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PubMed2001

Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur.

OBJECTIVES: To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures. DESIGN: A prospective, randomised controlled clinical trial with observer blinding. SETTING: A regional teaching hospital in the United Kingdom. PATIENTS: All patients admitted from the local population with intertrochanteric fractured femurs were included. There were 400 patients entered into the study and 399 followed-up to one year or death. INTERVENTION: The devices were assigned by randomization to either a short-type Gamma nail (203 patients) or a Richard's-type sliding hip screw and plate (197 patients). MAIN OUTCOME MEASUREMENTS: The main surgical outcome measurements were fixation failure and reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year. RESULTS: The requirement for revision in the Gamma nail group was twelve (6%); for Richard's group, eight (4%). This was not statistically different (p = 0.29; odds ratio, 1.48 [0.59-3.7]). A subcapital femoral fracture occurred in the Richard's group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richard's group (p = 0.13). Three required revision to another implant. Lag-screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richard's group (2%). This was not statistically significant (p = 0.37; odds ratio, 2.29 [0.6-9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year. CONCLUSIONS: The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate.

Adult↗
PubMed2004

Rotational malalignment after intramedullary nailing of femoral fractures.

OBJECTIVES: Intramedullary nailing has been accepted as the treatment of choice for femoral shaft fractures. The aim of our study was to determine the incidence and implications of rotational malalignment after intramedullary nailing using computed tomography measurements. DESIGN: Cohort study. SETTING: Patients who postoperatively visited the orthopaedic outpatient and radiology clinics. PATIENTS: Seventy-six patients, 59 men and 17 women, with a mean age of 28.4 years (15-88). INTERVENTION: Patients treated on a fracture table with an antegrade reamed AO nail (n = 46) or Grosse Kempf nail (n = 30) for a unilateral femoral shaft fracture between 1988 and 1998 were included in the study. MAIN OUTCOME MEASUREMENTS: Patients filled out a questionnaire concerning pain, daily activities, and sport. Oxford, Western Ontario and McMaster University osteoarthritis index, and Harris Hip and Knee Society scores were obtained. Physical exams and computed tomography measurements were established. RESULTS: Twenty-one patients (28%) were found to have a rotational malalignment of 15degrees or more. There was no significant difference in rotational deformity with either the AO or Grosse Kempf nail. The incidence of malrotation was independent of the fracture level. Patients with a torsional deformity had difficulties with more demanding activities like running, sports, and climbing stairs. Patients with an external rotational malalignment (n = 12) have more functional problems than patients with an internal rotational malalignment (n = 9). Clinically determined rotation differences are not accurate (+/-20degrees) compared with the established computed tomography measurements. CONCLUSIONS: Rotational malalignment after intramedullary nailing for femoral fractures is found in 28% of the patients in this study. These patients have difficulties with more demanding activities, especially when they have an external torsional deformity.

Adolescent↗
PubMed2006

Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal.

OBJECTIVE: The purpose of this study is to compare a cephalomedullary nail that uses a piriformis fossa starting point to one that uses a trochanteric starting point, in the treatment of high-energy proximal femur fractures in young patients. Our hypothesis was that a nail that uses a trochanteric starting point would result in less blood loss than a nail that uses a piriformis fossa starting point. DESIGN: Prospective, randomized. SETTING: Level 1 trauma center. PATIENTS: Thirty-four consecutive patients aged between 18 and 50 years who sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck/shaft fracture due to a high-energy injury were enrolled. INTERVENTION: Patients were randomized to have their fractures repaired with a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Surgery was performed on a fracture table, in supine or lateral position according to the surgeon's preference. Direct fracture exposure was avoided. Reduction was obtained through traction, patient positioning, and manual pressure. If necessary, stab-wound incisions were made to introduce instruments to improve reduction. Intramedullary reamers were used, and all nails were statically locked. Bone grafting was not used. MAIN OUTCOME MEASURES: Blood loss, incision length, duration of surgery, and body mass index were recorded for each patient. Surgeon's assessment of ease of use of the device and quality of reduction were noted. Patients were to be followed up to assess fracture union. Hip and knee ranges of motion at latest follow-up were measured. Radiographs obtained at the time of union were assessed for varus malalignment. Return to work status was recorded, and the Harris Hip Score was used to assess hip function. RESULTS: There were 17 patients in each group. The 2 groups did not differ with regard to blood loss, incision length, and duration of surgery or intraoperative complications. Body mass index was significantly linked to duration of surgery (P<0.001) and incision length (P<0.001). Surgeon's assessment of ease of use and reduction quality for the two devices did not differ. The rate of varus malunion did not differ between the 2 groups. Two patients were lost to follow-up before fracture union. All other fractures healed with no need for bone grafting or other procedures to obtain union. One obese patient developed a wound infection that resolved after debridement and a course of antibiotics. A total of 6 patients were lost prior to their 1-year follow-up visit. Among the remaining 28 patients, at an average follow-up of 14 months, no difference was noted between the 2 groups with regard to return to work status, Harris Hip Score, or hip and knee ranges of motion. CONCLUSIONS: Both devices yield predictably good results in these difficult fractures. We found no difference between the two devices with regard to incision length, duration of surgery, blood loss, reduction, ease of use, union rate, complication rate, or outcome.

