A foolproof technique for lock-check and distal locking in interlock nailing

Interlocked nailing as a treatment modality for long bones' fracture is one of the most widely performed orthopedic surgeries. Closed locked nailing is also the gold standard method of treating femoral and tibial shaft fractures. But the most variable factor in this procedure is distal locking. It may sometimes be time consuming and involve radiation exposure. The freehand technique for distal locking of intramedullary nails is plagued with dependence on an image intensifier which may not be available at all centers especially in developing countries like ours. Also, the radiation and operative time increase with this method.Hence, there is a need to develop a radiation safe and sound method in this green world to decrease carbon emissions to replace/supplement freehand distal locking techniques. “Tak-Tak” method described here decreases our dependence on the image intensifier and in addition improves accuracy when using aiming jigs.     

Intramedullary nailing in femoral shaft fractures. Evaluation of a group of 101 cases

The Authors analyse the results of intramedullary nailing in a group of 101 femoral shaft fractures. Used nails: Universal Synthes (62 cases), Russel-Taylor (14), Gamma long (10), uncannulated femoral nail (9), cannulated femoral nail (4) and proximal femoral nail (2). Stabilisation of the femoral shaft fracture was possible using a reamed technique in 91 cases, unreamed in 10. All nails were locked. Dynamisation was performed in 35 cases and was not in 66. The fracture heal was faster with the reaming and dynamisation technique. Ten fractures were open (5 Gustilo I, 5 Gustilo II) and stabilisation with Universal Synthes nail (8 cases), Russel-Taylor nail (1) and Gamma long nail (1) was performed. No infection was detected. Lung embolism (6) and deep vein thrombosis (3) occurred only in the case of reamed nails. All results confirm the locking nail system as the best treatment in the shaft fractures, especially with new-generation nails.     

Safe surgical technique: intramedullary nail fixation of tibial shaft fractures

Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.     

One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening

OBJECTIVE: To assess the effectiveness of a one-stage lengthening using a locked nail technique for the treatment of distal femoral shaft nonunions associated with shortening. DESIGN: Retrospective. SETTING: University hospital. PATIENTS AND METHODS: During a 6-year period, 36 distal femoral shaft nonunions associated with shortening (>1.5 cm) were treated by the one-stage lengthening technique. Indications for this technique were distal femoral shaft aseptic or quiescent infected nonunions, 1.5-5 cm shortening, and a fracture level suitable for the insertion of two distal locked screws. The surgical technique involved skeletal traction using the femoral condyle, local débridement, lengthening by 相似文献   

Locked intramedullary femoral nailing without fracture table or image intensifier

The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18–70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist–Hansen types I and II) diaphyseal fractures of the femur.     

Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review

Introduction  

Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults.     

Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures

OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).     

Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union

OBJECTIVES: To investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunion after intramedullary (IM) nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing. DESIGN: Retrospective consecutive clinical series. SETTING: Level I trauma center and tertiary university hospital. PATIENTS: Twenty-three patients were identified whose radiographs failed to show progression of healing for four months after treatment with a reamed IM femoral nail. Nineteen patients had undergone primary IM nailing of an acute femoral shaft fracture, one patient had been converted to an IM nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing. INTERVENTION: All patients were treated by exchange reamed femoral nailing. The diameter of the new nail was one to three millimeters larger than that of the previous nail (the majority were two millimeters larger). The intramedullary canal was overreamed by one millimeter more than the diameter of the nail. Most of the nails were statically locked, and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed or by applying compression with a femoral distractor. MAIN OUTCOME MEASUREMENTS: Radiographic evaluation of union was determined by the presence of healing on at least three of four cortices. Factors reviewed included the patient's age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures. RESULTS: Tobacco use was found to have a detrimental impact on the success of exchange reamed nailing. All eight of the nonsmokers healed after exchange reamed nailing, whereas only ten of the fifteen smokers (66.7 percent) healed after exchange reamed nailing. Overall, exchange reamed femoral nailing was successful in eighteen cases (78.3 percent). Three patients achieved union with additional procedures. Intramedullary cultures were positive in five cases; all of these achieved successful union. CONCLUSIONS: Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed IM nailing has low morbidity, may obviate the need for additional bone grafting, and allows full weight-bearing and active rehabilitation. Tobacco use appears to have an adverse effect on nonunion healing after exchange reamed femoral nailing.     

