and cortical thickening. Serum chromium levels were substantially elevated in the patients with a modular femoral nail, and such levels may serve as a marker of fretting corrosion of these devices.

Adult↗
PubMed1991

[Increasing compartment pressure in tibial intramedullary nailing. A phenomenon inherent in the therapy?].

At the Department of Surgery of the Bergmannsheil Hospital, a total of 58 patients treated with intramedullary nailing were reviewed with reference to the condition of the soft tissue. During intra- and postoperative treatment a bilateral fasciotomy was required in 8 patients. The subfascial pressure in the deep flexor compartment measured in 11 patients during secondary closed placement of intramedullary nails showed a slight increase of pressure in the deep flexor compartment from 8 mmHg to 40 mmHg after extension of the leg positioned on the operating table. After reduction the pressure increased significantly, from 50 mmHg to 80 mmHg. The postoperative pressure measured after 20 min was less than 50 mmHg in 9 patients. In 2 patients with manifest compartment syndrome (compartment pressure greater than 50 mmHg) immediate fasciotomy was required. Besides commonly known traumatic effects, parameters inherent in the therapy caused an increase in compartment pressure were critically reviewed with reference to their clinical relevance. The reasons for an increase in compartment pressure during closed placement of intramedullary nails in the lower leg are high position of the leg (hydrostatic effect), stretching of the soft tissue by reduction (decrease of volume), and possibly hematoma with outflow into the deep flexor compartment (increase of content).

Adolescent↗
PubMed2000

Leg lengthening for short stature in Turner's syndrome.

We describe ten patients with Turner's syndrome (karyotype 45, XO) who had leg lengthening for short stature. A high incidence of postoperative complications was encountered and many patients required intramedullary fixation as a salvage procedure. We discuss the reasons for this and highlight the differences between our findings and those of a similar series recently reported. In view of the considerable difficulties encountered, we do not recommend leg lengthening in Turner's syndrome.

Adolescent↗
PubMed2000

Treatment of femoral shaft fractures with Grosse-Kempf intramedullary nail.

Ninety consecutive femoral shaft fractures in 87 patients treated by reamed Grosse-Kempf intramedullary nailing were reviewed. The median observation time was 45 months. The functional results were excellent or good in 82% of the fractures, fair in 16%, and poor in 2%. Four non-unions and two superficial infections were observed. Leg shortening of more than 2 cm was recorded in 2 patients. Rotatory malalignment exceeded more than 15 degrees in 2 patients. We conclude that reamed Grosse-Kempf intramedullary nailing is an excellent treatment for femoral shaft fractures. Although this study represents the first period during which we used the nail, the number of complications was acceptable.

Adolescent↗
PubMedDate not supplied

Retrograde intramedullary nailing of femoral diaphyseal fractures.

OBJECTIVES: To prospectively evaluate the results of retrograde intramedullary nailing of femoral shaft fractures. DESIGN: Prospective, consecutive series. PATIENTS AND SETTING: All patients with a femoral shaft fracture admitted at an urban Level 1 trauma center from December 1995 to December 1996 were treated with a retrograde femoral intramedullary nail. INTERVENTION: Retrograde femoral intramedullary nailing was performed on a radiolucent operating room table. Through a three-centimeter medial parapatellar incision, a reamed ten-millimeter retrograde nail was inserted. METHODS: From the time of injury until union, the following parameters were assessed: operative time, blood loss, extent of comminution, open grade, associated injuries, Injury Severity Score, body mass index, time to union, secondary procedures, range of motion in the knee. and complications. RESULTS: Fifty-seven patients with sixty-one fractures were available for follow-up, which averaged 43.1 weeks. Fifty-two percent of fractures demonstrated Winquist Type 3 or 4 comminution. Twenty-six percent of the fractures were open. Fifty-two fractures healed after the initial nailing, five of seven dynamized nails healed, and one patient with bone loss requiring bone graft united yielding a final union rate of 95 percent. Of the three nonunions (5 percent), two healed with exchange nailing and one remains asymptomatic at seventy-one weeks. One patient developed a late septic knee that resolved with treatment. Excellent range of motion in the knee was obtained by those patients who did not have other ipsilateral limb injuries. CONCLUSIONS: This consecutive series had a 95 percent union rate after nailing and dynamization as necessary. No knee problems were associated with the retrograde femoral intramedullary nailing technique. The one septic knee raises concerns about the use of retrograde nailing in severe open femoral shaft fractures. Retrograde femoral nailing should be given serious consideration as an alternative to antegrade femoral nailing.

Adolescent↗