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.     

Tibial fractures Reamed versus unreamed intramedullary nailing

AMEDLINEsearchwasperformedtoidentifystudiespublishedfromJanuary1997toNovember2003com-paringreamedintramedullary(IM)nailingwithun-reamedIMnailingfortibialfractures.Fromalistof16articles,threerandomizedclinicaltrialscomparingreamedIMnailingtounreamedIMnailingwereidentified.Weincludedstudiesexaminingbothopenandclosedtibialfractures.Weexcludedanalysesofnonrandomizedtrials.StudiesStudy1KeatingJF,OBrienPJ,BlachutPA,etal(1997)Lockingintramedullarynailingwithandwithoutreamingforopenfractur…     

Femoral shaft fractures——Reamed versus unreamed intramedullary nailing

AMEDLINEsearchwasperformedtoidentifystudiespublishedfromJanuary1998toJanuary2003comparingreamedwithunreamedintramedullarynailinginfemoralshaftfractures.Fromalistof11articlesidentifiedfromthesearchstrategy,threearticles,alleitherrandomizedorquasi-randomizedclinicaltrials,wereidentifiedthatmadethedesiredcomparison.Weexcluded1randomizedtrialwhosemainoutcomewastransesophagealechocardiographyforquantificationofemboliusingreamedandunreamedfemoralnailing.Wealsoexcluded:fivecaseseries,oneprelimina…     

Training effect of using Touch Surgery™ for intramedullary femoral nailing

BackgroundSimulation in orthopaedic training is becoming increasingly popular and has been widely used in formal curricula. However, these resources are expensive and not easily accessible to every trainee. Other means of disseminating surgical education through virtual reality (VR) multimedia can act as useful adjunct to traditional methods of teaching. One validated VR platform is Touch Surgery, a cognitive task simulation and rehearsal app.ObjectivesThe primary objective of this study was to identify the training effect of Touch Surgery intramedullary femoral nailing (IFN) modules using objective performance metrics over six consecutive attempts. Secondary objectives consisted of validated multiple choice questions (MCQ) testing before the first (pre) and after the sixth (post) attempts.Methods27 medical undergraduates were recruited to complete the decision-making process six consecutive times for four modules on the procedural steps of IFN. The modules consisted of (i) preparing the patient and equipment, (ii) femoral canal preparation, (iii) nail insertion and proximal locking, and (iv) distal locking and closure. Real-time objective performance metrics were obtained, stored electronically and analysed using the median and Bonett–Price 95% confidence intervals from the participants’ attempts to assess training effect. Significance was calculated using the Mann–Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. Significance was set as 2-tailed p-value <0.05.ResultsMedian performance scores per attempt for all four modules demonstrated a significant improvement ranging from 58 to 115%. Scoring variability and distribution was reduced and more predictable per attempt. Logarithmic learning curves elicited strong positive correlations between the number of attempts and scoring. Mean scores for pre and post-study MCQs tests significantly improved from 83 to 94% in all modules.ConclusionIFN modules on Touch Surgery app demonstrated a significant training effect with practice. Novices demonstrated cognitive competencies to ensure patient safety prior to operating. The app is an effective adjunct to traditional learning methods and has the potential for curricular implementation.     

Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes?

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: “fixed” and “bio”, avoidance of reaming for the antegrade technique and utilization of “semi-reaming” for the retrograde technique, guidelines for reducing complications, setting the best “timing” for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures.     

Femoral shaft fractures: is rigid intramedullary nailing safe for adolescents?

Despite recent reports of avascular necrosis of the femoral head after intramedullary nailing in children, this fixation method is still being advocated for the treatment of femoral shaft fractures. In this article, we report a case of early-onset, severe, symptomatic avascular necrosis of the femoral head after intramedullary nailing in a 13-year-old boy. Given the possibility of this devastating complication, surgeons should consider the risk-benefit ratios of various techniques for managing femoral shaft fractures in adolescents.     

Failures and complications in intramedullary nailing of children’s forearm fractures

Purpose  

There are published studies of outcomes in the use of ESIN that raise concerns about serious complications: the aim of this study is to report our experiences over 17 years of use of this technique, which shows that complications and failures are insignificant when the method is applied correctly.     

How risky is early intramedullary nailing of femoral fractures in polytraumatized patients?

There is controversy over both the time of intervention and the technique of surgical stabilisation of femoral fractures in polytraumatized patients. Retrospective analysis of data on 55 such patients revealed that stabilisation within the first 24 h using locked, unreamed nails had no negative impact on the rate of pulmonary complications. The frequency of complications was assessed by comparing immediate intramedullary (IM) osteosynthesis with extramedullary stabilisation in patients with or without concomitant blunt thoracic trauma. Due to the small study population and discrepancies the size of subgroups, no definite statistical conclusions were possible. However, our results suggest that the frequency of complications is determined by the overall severity of injury rather than by the type of acute surgical treatment.     

Does the magnetic-guided intramedullary nailing technique shorten operation time and radiation exposure?

