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We report an unusual case of two nail-bed streaks under one nail, revealing melanoma in situ affecting the nail bed and plate, but not the nail fold. This unusual mode of presentation together with the absence of any nail-fold involvement has not been reported previously. We highlight the need for early histological assessment of nail-bed lesions and discuss subungual melanoma.
Fifteen finger tip amputations through the proximal half of the nail bed were reconstructed with palmar V-Y advancement flaps and full thickness nail bed grafts. The undersurface of the V-Y flap was sutured to the nail bed remnant and the raw area was covered with full thickness nail bed grafts from the amputated part. They were followed for a minimum period of one year and the nail bed grafts took fully in all patients. The results were best in the thumb and least favourable in the little finger but all the patients were happy with the cosmetic result and the functional outcome. This technique results in an average gain of 5 mm of extra length to the nail. This is a useful technique when replantation of a distal fingertip amputation is not possible.
Despite several studies showing a higher incidence of peri-implant femoral fractures with the Gamma nail than with a sliding screw plate (SSP), the Gamma nail has remained the standard implant for trochanteric fractures in many hospitals. We recorded 921 trochanteric fractures in the city of Oslo during 2 years and compared the reoperation frequency in patients treated with the Gamma nail (n 379) and SSP (n 542). The distribution of age and gender in the two treatment groups was the same. 65 patients were reoperated on, several of them more than once. The only significant difference between the two surgical methods in complications leading to a reoperation was the frequency of femoral shaft fractures. 17 of the patients treated with the Gamma nail had a new femoral fracture postoperatively, compared to 3 of those with a SSP. The relative risk of another femoral fracture after surgery was 12 (95 % CI: 2.7-52) if the surgical device was a Gamma nail compared to a SSP. The Gamma nail therefore can not be recommended as the standard implant for trochanteric fractures.
BACKGROUND: We have previously reported on injuries suffered by young children exposed to methacrylic acid-containing nail primers and the need for public education efforts concerning this potential household hazard. However, some primers contain alternative ingredients, which may or may not pose the same risk; product labeling information is variable and may be confusing to consumers. OBJECTIVE: To investigate the relationship between pH of different primer products, product contents, and appropriateness of product labeling and packaging. METHODS: Twenty-three commercially available primers were grouped by product contents: (methacrylic acid vs others). Product pH was measured and product labels were scored on 7 warning points: "poison and/or corrosive," a "caution to avoid contact and/or to use a barrier when handling the product," a "skin first aid," and "eye first aid," an "ingestion first aid," a caution to "keep out of reach of children," and a "in emergency, contact a poison center." A summative "global hazard notification score" was calculated for each product. Data were analyzed using correlations and the two-sample t-test. RESULTS: None of 23 products tested were contained in a child-resistant container and none included all 7 label items. Product pH ranged from 1.90-8.55 (mean pH 4.59 +/- 1.99); 20 products had pH < 7.0. Only 1 product advised, in the event of a poisoning, that a poison center be contacted. Of 20 acidic products, only 7 alerted users that the contents could cause burns. The mean global hazard notification score (MAX = 7) was 3.6; global hazard notification score did not correlate with pH. Methacrylic acid-containing products had a lower pH (mean 3.43 +/- 0.78) than those without methacrylic acid (mean 5.34 +/- 2.18), p = 0.008. When the primer bottle was separated from the rest of the packaging which comprised the artificial nail "kit," 50% of products lost all of their warning information. CONCLUSIONS: Most, but not all, artificial nail primers analyzed in this study were highly acidic. Labeling and packaging of many nail primers are inadequate, given the potential of methacrylic acid in these products to cause burns and the toxicity of most nail primers. We agree with the Consumer Product Safety Commission's recently proposed rule to require cosmetic manufacturers to repackage methacrylic acid-containing household products in child-resistant containers. We also urge manufacturers to alert consumers to the hazards of nail primers by better labeling. Manufacturers should also investigate the feasibility of either substituting other chemicals or lowering the concentration of methacrylic acid.