Treatment of femoral shaft aseptic nonunion associated with broken distal locked screws and shortening

BACKGROUND: This retrospective study investigated the treatment of femoral shaft aseptic nonunions associated with broken distal locked screws and shortening. METHODS: In this study, 11 femoral shaft aseptic nonunions associated with both broken distal locked screws and shortening in 11 consecutive adult patients were treated. All nonunions were associated with at least 1.5 cm (range, 1.5-3.5 cm) shortening. These nonunions were treated by removal of locked nails, one-stage femoral lengthening, static locked nail stabilization, and corticocancellous bone graft supplementation. Postoperatively, ambulation with protected weightbearing was encouraged as early as possible. RESULTS: Ten nonunions were followed up for a median of 4.1 years (range, 1.8-5.5 years), and nine fractures healed at a median of 4 months (range, 3-6 months). The nonunion case had broken locked screws again at 5 months and was treated with exchange nailing. The fracture healed uneventfully at 4 months. No other complications occurred. CONCLUSIONS: The key to removal of broken screws is withdrawal of the nail slightly to release the incarcerated broken screw end. The screw end then is pushed out with a used Knowles' pin or a smaller screwdriver under image intensifier guidance. Concomitant one-stage femoral lengthening to treat nonunion with shortening has a high success rate.     

Locked nailing of comminuted and unstable fractures of the femur

Forty comminuted or unstable fractures of the femoral shaft were treated by closed intramedullary reaming and locked nailing. Twenty-four fractures were severely comminuted, and the other 16, in the distal or proximal third of the shaft, were classified as unstable. At 12 to 30 months postoperatively all the fractures had healed. Three patients had lateral rotation deformity of 5 degrees to 10 degrees, three had shortening of 1 to 2 cm and two had lengthening of about 1 cm. There were no infections or delayed unions. Closed intramedullary locked nailing can provide stability in fractures of the femoral shaft, irrespective of the degree of comminution and the site of injury.     

Marknagelung geschlossener Unterschenkelschaftbrüche

Intramedullary nailing is the operative method of first choice for closed fractures of the tibial shaft. In general, the method is well taught and has proven its worth in many clinics. If attention is paid to the technical recommendations very good results can be obtained with both the reamed and the unreamed technique. In German-speaking areas unreamed locked nailing with solid nails is preferred; in the Anglo-American world the reamed technique is more widely accepted. After-treatment aims at achieving early functional recovery. The favorable biomechanical conditions for load transfer associated with osteosynthesis mean that weight-bearing is possible early, even while the soft tissue situation is still settling down and the fracture healing. Provided there are no complications or malalignments, closed intramedullary nailing of closed tibial shaft fractures is one of the most gratifying operative procedures permitting early functional rehabilitation.     

Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures

OBJECTIVE: To determine the effectiveness of exchange reamed nails for treatment of aseptic femoral delayed unions and nonunions. DESIGN: Retrospective chart review. PATIENTS: Nineteen patients admitted to the Carolinas Medical Center Level I trauma center from 1990 to 1996 for repair of femoral shaft fracture nonunion following contemporary locked nailing performed at least six months previously. These patients showed no radiographic evidence of progression of fracture healing for three months and had clinical symptoms of nonunion. INTERVENTION: Exchange reamed nails to treat ununited femoral shaft fracture. MAIN OUTCOME MEASUREMENTS: Radiographic and clinical evidence of union of the fracture or of the necessity for additional procedures. RESULTS: In 53 percent of the patients the secondary procedure resulted in fracture union, whereas in 47 percent, one or more additional procedures were required. Eight of the nine fractures that did not unite with exchange nailing united after a subsequent procedure (bone grafting, compression plating, or nail dynamization). Neither the type of nonunion, the location of the shaft fracture, the use of static versus dynamic cross-locking, nor the use of tobacco products was statistically predictive of the need for additional procedures. CONCLUSIONS: Reevaluation of routine exchange nailing as the recommended treatment for aseptic femoral delayed union or nonunion may be required. A significant number of patients who undergo reamed exchange nailing will require additional procedures to achieve fracture healing.     