Adolescent↗
PubMed2006

Flexible intramedullary nail removal using a broken screw removal set.

The use of flexible titanium intramedullary nails for management of pediatric long bone fractures and some adult fractures has become common. Nail removal after union can be challenging and often requires a larger exposure than nail placement to allow the insertion of grasping devices, such as pliers. A percutaneous technique for the removal of flexible intramedullary nails using extraction bolts from a broken screw removal set is presented. The technique is especially useful when the end of the nail is not prominent and where a hollow reamer from the same set can expose the nail end for the extraction bolt to be used.

Adult↗
PubMed1988

Heterotopic ossification around the hip with intramedullary nailing of the femur.

Heterotopic ossification (HO) at the proximal end of a reamed intramedullary femoral nail is a complication of the procedure. Kuntscher stated that these "callus caps" were due to the prominence of the nail above the greater trochanter. A study of patients undergoing locked intramedullary nailing of the femur to assess subsequent development of heterotopic ossification at the proximal end of the implant was done. The purpose was to study the clinical significance of the ectopic bone and identify etiologic factors of bone formation. This group consisted of 59 patients with 60 locked intramedullary nails who were reviewed after prospective clinical and radiologic followup. Ectopic bone around the proximal end of the nail was classified with respect to quantity and clinical importance. A number of parameters were evaluated and a multifactorial analysis was performed. There were 52 males and seven females. Heterotopic bone was graded as: none--32%; minimal--20%, mild--28%; moderate--15%; and severe--5%. There was a positive correlation between bone formation and head injury, Injury Severity Score, and ventilator and ICU days. Prominence of the nail was not significant.

Adolescent↗
PubMed1991

Subtrochanteric fractures treated with interlocking nailing.

In a prospective study of 31 subtrochanteric fractures treated with Grosse-Kempf interlocking nails with a followup period of at least 1 year, there was a 87.1% (27/31) union rate, and a union period of 4.2 +/- 1.8 months. Knee range of motion in 28 acute traumatic cases was on average 127.5 +/- 23.0 degrees. The significant complications included: nail breakage, 3.2% (1/31); nonunion without nail breakage, 9.7% (3/31); neglected femoral fracture with malunion, 3.2% (1/31). The interlocking nailing has the advantages of: a) closed method, b) weight-sharing principle, c) shortening prevention, d) non-rigid fixation. From the theoretical and clinical comparison among the various implants, we conclude that closed interlocking nailing is one of the better instruments for subtrochanteric fracture treatment, and moreover, the most reasonable of all. However, for the higher level subtrochanteric fractures, reconstruction-style locking nails should be chosen.

Adolescent↗
PubMed1998

Treatment of closed humeral shaft fractures with intramedullary elastic nails.

PURPOSE: Our purpose is a retrospective study of the results of diaphyseal humeral fracture treatment by elastic intramedullary nailing in comparison with plate osteosynthesis. METHODS: Thirty cases were reviewed, with an average follow-up of 2 years. In 14 cases, flexible nails were used, and in the remaining 16 cases, A-O plates were used. We considered patients' sex and age, fracture type according to the A-O classification, type of treatment, consolidation defects, additional therapeutic procedures, healing time, and functional recovery. The surgical technique of elastic nailing appeared very simple, safe, and rather atraumatic because the nail is introduced in a retrograde manner and does not need proximal interlocking. RESULTS: The results of elastic nailing, in terms of fracture healing time and functional recovery, appeared comparable with the results of plating, and complications appeared milder. CONCLUSION: We conclude that intramedullary elastic nailing is valid for routine use in appropriately selected humeral shaft fractures.

