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PubMed1996

[Intramedullary nailing of open fractures].

The goal of treatment of open fractures is to prevent infection, promote fracture healing, and restore normal limb alignment and function. The initial treatment of these fractures includes: debridement, soft tissue coverage, antibiotic therapy, and fracture stabilization. Four different techniques for intramedullary nailing for the fixation of open fractures have been employed: (1) unreamed, unlocked nails (i.e., Ender and Lottes, which have low infection rates, but are mechanically insufficient); (2) reamed unlocked nailing (which relies on overreaming to provide stability through bone-nail surface contact, but is associated with high infection rates); (3) reamed locked nailing (which may rely on limited reaming because of the interlocking screws); and (4) unreamed nailing (which always relies on interlocking screws and is associated with function better than and infection rates similar to those with external fixation, but has an increased incidence of screw breakage). In contrast to the biological problems in the tibia, those problems encountered in the femur are more predominantly mechanical in origin. For humeral shaft fractures, shoulder problems associated with the antegrade approach are frequent, and bypassing the rotator cuff with a retrograde approach appears advantageous.

Anti-Bacterial Agents↗
PubMedDate not supplied

Surgical management of diaphyseal humeral nonunion after intramedullary nailing: Wave-plate fixation and autologous bone grafting without nail removal.

Six patients with a nonunion of the humeral diaphysis after intramedullary nailing were treated with a wave plate and autologous bone graft but without removal of the intramedullary implant. The mean duration of the nonunion was 19 months (range, 6-36 months). At a mean follow-up of 12 months (range, 6-18 months), all six nonunions had healed, and patient satisfaction was high. Five patients had regained full shoulder function. One patient, who was treated for a rotator cuff tear before the humeral fracture, had a satisfactory functional outcome. Elbow motion was full in all but one patient. One patient had a postoperative radial nerve palsy, which recovered partially but did not require further surgery. This report suggests that healing of humeral nonunions can be achieved in the presence of intramedullary hardware.

Adult↗
PubMed2004

Does graded reaming affect the composition of reaming products in intramedullary nailing of long bones?

Reaming products taken during intramedullary nailing were examined to identify possible differences in their composition depending on the reaming percentage. Reaming products were taken from 39 fresh closed tibial and femoral diaphyseal fractures in patients with an average age of 29 years. According to histology, reaming products mainly consisted of bone trabeculae, viable or nonviable, and bone marrow stroma. A statistically significant reverse correlation exists between viable bone mass percentage and reaming progress. Reaming 1 mm less than the minimum canal diameter provides a higher viable bone mass percentage, which might be an important factor in the bone healing process.

Adolescent↗
PubMed2005

Rotational stability of Seidel nail distal locking mechanism.

The intramedullary distal locking mechanism in the Seidel nail uses interference fit, avoiding the need of a screw traversing soft tissue and the risk of neurovascular injury. However, there is concern for its rotational stability. This study was designed to test the rotational stability of the distal locking mechanism under the least stable conditions. A transverse osteotomy was performed 10 cm proximal to the trochlea in 10 cadaveric humeri, followed by insertion of a 9 mm diameter Seidel nail and distally locked. The proximal humeral segments were removed. Rotational test to failure was performed with a material testing machine. The initial medullary diameter and the amount of flange spread measured 9.95 mm and 11.28 mm, respectively. Most of the flanges were found to be incompletely deployed. Failure occurred by slippage of the flanges. The average failure torque and torsional stiffness of the nail bone construct tested were 0.262 N m and 0.070 N m/ degrees . The Seidel nail distal locking mechanism has low rotational stability on mechanical testing. However, the low failure torque tested in vitro does not always preclude successful fracture healing and a good clinical outcome. Whether the presence of rotational micro motion would be beneficial to bone healing would need further investigation.

Adult↗
PubMedDate not supplied

Improved intramedullary nail interlocking in osteoporotic bone.

