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PubMed2004

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.

BACKGROUND: Cephalocondylic intramedullary nails, which are inserted proximally to distally (cephalocondylic), have been used for the surgical treatment of extracapsular hip fractures. OBJECTIVES: To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the fourth substantive update of our original review which compared the Gamma nail with the sliding hip screw (SHS). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, several orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: May 2003. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Eighteen trials comparing the Gamma nail with the SHS were included, with data available for 2575 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate for other outcomes. Five trials involving 623 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. One trial of 206 patients with a trochanteric fracture showed no advantages for proximal femoral nail (PFN) compared with the SHS. One trial of 60 patients reported favourable preliminary results for an experimental mini-invasive static intramedullary nail compared with the SHS. One trial of 230 patients, which compared the Kuntscher-Y nail with the SHS, reported no major difference in outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Two trials, involving 65 patients with reverse and transverse fractures at the level of the lesser trochanter, compared an intramedullary nail (Gamma or PFN nail) with an extramedullary implant (a 90-degree blade plate or dynamic condylar plate). The intramedullary nails were associated with better intra-operative results and fewer fracture fixation complications for these rare fractures. REVIEWER'S CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, it appears that the SHS is superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, reversed fracture lines and subtrochanteric fractures).

Adult↗
PubMed2003

Closed reduction of forearm refractures with flexible intramedullary nails in situ.

BACKGROUND: Refractures of the forearm after flexible intramedullary nailing are rare. An alternative to nail replacement is closed reduction with the nails in situ. We successfully performed this maneuver on a thirteen-year-old boy. However, no data on the stability of previously bent nails are available. The purpose of the present study was to assess the mechanical stability of titanium and stainless steel flexible intramedullary nails after one cycle of reversed bending. METHODS: In an in vitro study, ten titanium and eighteen stainless steel 3.0-mm flexible intramedullary nails were subjected to an increasing lateral bending force until the point of first plastic deformation. As an analogy to the clinical case, they were then bent to an angle of 21 degrees and were manually reduced back to their original straight position and the experiment was repeated. The forces needed to achieve first plastic deformation and modified spring constants (force/deflection) were calculated and were compared between the native and previously bent nails. RESULTS: The average force required for permanent deformation of the previously bent nails was reduced by 37% for both titanium and stainless steel nails (from 21 to 13.2 N for titanium nails [p < 0.01] and from 25 to 15.7 N for stainless steel nails [p < 0.001]). The average modified spring constant decreased by 15.1% (from 0.814 to 0.691 N/ degrees ) for titanium nails (p < 0.001) and by 12.2% (from 0.991 to 0.870 N/ degrees ) for stainless steel nails (p < 0.001). Overall, steel nails were stiffer and stronger than titanium nails were. There was no macroscopic evidence of metal fracture or fatigue after one cycle of reversed bending to 21 degrees. CONCLUSIONS: Closed reduction of a forearm refracture with flexible intramedullary nails in situ is a safe, noninvasive, and effective alternative to nail replacement. However, mechanical stability of the nails is significantly reduced after the procedure. Therefore, the patient should be instructed to avoid any excessive forces to the forearm until fracture union has been documented radiographically, and casting for a limited time may be appropriate.

Adolescent↗
PubMed1991

Intramedullary nailing for impending pathological subtrochanteric fractures.

We reviewed ten patients with metastatic carcinoma and impending pathological fractures of the subtrochanteric region of the femur who had prophylactic insertion of the Russell-Taylor reconstruction nail. There were no operative complications or long-term mechanical failures. This reconstruction nail has some technical and biomechanical advantages over other implants and is ideal for the management of such cases.

Adult↗
PubMed1998

[Osteosynthesis with elastic nailing for treatment of tibial fracture].

Results of treatment of 163 tibial fractures in 47 females and 116 males aged 15-76 operated with closed elastic intramedullary osteosynthesis are presented. A bundle of universal intramedullary nails preshaped depending on fracture pattern served for osteosynthesis in 144 closed fractures, 18 open fractures of first degree and 1 second degree open fracture. In all cases but one fracture healed. Late results were assessed in 70 cases. There were 46 good results, 23 fair and 1 poor result. Simple surgical technique, good stability, stimulating of bone healing by compression and minor risk of infection constitute advantages of this method.

Adolescent↗
PubMed1987

Interlocking medullary nails--radiation doses in distal targeting.