Antegrade nailing of femoral shaft fractures combined with neck or distal femur fractures

Introduction Complex femoral fractures pose considerable therapeutic challenges to orthopedic surgeons. We present a retrospective review of 25 patients with complex femoral fractures treated with intramedullary locked nailing and supplemental screw fixation.Materials and methods Fifteen patients with ipsilateral femoral neck and shaft fractures (group 1) and 10 patients with ipsilateral femoral shaft and distal femur fractures (group 2) were treated from 1990 to 1998. High-energy injuries occurred in all patients. There were 4 open fractures. Antegrade, locked nailing of diaphyseal fractures was performed in all cases. Supplemental screws for the neck were used in all patients in group 1 and in 3 patients in group 2.Results All of the fractures united during the follow-up. Five patients in group 1 underwent reoperation (33.3%): one due to a delayed union, the second due to an implant failure, the third due to a nonunion of a neck fracture, and the last two because of an initially missed femoral neck fracture. None of the patients in group 2 underwent reoperation. Angular malalignment of the shaft was found in 6 fractures in group 1 (average 4.8^o, range 3^o–11^o) and in 4 fractures in group 2 (average 6^o, range 3^o–12^o). Shortening of the limb occurred in 3 patients in group 1 (average 1.4 cm, range 1–1.8) and in 1 patient in group 2 (2 cm). Loss of fixation was seen in 1 patient in each group. Avascular necrosis and infection were not seen in any case in both groups.Conclusion Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. New nail designs, usually more expensive than the conventional nails, have been introduced into the market for this purpose. One has to keep in mind that antegrade, locked nailing of femoral shaft fractures combined with neck or distal femur fractures is a technically demanding but efficacious procedure. The success rate is high when the technique is meticulously implemented.     

Early weight-bearing after statically locked reamed intramedullary nailing of comminuted femoral fractures: is it a safe procedure?

BACKGROUND: The purpose of this study was to determine the safety of early weight-bearing after statically locked reamed nailing of comminuted fractures of the femoral diaphysis, and to assess the rate of implant failure and fracture healing. METHODS: Thirty consecutive patients with comminuted diaphyseal femur fractures (Winquist type II, III, and IV) were treated with statically locked reamed intramedullary nailing. Six patients were lost to follow-up, and the remaining 24 patients were followed at least 1 year. Early weight-bearing was allowed and encouraged in the first 2 weeks after the operation. The nail diameters were 13 mm in 16 patients, 12 mm in 6 patients, and 14 mm in 2 patients. RESULTS: Most of the patients could start weight-bearing between the first 2 and 4 weeks postoperatively. None of the patients, except one, were using any walking aids at the second month postoperatively. All the fractures healed without any significant complications. Nail bending or breakage did not occur in any patients, but there was slight bending in one distal interlocking screw and one proximal interlocking screw. The fractures of the patients with bent screws healed uneventfully. CONCLUSION: This study showed that early weight-bearing after reamed static interlocking nailing of Winquist type II, III, and IV femoral fractures is a safe and effective method, and the risk of implant failure does not preclude the procedure.     