Adolescent↗
PubMed1999

Reamed intramedullary nailing of the femur: 551 cases.

BACKGROUND: The care of the patient with the fractured femur entails a multiple surgical team approach. Healing of the fracture and expediency in the operating room are both important. We sought to determine the results of the treatment of fractures of the femoral shaft with interlocking femoral nails inserted with closed techniques, and to compare the outcomes of fractures nailed by using a fracture table with those stabilized with the leg draped free on a radiolucent table. METHODS: Eight hundred eighty-two consecutive patients with fractures of the femoral shaft treated with a first-generation intramedullary nail at the authors' institution during the years 1986 to 1996 were identified. Five hundred fifty-one fractures in 515 patients met the inclusion criteria. RESULTS: Treatment with an intramedullary nail led to a union rate of 98.9%. There were six infections, all occurring in closed fractures. Thirty-eight percent of the fractures had hardware removed, most commonly because of pain. One nail and 13 locking bolts broke. Four hundred eighteen fractures had adequate radiographs available to assess fracture alignment. No fracture healed with more than 10 degrees of angulation in either plane. Forty-four fractures healed with more than 5 degrees of angulation. A distal third fracture was found to be associated with an increased incidence of malalignment. There were no differences in outcomes between fractures stabilized with or without a fracture table. CONCLUSION: Reamed intramedullary nailing of femoral shaft fractures results in a low rate of nonunion, malunion, infection, and hardware failure. There is no difference in the outcomes of fractures treated with and without the use of a fracture table. This is particularly useful in the patient with multiple injuries for whom transfer to a fracture table may not be time effective.

Adolescent↗
PubMed1999

Treatment of fractures of femur and tibia with the telescopic locking nail: design of a new implant and the first clinical results.

BACKGROUND: This study was carried out to evaluate the first clinical experiences with the telescopic locking nail (TLN). The TLN is a newly developed universal locking nail system for both femur and tibia that permits cyclic dynamic loading at the fracture site while weightbearing. The nail can also be used for static interlocking or for compression of the fracture elements. The nail is strong enough to permit immediate weightbearing, and the diameter of 9 mm allows unreamed introduction in many cases. MATERIALS: Seventy-one consecutive patients were treated with the TLN, 24 patients with femoral and 47 patients with tibial fracture or nonunion. RESULTS: Functional outcome, complication rate, and union rate were comparable to other interlocking nail systems. CONCLUSION: Its distinctive biomechanical properties and its universal application in both femur and tibia make the TLN a sophisticated, yet in practice simple, new asset in the practice of intramedullary nailing.

Adolescent↗
PubMed2002

Similar central hemodynamics and oxygenation in reamed and unreamed intramedullary nailing of tibial fractures.

BACKGROUND: Reamed intramedullary nailing of a long bone fracture is considered to be of crucial importance in the genesis of pulmonary disturbances. Use of unreamed nailing technique has been encouraged to avoid temporary deterioration in lung functions. METHODS: Central hemodynamic changes were recorded in 20 healthy adults with a unilateral simple tibial fracture undergoing reamed or unreamed intramedullary nailing. The patients were cannulated with a pulmonary artery catheter. Intramedullary nailing was performed during general anesthesia. Pre- and immediate postoperative hemodynamic variables were compared. RESULTS: Unchanged cardiac performance but pathologically altered pulmonary vascular tone were unrelated to the type of nailing technique. Increased oxygen consumption was observed as well. CONCLUSION: Changes in cardiac and pulmonary hemodynamics are already present after the trauma and before the intramedullary nailing procedure.

Adult↗
PubMedDate not supplied

Biomechanical comparison of intramedullary nail and blade plate fixation for tibiotalocalcaneal arthrodesis.