Distal interlocking of intramedullary nails involves the use of a fluoroscope and a targeting device. A specially designed awl makes the interlocking procedure simple and efficient. The 30-cm-long side arm of this awl protects the surgeon's hand from direct radiation, and measurements of X-ray exposure show that the protection against radiation is sufficient.

Bone Nails↗
PubMed1984

A model of experimental post-traumatic osteomyelitis in guinea pigs.

A model of experimental post-traumatic osteomyelitis is described in which the femur of guinea pigs was fractured and infected with E. coli (10(5)) or Staphylococcus aureus (10(4)). Traumatized uninfected animals served as controls. The animals were further divided within each group by treating the fractured site with an intramedullary wire in one half. Osteomyelitis developed and became chronic in all guinea pigs infected with Staph. aureus, and in nine of 12 infected with E. coli. All animals infected with E. coli treated with an intramedullary wire developed chronic osteomyelitis; only four of seven from E. coli-infected animals with fractures developed this disease. Moreover, Staph. aureus could be recovered from the osseous tissue in the chronic stage of the disease regularly, while E. coli was only present in the early weeks after operation, but not in the chronic stage.

Animals↗
PubMed2001

Metastatic fractures of the tibia.

Pathologic fractures of the tibia due to a metastasis are rare. The treatment of an established fracture is sometimes conservative, but more often surgical. The purpose of the surgical procedure is to improve the quality of life and the ambulatory status, to relieve pain and to facilitate activities of daily living and nursing care. Four cases of operatively managed metastatic fractures of the tibia are presented with emphasis on the surgical technique. The scarce literature on metastatic tibial fractures in reviewed. The operative technique to be used does not only depend on the location of the tumor but also on the primary tumor, the response to adjuvant therapy and the life expectancy. For metastatic shaft fractures an intramedullary nail, sometimes augmented with bone cement, is preferred. For distal or proximal fractures a compound osteosynthesis with plates and screws offers a good solution. In the epiphyseal and metaphyseal region of the tibia an amputation or a tumor prosthesis is the procedure of choice.

Activities of Daily Living↗
PubMed1999

Insufficiency fracture of the femoral neck after intramedullary nailing.

We report a patient with insufficiency fracture that occurred after intramedullary nailing for a subtrochanteric fracture. Intramedullary nailing is speculated to have increased the stress in the already osteoporotic subcapital region. It therefore should be recognized as a causative factor in insufficiency fracture of the femoral neck. Careful follow-up is needed for patients with this condition.

Aged↗
PubMed2000

Flexible intramedullary nailing for the treatment of unicameral bone cysts in long bones.

BACKGROUND: Unicameral bone cyst is characterized by its tenacity and risk of recurrence. Pathological fracture is common and is often the presenting symptom. The objective of the present study was to evaluate the results of flexible intramedullary nailing for the treatment of a unicameral bone cyst with or without a pathological fracture. METHODS: Flexible intramedullary nailing for the treatment of a unicameral bone cyst was performed in thirty-two patients. Thirty of these patients presented with a pathological fracture; twenty-four were managed immediately with intramedullary nailing, and the other six had been managed conservatively at other clinics before they were referred to our department. The remaining two cysts were detected incidentally. The cyst was located in the humerus in twenty-one patients, in the femur in nine, and in the radius in two. The mean age of the patients at the time of surgery was 9.8 years, and the mean duration of follow-up was 53.7 months. Radiographic evaluation was performed according to the criteria of Capanna et al., and the cyst was classified as completely healed, healed with residual radiolucency (osteolysis), recurred, or having no response. RESULTS: The healing period ranged from three to 105 months. Fourteen cysts healed completely, and sixteen healed with residual radiolucent areas visible on radiographs. There was recurrence of two cysts that had healed with residual radiolucency. All of the cysts in the present study responded to treatment. A change of nails was necessary in nine patients, as the nails had become too short after bone growth. No major complications were observed. CONCLUSIONS: Flexible intramedullary nailing provides early stability, which allows early mobilization and thus obviates the need for a plaster cast and decreases the prevalence of the most common complication: a pathological fracture. This method of treatment also allows for an early return to normal activity.

Bone Cysts↗
PubMed1986

Open intramedullary nailing of the femoral shaft fracture.

There is a growing trend to closed intramedullary nailing of femoral shaft fractures that we partially subscribe to. This report, however, concerns open reduction and intramedullary nailing of femoral shaft fractures from 1972-1982. Two groups of fractures are discussed independently--22 pathologic fractures and 88 traumatic fractures. Mortality figures as well as functional and anatomic results are presented. Complications include one superficial infection, two nonunions, and two delayed unions. This study provides us with a baseline measure for comparison with other methods now under consideration and on trial.