OBJECTIVE: Intramedullary nail locking bolts often fail to gain purchase or cut out in osteoporotic bone. The biomechanical stability of a bladelike device that lowers intraosseous stress levels by distributing the load over a greater volume of bone was compared with conventional locking bolts in osteoporotic bone. METHODS: Standardized simulated comminuted supracondylar femoral fractures (segmental defect) in fresh-frozen paired osteoporotic (bone mineral density <200 milligrams per cubic centimeter) human cadaveric femurs were stabilized with a retrograde unreamed distal femoral nail and distally interlocked with conventional locking bolts or a bladelike device. The distal portions of the fixator-bone constructs were tested under axial load, and the stiffness and strength were compared (pairwise). RESULTS: Interlocking with a bladelike device was 41 percent stiffer (p = 0.01) and 20 percent stronger (p = 0.02) than that with conventional locking bolts. All posttesting radiographs showed compaction of the cancellous bone distal to the interlocking devices. Even after nail displacements of twelve millimeters, only a few locking bolts were plastically deformed and no bladelike device showed gross plastic deformation. CONCLUSION: This study showed the biomechanical benefits of increasing the bone-implant interface surface for improving the acute stiffness and strength of fracture fixation in osteoporotic cancellous bone. The fixator-bone construct withstood higher forces before failure in these fragile bones.

Aged↗
PubMed2006

Treatment of open tibial shaft fractures using tightly fitted interlocking nailing.

Between 2000 and 2003 we treated 23 patients who sustained open tibial shaft fractures with tightly fitted interlocking intramedullary nailing. There were three grade I, eight grade II, nine grade IIIa, and three grade IIIb open fractures. Nail diameters were decided on using preoperative and intraoperative radiographs. Nails were introduced after gentle passage with a 7- to 8-mm hand reamer. Union was obtained in all cases. Nine (37.5%) fractures, however, required additional procedures before union. Three of them gained union through exchange nailing, bone graft, and bone transport, respectively. The remaining six underwent dynamisation. Two of them required an additional exchange nailing for non-union; thereafter one healed and the other gained union through an additional bone graft. Deep infection occurred in one case. Screw breakage occurred in one case only. Tightly fitted nailing produced a significantly lower incidence of locking screw breakage. However, even with this advantage, this technical modification has failed to show clinical advantage in terms of higher healing rate or lower rate of secondary procedures.

Adolescent↗
PubMed1986

Infection following intramedullary nailing of long bones. Diagnosis and management.

In 30 patients (23 femurs and 7 tibias) with infection of long bone fractures following intramedullary (IM) nailing, the follow-up study ranged from eight to 84 months (mean, 20 months). Six patients retained active infection at the time of follow-up examination. Ununited fractures were present in four and sequestra in two patients. Stabilization for fracture healing after irrigation and debridement with appropriate systemic antibiotic therapy was the critical factor in the orthopedic management of this series of patients.

Adult↗
PubMed2000

Treatment of humeral shaft delayed unions and nonunions with humeral locked nails.

OBJECTIVE: To report experience with use of humeral locked nails in treating humeral delayed unions and nonunions. The following techniques yielded encouragingly good results: static locking, short-to-long segment nailing, bone grafting, fracture compression, and minimal surgical trauma. DESIGN AND METHODS: A total of 41 consecutive patients with 13 delayed unions and 28 nonunions were treated with humeral locked nails. Delay from trauma to surgery averaged 4.2 months for delayed union and 15.5 months for nonunion. The average age of patients was 50.2 years; average follow-up time was 23.2 months. There were 7 proximal-third fractures, 21 middle-third fractures, and 13 distal-third fractures. The antegrade approach was used for 13 fractures and retrograde for 28. Open nailing was performed in 39 fractures and closed nailing in 2. If the fracture motion was still present after nail insertion, axial compression of the fracture site was specially applied. Bone grafting was performed in the fractures with open nailing. Thirty-four fractures were nailed with 8-mm nails, and 7 fractures were nailed with 7-mm nails. RESULTS: With a single operation, all but two patients achieved osseous union in, on average, 5.6 months. One of these two patients eventually gained union after another surgery with fracture compression along the original nail and concurrent bone grafting. The second patient, undergoing hemodialysis for chronic renal failure, had persistent nonunion. At follow-up, for patients with antegrade nailing, all but four patients had less than 20 degrees limitation of shoulder abduction. For patients with retrograde nailing, all but two had less than 10 degrees limitation of elbow motion. Only the patient with persistent nonunion had continual pain and significant impairment of arm function. CONCLUSIONS: Humeral locked nailing seems to be effective for humeral delayed unions or nonunions. It may be an acceptable alternative for fractures unsuited for plate fixation, such as those with comminution, osteoporosis, or a severely adhered radial nerve.