OBJECTIVE: Tibiotalocalcaneal arthrodesis is used to manage severe bone loss, arthritis, and/or instability. The goal is to relieve pain through a stable, well-aligned hindfoot and ankle. The purpose of this study was 2-fold: to biomechanically compare 1) initial stability, and 2) the effect of bone density on the stability of intramedullary nail and blade plate fixation in tibiotalocalcaneal arthrodesis. DESIGN: Biomechanical study using anatomic specimens. METHODS: Ankle and subtalar joint capsules were exposed for 7 pairs of fresh-frozen anatomic specimens. One ankle from each pair was instrumented with an interlocked intramedullary nail inserted retrograde across the subtalar and ankle joint while the contralateral hind foot was stabilized with a lateral cannulated blade plate. Specimen stability was tested in plantar/dorsiflexion and inversion/eversion to a maximum bending moment of 12 Nm and in internal/external rotation to a maximum torque of 7 Nm. Physical measurements of bone density were made to determine its effect on stability. MAIN OUTCOME MEASURES: Maximum angular displacement of the constructs in plantarflexion, dorsiflexion, inversion, eversion, internal rotation, and external rotation. RESULTS: No significant differences were observed between the plated and nailed constructs in the 3 loading configurations (Power = 0.77). Only 6 pairs were included in the results because of fixation failures. A small but significant reduction in internal rotation alone of 1.8 degrees was found with the plated compared with the nailed construct (P = 0.045). Reduced stability was associated with lower bone density in torsion and inversion/eversion in the plated constructs (r = 0.67- 0.87) with a similar trend seen in torsion in the nailed constructs (r = 0.5). CONCLUSION: Initial construct stabilities and the effect of reduced bone density were found to be similar between the blade plate and the intramedullary nail in tibiotalocalcaneal arthrodesis, thus implant choice may be based on other clinical factors, such as surgeon preference or soft-tissue status.

Aged↗
PubMed2006

Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures?

OBJECTIVE: Evaluate whether supplementary fibular fixation helped maintain axial alignment in distal metaphyseal tibia-fibula fractures treated by locked intramedullary nailing. DESIGN: Retrospective chart and radiographic review. SETTING: Three, level 1, trauma centers. PATIENTS: Distal metaphyseal tibia-fibula fractures were separated into 2 groups based on the presence of adjunctive fibular plating. Group 1 consisted of fractures treated with small fragment plate fixation of the fibula and intramedullary (IM) nailing of the tibia, whereas group 2 consisted of fractures treated with IM nailing of the tibia without fibular fixation. OUTCOME MEASURES: Malalignment of the tibial shaft was defined as 1) >5 degrees of varus/valgus angulation, or 2) >10 degrees anterior/posterior angulation. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Leg length and rotational deformity were not examined. RESULTS: Seventy-two fractures were studied. In 25 cases, the associated fibula fracture was stabilized, and in 47 cases the associated fibula fracture was not stabilized. Cases were more likely to have the associated fibula fracture stabilized where the tibia fracture was very distal. In multivariate adjusted analysis, plating of the fibula fracture was significantly associated with maintenance of reduction 12 weeks or later after surgery (odds ratio = 0.03; P = 0.036). The use of 2 medial-lateral distal locking bolts also was protective against loss of reduction; however, this association was not statistically significant (odds ratio = 0.29; P = 0.275). CONCLUSIONS: In this study, the proportion of fractures that lost alignment was smaller among those receiving stabilization of the fibula in conjunction with IM nailing compared with those receiving IM nailing alone. Adjunctive fibular stabilization was associated significantly with the ability to maintain fracture reduction beyond 12 weeks. At the present time, the authors recommend fibular plating whenever IM nailing is contemplated in the unstable distal tibia-fibular fracture.

Adolescent↗
PubMedDate not supplied

Removal of flexible titanium nails in children.

Removal of hardware in children after orthopaedic procedures is controversial. The authors retrospectively reviewed hospital charts and radiographs of 143 children who underwent removal of flexible titanium nails from the femur and the forearm. In 16 children the nails were removed because of protrusion, skin irritation, and some discomfort. Most of the patients were asymptomatic and underwent nail removal electively, according to the authors' policy for routine hardware removal in children. Complications included unsuccessful nail removal in three children and refractures after nail removal in two. Although the authors are still inclined to remove flexible titanium nails in most of the patients, the need for routine elective execution of this procedure may be questionable.

Adolescent↗
PubMed2005

Use of the eponychial flap to restore the length of a short nail: a review of 30 cases.

BACKGROUND: Distal digital amputations may result in composite tissue loss, affecting both the fingertip and the nail complex. Most surgical procedures that are used for fingertip reconstruction do not restore the nail defect. METHODS: The eponychial flap is a new technique where a backward plication of the nail wall is used to expose the nail root and lengthen the visible part of the nail of the amputated digit. RESULTS: The authors describe the anatomical basis and the operative technique of this flap and also review a series of 30 eponychial flaps that were performed in 28 patients. All patients presented fingertip defects treated with volar advancement flaps. This procedure was followed by an eponychial flap that restored the length of the short fingernail. CONCLUSIONS: The eponychial flap procedure is an easy and reliable technique that is indicated in distal transverse digital amputations to lengthen the short injured nail. It can be associated with any method used for repairing the fingertip defect, thus enhancing the final cosmetic result of the digital reconstruction.