Adolescent↗
PubMed1993

[Stable interlocking intramedullary nailing of humeral fractures with the Seidel nail].

22 fractures of the humerus (15 traumatological, 7 pathological) were treated with the Seidel-Nail. The results after a follow-up between 4 and 20 months showed good mobility of the shoulder. As major complications two paresis of the radial nerve occurred. One disappeared spontaneously. The Seidel-Nail is a good implant for all kind of shaft fractures with an intact distal fragment of 5 cm and also for fractures of an intact humerus head.

Aged↗
PubMed1999

Femoral fracture at the proximal end of an intramedullary supracondylar nail: a case report.

Retrograde intramedullary supracondylar nails have been added to the orthopedic armamentarium for treatment of distal femoral fractures. Major complications of this new technique have not been noted. We report a case of a femoral fracture at the proximal end of a retrograde intramedullary supracondylar nail. We hypothesize that this complication may be due to the proximal end of the nail acting as a stress riser, with the cortical holes drilled for the interlocking screws compounding this effect.

Accidents, Traffic↗
PubMed2002

Fat embolism syndrome.

Fat embolization and the clinical syndrome associated with this pathology are poorly understood complications of skeletal trauma. Fat embolization is characterized by release of fat droplets into systemic circulation after a traumatic event. Fat embolism syndrome (FES) is an infrequent clinical consequence of fat embolization. Classically, FES presents with the triad of pulmonary distress, mental status changes, and petechial rash 24 to 48 hours after pelvic or long-bone fracture. FES incidence increases with the number of fractures sustained by an individual. Many clinicians believe that FES incidence has decreased over the past several decades secondary to advances in resuscitative measures. FES pathophysiology remains unclear. Current theories involve common mechanical and biochemical mechanisms that explain how fat emboli manifest as FES. Much controversy surrounds the question of whether there is a causal relation between intramedullary nailing and FES onset. Clinical diagnosis is essential, as laboratory and radiographic findings are nonspecific. Early supportive pulmonary therapy and other resuscitative measures may halt the pathophysiologic cascade and prevent clinical deterioration. Fortunately, if FES is diagnosed early, and pulmonary and cardiac functions are optimally supported, prognosis is very good.

Bone and Bones↗
PubMed1990

Locked intramedullary nailing for displaced tibial shaft fractures.

We analysed the results of 93 tibial shaft fractures treated with the Grosse-Kempf locked nail. Twenty-six fractures were comminuted, 19 were open grade I to II, and 54 were located outside the middle third of the tibia. The deep infection rate was 3.2%. There were only two poor results. The use of this method is recommended and discussed.

Adolescent↗
PubMed1994

Preliminary clinical experience with a new fluted humeral nail.

The early clinical results of humeral nailing using a fluted intramedullary nail with a locking screw are reported. The True-Flex nail has been designed with a proximal cancellous screw to prevent 'back-tracking' and with flutes to give rotational control. The design features have proved to be successful in the authors' brief clinical experience in 12 patients with complicated fractures, non-unions or pathological lesions. Eight of the 10 fractures healed uneventfully, one by delayed union; one had to be revised because of loosening due to use of a nail which was too narrow. There were no serious complications. Return of function in the arm was good. This humeral nail may be suitable for fixation of some complicated and difficult fractures and lesions of the humeral shaft.

Adult↗
PubMed2007

[Elastic titanium nails in minimally invasive osteosynthesis for mid-clavicular fractures].

BACKGROUND: In up to 31% of cases, conservative treatment of mid-clavicular fractures leads to unsatisfactory results. The aim of this study was to define the value of minimally invasive elastic stable intramedullary nailing (ESIN) of mid-clavicular fractures with titanium elastic nails. MATERIAL AND METHODS: Within 5 years, ESIN was performed in 45 patients. We studied the functional results and complications. RESULTS: Retrospectively we analysed the results of all patients at a mean follow-up of 24.7+/-2.4 months. Iatrogenic perforation of the lateral cortex occurred twice and medial migration in eight patients. Superficial skin infection developed in one. Nail breakage after fracture healing was observed twice. Twelve patients sustained clavicular shortening of > or =5 mm in relation to the intact contralateral side. After 6 months the mean constant score was 94.3+/-2 points, and the mean DASH score was 5.4+/-2.2 points. CONCLUSION: Intramedullary stabilisation of mid-clavicular fractures with titanium elastic nails is a minimally invasive technique with good functional results. Patients must be informed about the possibility of open reduction in about half of the cases as well as shoulder asymmetry, migration of the nail, and iatrogenic nerve and vessel injury.