Postmortem fingernail and toenail specimens were utilized for the detection of cocaine analytes and opiates. Nail clippings were obtained from suspected overdoses and/or drug users. Nail clippings were washed with methanol and then solubilized in 0.1M potassium phosphate (pH 5.0). Analytes were isolated from the solubilized nails and methanolic washes by solid-phase or liquid-liquid extraction techniques. Quantitation was performed by gas chromatography-mass spectrometry. Clippings from each hand and foot were analyzed separately for comparison purposes. Concentrations of all the analytes were significantly higher in fingernails than in toenails. Cocaine analytes were detected in the nails of 15 cases with the following concentration ranges (ng/mg): cocaine (n = 15) 1.2-414.1; benzoylecgonine (n = 15) 1.4-170.3; ecgonine methyl ester (n = 14) 0.19-27.0; norcocaine (n = 12) 0.11-32.7; cocaethylene (n = 2) 0.08-2.93. Opiates were detected in 17 cases with the following concentration ranges (ng/mg): morphine (n = 15) 0.05-407.9; 6-acetylmorphine (n = 15) 0.04-504.0; codeine (n = 9) 0.06-8.84; hydromorphone (n = 4) 0.02-0.45. Oxycodone and hydrocodone were each detected in one case. The extent of drug incorporation due to external contamination was evaluated by comparing the differences in the amount of drugs detected in fingernails and toenails, along with the corresponding washes of those nails. These results demonstrate the usefulness of nails as postmortem specimens in detecting drugs of abuse.
The authors present 2 children in whom a hard palate mucosal graft was used for a defect of the nail bed after resecting subungual exostosis. After the tumor was resected with the overriding nail bed, hard palate mucosa without periosteum was grafted to the nail bed defect. In both patients the graft took completely, and within 2 weeks after the operation the patients were able to enjoy activities of daily life, including athletic movement, without any symptoms. Nail growth was uneventful and was complete in 4 or 5 months after the operation without any complications. The authors think that a hard palate mucosal graft is a valid choice for a defect of the nail bed, and the mucosa does not need to be harvested with periosteum. The grafting of hard palate mucosa without periosteum to a defect of the nail bed contributes to a shorter healing time, resulting in a reduction in the period of restriction of movement in activities of daily life, and this is a great advantage in children.
Subtrochanteric osteotomies were created in 18 matched pairs of embalmed cadaveric femora. The femora were stabilized with a Synthes, Zimmer, or Richards second generation femoral reconstruction nail with retrograde blade or screws. The femoral pairs were randomly assigned to groups based on nails used: Synthes versus Zimmer, Synthes versus Richards, and Zimmer versus Richards. The reconstructions were cyclically loaded in bending for 2000 cycles and then loaded to failure. The mean stiffness of the Synthes, Zimmer, and Richards reconstructions was 17%, 40%, and 40% of the intact femora, respectively. The Richards construct was the strongest, and predominately failed by fracture at the distal interlocking screw hole. The Zimmer construct failed by bending of the nail at the osteotomy site and fracture of the proximal femoral shaft. The Synthes construct was the most flexible and least strong and failed by bending of the spiral, retrograde blade with concomitant fracture of the femoral neck. This study indicates that fixation of subtrochanteric femur fractures with a Synthes spiral blade or Richards or Zimmer reconstruction nails provides stable fixation for postoperative loading conditions. However, the Richards and Zimmer nails were able to withstand higher loads than was the Synthes nail before failure.
It was hypothesized that transverse locking screws of intramedullary nails, seated above the lesser trochanter, provide equal strength to that of reconstruction nails, and that screws placed through the medial cortex of the femoral neck do not have adverse biomechanical effects during physiologic loading. Synthetic femurs (n = 10) and paired anatomic specimen femurs (n = 14) were tested intact and with an intramedullary device in place. Intact specimens were loaded nondestructively, then a segmental subtrochanteric defect was created and either a high seated transverse locking nail or a reconstruction nail was inserted and statistically locked. Axial and torsional stiffness were determined followed by axial failure testing. Mechanical parameters evaluated were stiffness, displacement, and energy. The implanted specimens did not show any statistically significant difference between transverse or reconstruction screw constructs with any of the measured parameters (stiffness, displacement, and energy). Failure tests in implanted specimens also did not show any statistically significant difference in yield load, yield displacement, or energy to failure between implant constructs. All anatomic specimens failed, with fractures of the proximal fragment involving medial and lateral cortices. Synthetic specimens did not fracture but showed failure with implant deformation at the level of the skeletal defect. The use of high seated transverse locking nails for complex proximal femoral fractures is a viable option and has comparable in vitro mechanical performance with reconstruction nails. Although not shown to be a problem in the present study, clinical evaluation of screws through the medial femoral neck cortex is required.
A prospective, randomized study comparing the compression hip screw with the Gamma nail in the treatment of 426 intertrochanteric fractures is reported. The median patient age was 80 years, and 71% were women The compression hip screw operation took less time except in Evans Type 5 fractures. Blood loss generally was less in the compression hip screw group except in patients with Type 5 fractures. The most frequent surgical problem for patients in the Gamma group was problems with distal locking. Cephalic position of the femoral head screw and cut-out were seen more often in the Gamma nail group. The Gamma nail more frequently preserved the fracture position obtained perioperatively. Whether there was distal locking of the Gamma nail in unstable fractures did not seem to affect the healing rate. Additional fissures or fractures in the proximal femur occurred during five Gamma nail operations and two compression hip screw operations. Postoperative walking ability did not differ between the groups. At 6 months 88% of the fractures were healed. In less comminuted fractures, the compression hip screw method is the preferred method of treatment whereas the Gamma nail is an alternative treatment for more comminuted Evans Type 5 fractures.