Aim

The aim of this study is to show whether a new magnetic-guided locking technique is superior to a standard freehand technique in terms of operation time and radiation exposure. This treatment will be used for distal locking of the tibia during intramedullary nailing.

Methods

This randomized trial is done through 80 patients having tibial fractures with a mean age of 25 years (range 16–67 years). In the magnetic locking group, there were 20 fractures of the distal third, 16 of the shaft, and 4 of the proximal tibia; in the freehand group, these numbers were 15, 20, and 5, respectively. The parameters like operation time, distal locking time, radiation exposure duration, and dose were compared.

Results

We placed 100 distal locking screws in the magnetic locking group and 95 in the freehand group. Fluoroscopy was necessary only in the freehand group. All screws were correctly positioned the first time in both groups. The magnetic locking group had a shorter mean surgical time (52 ± 6.2 vs 70 ± 10.9 min; P < 0.01), a shorter mean distal locking time (5 ± 1.1 vs 16 ± 2.0 min; P < 0.01), and a shorter mean placement time for each screw (2 ± 0.5 vs 7 ± 1.2 min; P < 0.01). The magnetic locking group had lower mean radiation exposures (8 ± 4.5 vs 40 ± 7.6 s; P < 0.01) and mean radiation exposure (5.4 ± 2.5 vs 25 ± 6.8 mGy range; P < 0.01).

Conclusions

For distal locking during tibial intramedullary nailing, the magnetic locking system is as accurate as the standard freehand technique, but it has lower operative times and radiation exposures compared to the standard freehand technique. Therefore, the magnetic locking system should be preferred to current standard freehand techniques.     

“Revision of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screw”

Background

Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications.

Methods

We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating.

Results

Between 2002 and 2017, we identified 40 patients with a mean age of 65.4?years (range 34–91?years) who met the inclusion criteria. At a mean follow-up period of 26.3?months (range 6–173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63?months (± 12.4?months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery.

Conclusions

The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.

     

Is device-assisted reduction prior to semi-extended intramedullary nailing of distal tibial fractures necessary?

IntroductionTraditional methods of nailing distal tibial fractures have an unacceptable risk of mal-alignment due to difficulty in obtaining and maintaining reduction intra-operatively. Methods to obtain and maintain reduction when nailing these fractures, and therefore reducing the risk of Mal-alignment include modified external fixators, distractors and commercial reduction tools. Semi-extended intramedullary nailing of distal tibial fractures via a supra-patellar approach is now being used more commonly. The aim of this study was to assess whether a commercial reduction device (Staffordshire Orthopaedic Reduction Machine − STORM, Intelligent Orthopaedics, Stafffordshire, UK) is necessary to reduce the risk of mal-alignment in patients undergoing semi-extended nailing for distal tibial fractures.MethodologyA case-control study was conducted in 20 patients who had STORM-assisted reduction of distal tibial fractures prior to intramedullary nailing and 20 controls without STORM. The control group was matched for age, sex, fracture type (AO/OTA), ASA and gender. All patients had an intramedullary nail (IMN) using the semi-extended system. Primary outcome measures were coronal and sagittal mal-alignment. Secondary outcome measure was unplanned return to theatre for complications and problems with fracture healing.ResultsThere was no difference in post-operative mal-alignment in both groups. There was no significant difference in time to union in both groups Both groups had equal number of patients requiring unplanned return to theatre. The STORM group was associated with a significantly increased operative time [p = 0.007, 130.3 min (SD 49.4) STORM vs 95.6 mins (SD 22.9) Control].ConclusionIntraoperative use of STORM significantly increases operative time with no difference in outcome. The superior orthogonal views and manual control obtained during semi-extended nailing via a supra-patellar approach obviate the need for additional methods: of intraoperative reduction for this fracture group.     

Secondary intramedullary nailing after distraction osteogenesis30 patients followed for 2–12 years

Background?There is no consensus about replacement of an external fixator by reamed intramedullary nailing in fracture cases. Patients and methods?We evaluated the outcome in 30 patients (33 segments) of secondary intramedullary nailing during the consolidation phase after callus distraction using an external device. The main reasons for nailing were docking site nonunion (17 patients), angular deformity or fracture of the lengthened area (8 patients) or intolerance of the external device (5 patients), in 11 patients combined with a delayed distracted callus maturation. The average follow-up time was 4 (2–12) years. Results?Intramedullary infection after nailing occurred in 1 case, and slight loss in callus length in 5 cases. Failure of union at the docking site with nail breakage occurred in 1 case. In the other patients, consolidation in the lengthened callus area and also union at the docking site were achieved on average 6 months after nailing. Interpretation?We believe that intramedullary nailing during the consolidation phase after bone lengthening or bone transport is a treatment option for delayed callus maturation or docking site nonunion, reducing prolonged use of the external fixator.     

Complications of Küntscher intramedullary nailing in a child: a case report

A fracture of the femur in a 7-year-old boy who was treated with retrograde Küntscher nailing is described. The follow-up period was 8 1/2 years. Deep infection, physeal injury of the femoral head, and trochanteric epiphysiodesis were serious consequences of the surgery.     