Adult↗
PubMed1989

[Managing pathologic femoral fractures in malignant bone tumors and skeletal metastases].

In adults pathological fractures of the femur are mostly caused by skeletal metastases. In our own collective of femoral fractures 58 were caused by skeletal metastases and five by multiple myeloma. Average age was 59.8 years, women prevailed. In most of the metastatic fractures breast cancer was found to be the primary tumour. In all cases fracture stabilization as a palliative measure was the only possible therapy. Two patients could not be operated on because of other vital problems. In femoral neck fractures resection and endoprosthesis was the operative measure of choice. The pertrochanteric and subtrochanteric fractures were mostly treated by composites of cement and the 95 degrees condylar-plate. Also in shaft fractures cement-implant composites were performed with straight plates. Rarely, intramedullary nailing was done. Exercising stability could always be achieved, weight-bearing stability in most of the cases. The mean survival time was 7.2 months regarding 43 patients with well documented course. Six patients are controlled regularly, the operative treatment was done on an average 16 months before.

Aged↗
PubMed2000

Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden.

OBJECTIVE: To quantify changes in variables of inflammation, coagulation, and fibrinolysis in blunt trauma patients with lower extremity fractures who underwent different types of surgical procedures. DESIGN: Prospective, cohort study. SETTING: Level I university trauma center. PATIENTS: We allocated 83 blunt trauma patients in stable condition and 22 patients eligible for elective hip replacement to four treatment groups. INTERVENTIONS: In 34 multiply traumatized patients with femoral fracture (group PTFF) and in 28 patients with an isolated femoral fracture (group IFF), primary unreamed intramedullary nailing for stabilization of the femoral shaft fracture was performed. In 22 patients, an elective uncemented total hip arthroplasty (group THA) was inserted for osteoarthritis, and in 21 control patients, an isolated ankle fracture (group AF) was acutely stabilized. MEASUREMENTS AND MAIN RESULTS: From serially sampled central venous blood, the perioperative concentrations of interleukin (IL)-6, of tumor necrosis factor-alpha, of prothrombin fragments 1 + 2, and of D-dimer cross-linked fibrin degradation products were evaluated. Intramedullary instrumentation for an isolated femur fracture caused a significant perioperative increase in the concentrations of IL-6 (preoperative IL-6, 52 +/- 12 pg/mL; IL-6 30 mins postinsertion, 78 +/- 14 pg/mL; p = .02). This increase was comparable with group THA (preoperative IL-6, 46 +/- 16 pg/mL; IL-6 30 mins postinsertion, 67 +/- 11 pg/mL; p = .03). A positive correlation occurred between both groups (r = .83, p < .0004). Multiple trauma patients demonstrated significantly (p = .0002) higher IL-6 concentrations than all other groups throughout the study period and showed a significant increase after femoral nailing (preoperative IL-6, 570 +/- 21 pg/mL; IL-6 30 mins postinsertion, 690 +/- 24 pg/mL; p = .003), whereas no perioperative change was seen in group AF. The highest IL-6 increases were associated with a longer ventilation time (group PTFF) and a longer period of positive fluid balances (groups PTFF, IFF, THA). The coagulatory variables demonstrated similar perioperative increases in groups IFF and THA, but not in groups PTFF and AF. The IL-6 concentrations and the prothrombin fragments 1 + 2 concentrations correlated between groups THA and IFF at 30 mins and at 1 hr after surgery (r2 = .64, p < .02). In all patients the clinical variables were stable perioperatively. CONCLUSIONS: Major surgery of the lower extremity causes changes to the inflammatory, fibrinolytic, and coagulatory cascades in patients with stable cardiopulmonary function. The inflammatory response induced by femoral nailing is biochemically comparable to that induced by uncemented total hip arthroplasty. In multiple trauma patients, increases, which occurred in addition to those induced by the initial trauma, were measured. Definitive primary femoral stabilization by intramedullary nailing imposes an additional burden to the patient with blunt trauma. A careful preoperative investigation is required to evaluate whether primary definitive stabilization can be performed safely.

Adult↗