Adult↗
PubMed2001

Initial rotational stability of distal tibial fractures nailed without proximal locking: the importance of fracture type and degree of cortical contact.

Although distally locked (dynamic) nailing is generally recommended for fractures below the isthmus of the tibia in the presence of adequate proximal nail-bone contact, rotational stability in the above situation appears to be a major concern and can increase the risk of malunion. However, there is no published experimental evidence to quantify this mechanical parameter or to relate factors such as the fracture pattern with the final clinical outcome. This in-vitro biomechanical experimental study was set out to measure the initial rotational stability of dynamically nailed fractures of the distal tibial diaphysis. Using a composite tibial model, three non-comminuted types (spiral, oblique and transverse) and various comminuted patterns (comminution, 0-85%) of dynamically nailed fractures of the distal tibial diaphysis were tested. Using a special rig to simultaneously apply axial and torsional loading measurements of torsional stiffness and the previously described "spring-back angle" were carried out. Our results showed that in terms of torsional stiffness and the "spring-back" angle oblique fractures are the most stable followed by transverse and spiral fractures. Furthermore, when testing of the above parameters against the degree of comminution was carried out, a significant reduction of rotational stability was evident with comminution of 50% or above. It is concluded that oblique fractures of the distal tibial third that can be reduced with at least 50% cortical apposition present the optimal rotational stability following dynamic nailing.

Biomechanical Phenomena↗
PubMed2004

Influence of post-mortem changes on DNA typing (D1S80, TH01, HLA DQA 1, and PM typing system): case studies for personal identification.

Between 1996 and 2002, we tested a total of 20 unidentified bodies for DNA typing. We describe here the relationships among detection rates achieved by four DNA typing systems (D1S80 typing, TH01 typing, HLA DQA1 typing, and PM typings), the post-mortem interval, types of specimens (bone, nail, and blood), post-mortem changes, and the site at which the corpse was found (indoors, outdoor, or in the sea). Detection rates for PM typings, HLA DQA1 typing, TH01 typing, and D1S80 typing in all cases were 94.7, 90.0, 73.7, and 50.0%, respectively. The success of the typings was highly influenced by the post-mortem interval. Using blood, almost all DNA types were detected, while the nail showed comparatively higher detection rates than bone. The detection rate decreased in order with indoor, outdoor, sea, and soil as the site at which the corpse was found. It is important to consider the specimen, the site at which the corpse was found, and the post-mortem interval to successfully achieve DNA typing.

Adult↗
PubMed2006

A novel surgical technique for transverse sternal bone defects using flexible intramedullary nailing.

Transverse sternal bone defects as a result of surgery or trauma remain an important clinical condition with serious sequelae. Patients sometimes complain of local pain during movement and breathing. Usually, defects are filled with prosthetic materials which remain permanently IN SITU. Small defects can be treated with autogenous bone grafts, whereas large defects are difficult to stabilize with common osteosynthetic techniques. Here, we report a new surgical technique using flexible intramedullary nailing ("Elastic Stable Intramedullary Nailing"--ESIN or "Embrochage Centro-Medullaire Elastique Stable"--ECMES) to stabilize a sternal defect after surgical removal of an osteochondral lesion. The defect was bridged by two elastic titanium nails and an autogenous corticocancellous bone graft. This new surgical technique showed a good clinical and functional outcome.

Adult↗
PubMed1990

Heterotopic ossification about the hip after intramedullary nailing for fractures of the femur.