Adolescent↗
PubMed2004

Thin split-thickness toenail bed grafts for avulsed nail bed defects.

Avulsed defect of a fingernail bed is a common injury in acute hand trauma. Insufficient management for this type of nail bed avulsion often leads to an irregular and nonadherent nail. The use of thin split-thickness sterile matrix graft from the great toe for immediate replacement of a nail bed defect can regain a smooth, adherent, and normal-looking nail. Between May of 1998 and December of 2001, we used thin split-thickness toenail bed grafts in 13 fingers of 12 patients with avulsed defects of the nail bed. The end results of this technique were excellent and no deformities occurred in the graft donor area. Thin split-thickness toenail bed graft is a good choice for the treatment of acute nail bed avulsion.

Adult↗
PubMed2006

Fracture strain and stability with additional locking screws in intramedullary nailing: a biomechanical study.

BACKGROUND: We studied the effect of additional locking screws on fracture strain and stability in tibial intramedullary nailing. METHODS: We drilled an additional diaphyseal locking hole into 8-mm solid tibial nails 185 mm from the proximal end of the nail, and locked it proximally and distally. An osteotomy was produced 4.5 cm distal to the additional hole, and the construct loaded axially, in flexion, extension, and torsion. The nails were also tested for their fatigue strength. RESULTS: With the additional locking screw, strain increased proximally during loading in neutral and flexion. Strain decreased on loading in extension. The extra locking screw decreased strain close to the osteotomy site in all loading positions. A significant reduction in angular motion at the osteotomy site occurred with the addition of the extra locking screw. The nails survived the fatigue test, although the stress increased around the additional locking hole CONCLUSIONS: Nails with additional locking options, by altering strain and motion at the fracture site, may have the clinical potential to affect fracture healing.

Biomechanical Phenomena↗
PubMed2006

The trochanteric nail versus the sliding hip screw for intertrochanteric hip fractures: a review of 93 cases.

BACKGROUND: The trochanteric nail, a redesigned short gamma nail, (Howmedica, Rutherford, NJ) was introduced in the United States during 1998 for the treatment of intertrochanteric fractures. METHODS: We retrospectively reviewed 93 patients who were treated for an intertrochanteric fracture with either a sliding hip screw (SHS) or the short trochanteric nail (TN). RESULTS: In all, 94% of the patients in the sliding hip screw group healed without complication. There was one case of femoral head necrosis, one lag screw cutout, and one hardware removal for pain. Eighty-nine percent of the patients in the trochanteric nail group healed without complication. There was one late fracture at the tip of the nail, three cases of lag screw cutout, and one nonunion. CONCLUSIONS: This study suggests that the trochanteric nail is a reasonable alternative to the sliding hip screw when used for intertrochanteric fractures, although it may be associated with higher complication rates.

Aged↗
PubMed1989

Glycosylated proteins of skin, nail and hair: application as an index for long-term control of diabetes mellitus.

The purpose of the present study was to compare the degrees of nonenzymatically glycosylated proteins in the skin (stratum corneum), the nail, the hair, and hemoglobin obtained simultaneously from the same subject and to evaluate the most useful sample for management of diabetic complications. Fifty-one diabetic patients and 20 control patients were examined, utilizing furosine determination. Furosine value of the skin in diabetics was 2.14 +/- 1.70%, whereas that in controls was 1.65 +/- 0.47%. Furosine value of the nail in diabetics was 6.67 +/- 3.30%, whereas that in controls was 4.16 +/- 1.62%. Furosine value of the hair in diabetics was 1.30 +/- 1.11%, whereas that in controls was 1.29 +/- 1.71%. Close correlations were detected between HbA1 (glycosylated hemoglobin) and furosine of the nail (r = 0.58, p less than 0.001), HbA1 and furosine of the skin (r = 0.48, p less than 0.001), and HbA1 and furosine of the hair (r = 0.43, p less than 0.01); however, poor correlations were found between furosine of the hair and the skin (r = 0.35, p less than 0.05) and furosine of the nail and the hair (r = 0.33, p less than 0.05). Furosine of the nail was significantly correlated with the FBS (fasting blood sugar) of the same time, previous 6, and previous 12 months. Furosine value of the nail, we believe, is the most useful indicator for evaluating long term control of diabetics and may provide useful information for management of diabetic complications.

Adult↗