Flexible intramedullary nailing has become a popular method of fixation of pediatric femoral fractures. The authors analyzed their first 5-year experience with titanium elastic stable intra-medullary nailing, specifically to report the complications associated with this technique and to provide recommendations to avoid these complications. Seventy-eight children with 79 femoral fractures were treated by this method. Complications included pain/irritation at the insertion site (41), radiographic malunion (8), refracture (2), transient neurologic deficit (2), and superficial wound infection (2). Ten patients required reoperation prior to union. Malunion and/or loss of reduction requiring reoperation was strongly associated with the use of nails of mismatched diameters (odds ratio = 19.4) and comminution of more than 25% (odd ratio = 5.5). Pain at the insertion site was significantly associated with bent or prominent nail ends. Most complications are minor, and many are preventable. Surgeons should advance nail ends to lie against the supracondylar flare of the femur to avoid symptoms at the insertion site and should avoid implanting nails of two different diameters. Comminuted fractures should be monitored carefully and might benefit from additional immobilization.
Closed intramedullary nailing is an accepted method of treatment for femoral shaft fractures. Technical complications of the procedure include fracture instability, which may result in proximal nail migration, malrotation, delayed union, and occasionally femoral bursting during insertion of the nail, sometimes leading to fracture instability as well as shortening. This study defines the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. The most significant factor in the proximal femoral component was found to be the position of the starting hole. Anterior displacement by greater than 6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which resulted in bursting of the proximal femoral component by lifting off the anterior cortex. Hoop stresses at the level of the fracture were less sensitive to lateral or medial placement of the starting hole. Distally, fracture stability was governed by femoral component length and reamed diameter. In the proximal and distal components, fracture stability and the potential for bursting were influenced by the particular nail used. This was due to significant differences in mechanical geometric properties between nails of different manufacturers. Case reports are presented to illustrate these biomechanical principles as they apply to clinical situations.
The most important mechanical characteristics of a nailing system are related to its stiffness (rigidity) and strength. This study evaluates the properties of three commercially available interlocking intramedullary nail systems using standardized test methods. An understanding of the mechanical properties along with the clinical data will assist the surgeon in choosing the optimum implant. Testing indicates that the bending strength and stiffness of the Grosse & Kempf, the AO/ASIF Universal, and the Russell-Taylor interlocking intramedullary nail designs are comparable. It is therefore not surprising that all of these nail systems have excellent clinical results. However, the nonslotted design is approximately 30 times more resistant to torsional loading than either the partially slotted design of the Grosse & Kempf nail or the fully slotted design of the AO/ASIF nail. The clinical relevance of the torsional values may not be known until a long-term comparison of the complication rates for these different systems is available. Analysis of screw design reveals a tradeoff in bending strength when compared to amount of bone purchase. The bending strength of fully threaded screws (allowing bicortical fixation) is less than that of partially threaded screws (allowing only unicortical fixation), which shows that for the implants tested, increased bone purchase requires a compromise in strength for similar sized screws.
The use of Ender nails for the treatment of femoral shaft fractures has been described as technically easier and less time consuming than current intramedullary nailing techniques. We reviewed our results with unlocked Ender nails in 26 stable and 17 unstable fracture patterns an average of 3-4 years after injury. Because of continued instability, 42% of the stable and 76% of the unstable groups required adjunctive stabilization in the form of skeletal traction, a cast, or an external fixator. Additionally, nail migration and shortening and loss of motion at the knee were seen in 14 fractures in each group. Although two thirds of the patients with stable fracture patterns obtained good or excellent results, no outcome in the unstable group was rated excellent and only 19% were considered good. We therefore recommend that rigid locked intramedullary nails be used in femoral diaphyseal injuries. The use of Ender nails should be limited to stable fracture patterns and locked with screws or wires. They may be particularly useful for fractures in femora with small medullary canals (less than or equal to 8 mm), fractures below noncemented femoral prostheses, and fractures in young children requiring intramedullary stabilization without injuring the physeal plates.