Is retrograde nailing superior to lateral locked plating for complete articular distal femur fractures?

IntroductionNonunion rates for distal femur fractures treated with lateral locked plating (LLP) remains as high as 18–22% despite significant advances with implant design and construct modulation. However, whether treatment of distal femur fractures with rIMN has improved outcomes compared to LLP has not been well characterized. The purpose of this study was to compare outcomes of complete articular distal femur fractures (AO/OTA 33-C) treated with either LLP or rIMN.Methods106 distal femur fractures in 106 patients between January 2014 and January 2018 were identified. Medical records were reviewed to collect patient age, gender, body mass index, sagittal and coronal plane alignment on immediate postoperative radiographs, time to union, incidence of nonunion, and incidence of secondary operative procedures for repair of a nonunion.ResultsOf 106 patients, 50 underwent rIMN and 56 underwent LLP. The mean age at the time of injury was 51 years (21 to 86 years) and there were 55 males. Average coronal alignment of 83.7° of anatomic lateral distal femoral angle (aLDFA) and sagittal alignment of <1° of apex anterior angulation in the rIMN group. In the LLP group there was an average of 87.9° of aLDFA and 1.9° of apex anterior angulation (p = .005 and p = .36). Average time to union in the rIMN group was 6 months and 6.6 months in the LLP group (p = .52). Incidence of nonunion in the rIMN group was 11.8% and 27.5% in the LLP group (p = .008). There were 8 secondary procedures for nonunion in the rIMN group and 18 in the LLP group (p = .43).ConclusionsOur results demonstrated a higher nonunion rate and coronal plane malalignment with LLP compared to rIMN. While prospective data is required, rIMN does appear to be an appropriate treatment for complete articular distal femur fractures with a potentially decreased rate of nonunion .     

Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?

Background

Clavicle fractures are common, accounting for 5–12 % of all fractures. Traditionally, displaced middle-third clavicle fractures have been managed non-operatively but the associated displacement often leads to mal-union with shortening, cosmetic deformity and occasionally non-union, with clinicians looking towards alternative operative methods such as intramedullary nailing (IMN). However, such methods have their own complications. In order to ascertain the effectiveness of IMN in the management of middle-third clavicle fractures compared with non-operative treatment, analysis of recent evidence is required and this review aims to achieve that, focusing on relevant, contemporary randomised-control trials.

Materials and methods

Essential search-terms identified from the research question were used to formulate a search strategy. A systematic search of multiple databases was then performed from 1966 until present and appropriate papers for appraisal identified.

Results

Thirteen papers were identified, with 10 excluded using appropriate eligibility criteria. The remaining papers were then critically appraised. With regards shoulder function, all papers demonstrated an association between IMN and a significantly (P < 0.05) superior shoulder function score, but no consensus with regards to complication rates. However, all have identified limitations; therefore, their overall findings must be considered conservatively.

Conclusions

Further, high-quality research, ideally in the form of well-designed, multi-centre RCTs is required to allow acceptable implementation of IMN of middle-third clavicle fractures into widespread practice. However, early results demonstrate that in young patients with displaced middle-third clavicle fractures, who are motivated to return to work, IMN provides superior functional results and should be considered. However, the importance of considering each patient individually as to their suitability for each management option, before coming to an informed decision with the patient rather than having a blanket approach to MTCF is essential.

Level of Evidence

Level 1.     

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.     

Clinical results of trochanteric fractures treated with the TARGON® proximal femur intramedullary nailing fixation system

The aim of this study was to investigate the outcome of 352 (71 males) patients with trochanteric fractures that were treated with the TARGON? PF nail. The mean age was 83 years. According to the Jensen classification, there were 35 cases in type 1,94 cases in type 2,75 in type 3,63 in type 4 and 85 in type 5. Postoperative all patients were allowed to fully weight bear from the first postoperative day. Clinical and radiological data were collected at regular time intervals. The average waiting time to surgical reconstruction for the 352 cases was 3.5 days (1-7). The mean length of hospital stay was 14 days (5-22). The operative times ranged from 11 to 125 minutes with an average time of 32 minutes. Fifty percent of the patients regained their mobility to their pre-injury level at the final follow up. Out of 310 patients (88%) who were available for radiographie assessment, all fractures united except one case. 300 (85%) of the lag screws were placed in the inferior area in the anteroposterior view and in the central area in the lateral view (IM), which is regarded as the optimal position. The lag screws back-slided between 0 and 19 mms with an average of 6 mm. Sliding distance of the lag screw for over 10 mm was seen in 42 cases (13%). Varus collapse of the femoral head-and-neck greater than 10° was observed in 6 cases. Postoperative complications developed in 6 cases (1.7%), including wound infection in two cases, and secondary fracture at the subtrochanteric region, nonunion, back-out of the guiding sleeve and medial perforation of the lag screw, each in one case. The presented case series indicates that the TARGON? PF system is an effective and safe internal fixation device for trochanteric proximal femoral fractures. Further, prospective comparative evidence regarding the use of this system is needed to analyse and validate the presented clinical impression of our centre.