A prospective study of 100 consecutive unilateral fractures of the shaft of the femur was performed to delineate the incidence of, and the factors predisposing to, heterotopic ossification about the hip after intramedullary nailing. Bone debris from reaming of the endosteal canal is deposited in the soft tissues surrounding the site of insertion of the nail, and we postulated that this debris may stimulate the formation of heterotopic bone and that decreasing the amount of debris left in the tissues after nailing may decrease the amount of heterotopic ossification. To test this theory, the patients were treated with routine intramedullary nailing and were randomly divided into two groups. In Group I, the operative incision was irrigated with 250 milliliters of normal saline solution with use of a bulb syringe before the wound was closed, and in Group II, the incision was irrigated with 3000 milliliters of normal saline solution with use of pulsatile lavage. The two groups were similar in all other respects. Eighty patients (eighty fractures; forty in Group I and forty in Group II) were available for follow-up and were evaluated in a blind fashion after the fracture had united. A grading system that was based on the length of the heterotopic ossification, as measured on antero-posterior radiographs of the hip, was used. In thirty-two of the patients (40 per cent), no heterotopic ossification developed, whereas minimum or mild ossification developed in twenty-seven patients (34 per cent). Moderate ossification developed in twelve patients (15 per cent) and severe ossification, in nine patients (11 per cent).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2002

Treatment of humeral diaphyseal nonunions by interlocked nailing and autologous bone grafting.

Twenty seven patients with humeral diaphyseal nonunion treated with interlocked nailing and autogenous bone grafting were retrospectively assessed. The mean age was 37 years (28 to 59 years). There were 16 women and 11 men. An average of 11 months (8 to 36 months) had elapsed between the initial trauma or treatment and presentation in our clinic. The nonunion site was in the distal third of the humerus in 18 patients (66%) and in the middle third in 9 (34%). Seventeen (73%) had hypertrophic and 10 (37%) atrophic nonunion. Patients were treated with locked intramedullary nailing and autogenous cancellous bone grafting. The mean follow-up was 42 months (28 to 62 months), and the mean time to union was 4.8 months (2.5 to 11 months). Three patients developed superficial infection. Union was achieved in all cases but one, in which there was multiple nerve injury. According to Steward and Hundley's scoring, results were good in 24 patients, fair in 2, and poor in one. Interlocked nailing and autologous bone grafting has a good rate of union provided nails of appropriate diameter are used and distal and proximal locking is performed correctly. We think that its low rate of infection, low risk of injury to the radial nerve, and low requirement for soft tissue dissection make it a suitable choice in the treatment of nonunions of the humeral diaphysis.

Adult↗
PubMed1992

Bone loss after locked intramedullary nailing. Computed tomography of the femur and tibia in 10 cases.

10 patients with previous femoral shaft fracture treated with locked intramedullary nailing were examined by computed tomography (CT) a few days after nail removal. The bone density, cortical thickness and geometric shape of the fractured extremity were compared with those on the contralateral side. Only a small reduction in cortical density and thickness (4 and 7 percent, respectively) was revealed outside the fracture area in the diaphyseal part of the nailed bones. A distinct reduction in trabecular density was observed in the femoral condyles as well as in the ipsilateral tibial condyle (19 and 17 percent, respectively). Our results indicate that the stress-reducing effect of intramedullary nails on the femoral diaphysis is small.

Adolescent↗
PubMed1998

The effect of reamed and nonreamed intramedullary nailing on fracture healing.

Intramedullary nailing has revolutionized the treatment of fractures. It is important to be aware of the biological and mechanical effects of reaming and nailing on bone. Most nails are substantially stiffer than bone, but because of their location in the medullary canal do not have nearly as adverse an effect on callus strength as plates. Reaming and nailing embolizes marrow contents into the systemic circulation and reduces blood flow to the total bone and cortex by 30% to 80%. This results in a hyperemic reaction that revascularizes the cortex depending on the type of nail used. Preservation of the soft tissue envelope around the fracture enhances this response resulting in fracture healing ratio of 98% when closed nailing techniques are used. The primary advantage of nonreamed nailing is better preservation of the blood supply to the cortex whereas the major advantage of reamed nailing is a more rigid construction, stronger implants, and earlier fracture union.

Biomechanical Phenomena↗
PubMed2003

Locked intramedullary nailing for difficult nonunions of the humeral diaphysis.

Antegrade intramedullary nailing and bone grafting was carried out for 27 patients with resistant atrophic nonunion of the humeral diaphysis. The initial fracture was open in 12 cases and closed in 15. There were ten proximal humeral fractures, 13 mid-shaft fractures and four distal humeral shaft fractures. Most had previous attempts at internal fixation with bone grafting. Fifteen cases united, but 12 remained ununited necessitating further surgical treatment. The failures were all in the more complex cases. Lack of rigidity and compression may be the problem.

Adolescent↗