Several questions relating to the biomechanics of the AO unreamed tibial nail were addressed in this study. These included the effects of the location of the nail bend on the reduction of a high proximal fracture, and the relation of proximal locking screw hole orientation and fracture component cortical contact to the mechanical stiffness of the construct. To measure fracture site malalignment with nail insertion, a motion transducer mounted on the distal tibial shaft was used to track the position of the proximal component during and after insertion of the nail. For studying the effect of screw hole orientation, the intramedullary (IM) nail was modified by drilling a second set of proximal screw holes with oblique instead of parallel alignment. The axial, torsional, and varus-valgus stiffnesses of the constructs with parallel or oblique screws and with or without fracture site contact were determined. In an experimental model with an osteotomy located proximal to the position of the bend in the nail when fully inserted, anterior displacement of the proximal fracture component (or posterior displacement of the distal component) of up to 1 cm was measured. Oblique proximal locking screws significantly decreased both varus/valgus angulation and medial/lateral translation under load, compared with the parallel screws. Constructs were 117% and 55% as rigid as the intact tibia in axial loading with and without cortical contact, and 6.5% and 3.1% as stiff in torsion.(ABSTRACT TRUNCATED AT 250 WORDS)
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.
OBJECTIVE: To determine the patellofemoral contact areas as well as mean and maximal pressures after retrograde intramedullary nailing in a cadaveric model. STUDY DESIGN: Pressure-sensitive film was used to analyze patellofemoral joint pressures after insertion of a retrograde femoral nail in a cadaveric specimen. METHODS: A retrograde femoral nail was inserted into seven cadaveric knees. Pressure-sensitive film was placed into the patellofemoral joint and physiologic loads (700 newtons) were applied to the knee joint at 90 degrees and 120 degrees of flexion. Testing was performed with the nail three millimeters deep to the cartilage (In), flush with the cartilage (Flush), and one millimeter prominent (Out). The intact knee served as the Control. RESULTS: The mean contact areas showed no statistical differences among the four groups. There was a significant increase in mean pressure at 120 degrees and maximum pressure at 90 degrees and 120 degrees for the Out group when compared with the Control, In, and Flush groups (p < 0.001). CONCLUSIONS: There were no significant differences in mean contact pressure, contact area, or maximum pressure among the Control, three-millimeter insertion depth, or flush insertion groups. There was, however, a significant increase in mean and maximum pressures with the nail one millimeter prominent. These results indicate that placement of a retrograde femoral intramedullary nail is critical, but that proper placement should not significantly influence the biomechanics of the patellofemoral joint.
OBJECTIVE: To investigate the effects of tibial exchange nailing in treating a tibial shaft aseptic nonunion and to establish optimal indications for using this technique. DESIGN: Prospective, consecutive. SETTING: University hospital. METHODS: Twenty-five consecutive tibial shaft aseptic nonunions were prospectively treated with the exchange nailing technique. Indications for this procedure were a tibial shaft aseptic nonunion that had previously been treated with an inserted nonreamed or reamed intramedullary nail, displayed less than one centimeter of shortening, was with or without rotational or angular deformity, exhibited no segmental bony defects, and was anatomically suited for conventional or locked reamed intramedullary nail stabilization. The marrow cavity was reamed as extensively as possible, and a rigid intramedullary nail with stable fixation was inserted. RESULTS: During a follow-up period of two to four years (median thirty-two months), twenty-four nonunions healed, on average, in four months (range three to six months). The one remaining nonunion healed four months after a cancellous bone grafting procedure. No wound infection or malunion was noted. CONCLUSION: Because of its high union rate, low complication rate, and simplicity of method, we believe that the exchange nailing technique should be considered preferentially for all indicated cases.
OBJECTIVES: To investigate and compare closed and open revision techniques in the treatment of ununited femoral shaft fractures associated with locked nail breakage. DESIGN: Retrospective. SETTING: University hospital. METHODS: Ununited femoral shaft fractures associated with locked nail breakage were treated with either closed or open revision (nine or eighteen cases, respectively). The closed technique entailed closed removal of the broken nail and reinsertion of a stable intramedullary nail after reaming the marrow cavity. The open technique included open removal of the broken nail, reinsertion of a stable intramedullary nail or plate, and cancellous bone graft supplementation. Union rate, union period, perioperative course, and complications were compared. RESULTS: Eight closed and fifteen open technique cases were followed for at least one year (median two years). Cases treated with the closed technique had a union rate of 100 percent, a union period of 4.4+/-0.9 months, an operating time of 1.5+/-0.4 hours, no blood transfusion, and no complications. Open technique cases demonstrated a union rate of 100 percent, a union period of 5.7+/-1.5 months (p = 0.033), an operating time of 2.4+/-0.4 hours (p < 0.001), blood transfusion of 1,000+/-500 milliliters (p < 0.001), and no complications. CONCLUSIONS: We recommend the closed revision technique because its union period and operating time are shorter, and it does not require a blood transfusion. Because there is no local wound dissection, infection rates should also be lower. However, the procedure is technically demanding. If it cannot be completed successfully, using the open technique can still achieve a satisfactory outcome.