Kallusbildung nach aufgebohrter und unaufgebohrter Femurverriegelungsnagelung Eine experimentelle Studie

This was a prospective randomized baboon animal study, the study protocol was approved by the ethical committee according to the international guidelines for animal research projects. In 8 animals a midschaft femoral osteotomy was stabilized with reamed femoral interlocking nailing and in 8 animals by unreamed locked femoral nailing. Polychrome sequence bone labeling was done 5 weeks postop. with calcein-green, 8 weeks postop. with xylenol-orange and 10 weeks postop. with oxytetracycline. 10 weeks postop. the animals were sacrificed, the femurs explanted and planimetric and epifluorescence histomorphometric evaluation of serial transverse sections were done. In planimetric histomorphometric evaluation in unreamed femoral nailing a mean endostal callus formation was recorded with 28.0 +/- 9.9 mm2 per section and in reamed femoral nailing with 11.5 +/- 5.0 mm2 (p < 0.001). Periostal callus formation was recorded in the unreamed group with 238.7 +/- 87.1 mm2 per section and in the reamed group with 142.1 +/- 71.9 mm2 (p < 0.001). In epifluorescence histological evaluation endostal as well as periostal callus formation was more extensive and earlier after unreamed than reamed femoral nailing. Endostal callus formation was found in all animals after unreamed femoral nailing, and was present in 2 out of 8 specimen in the reamed group. Also 1 out of 8 animals in the reamed group developed a non-union. Unreamed femoral nailing with low diameter interlocking nails proved to be safe regarding bone healing in this experimental model with obvious advantages both in amount and time course of callus formation compared to reamed femoral nailing. Based on this results unreamed femoral nailing techniques can be recommended for femoral fractures.     

Early patellofemoral osteoarthritis caused by an osteochondral defect after retrograde solid nailing of the femur in sheep

BACKGROUND: Retrograde femoral nailing (RFN) is an increasingly used technique for internal fixation of femoral fractures. Geometrically and empirically, the nail entry zone is close to the center of the femoral groove, causing concern about the development of patellofemoral osteoarthritis. METHODS: We studied the effect of opening the distal femur through the femoral groove on the development of osteoarthritis in sheep after retrograde reamed insertion of a solid titanium nail into the femoral canal. Knees were radiographically and macroscopically studied for the presence of osteophytes and signs of cartilage degeneration. Controls underwent the same procedure without opening the femoral groove. RESULTS: The study group showed time-dependent macroscopic and radiographic signs of osteoarthritis with predominant involvement of the patellofemoral joint. CONCLUSION: RFN can cause patellofemoral osteoarthritis. Care should be exercised to use RFN in isolated supracondylar or shaft fractures of the femur in healthy young adults.     

Evaluation of the Stryker S2 IM Nail Distal Targeting Device for reduction of radiation exposure: a case series study

Distal locking is one challenging step during intramedullary nailing of femoral shaft fractures that can lead to an increase of radiation exposure. In the present study, the authors describe a technique for the distal locking of femoral nails, implementing a new targeting device in an attempt to reduce radiation exposure and operational time. Over a 2-year period, 127 consecutive cases of femoral shaft fractures were included in the study. All cases were treated with nailing of femoral shaft fractures with an unslotted reamed antegrade femoral nail and distal locking was performed with the use of a proximally mounted aiming device. Mean duration of the procedure was 63.5 ± 18.1 min while the duration for distal locking was 6.6 ± 2.6 min. In all successful cases, exposure from intraoperative fluoroscopy was 17.2 ± 7.4 s for the whole operative procedure, and for distal locking was 2 shots, 1.35 s (range, 0.9–2.2 s) and 1.9 mGy (range, 1.1–2.9 mGy). Five cases (3.9%) were unsuccessful, but overall no intraoperative complications were encountered from the application of this technique. The ability of the device to correspond to the level of nail deformation and to properly identify the distal holes, reduced exposure to radiation compared to other published reports, and should be considered as a valuable tool for distal locking of femoral fractures.     

Marknagelung geschlossener Oberschenkelschaftbrüche

Antegrade femoral nailing with interlocking nails is the most common surgical treatment for diaphseal fractures of the femur. It can be performed with or without reaming of the shaft. The decision on whether or not reaming is indicated must be made with reference to each patient's specific problems to avoid complications. Since there is a higher risk of pulmonary complications when the reamed technique is used, unreamed nailing should be preferred in cases of multiple injuries. The different surgical tehcniques for nailing are presented, as are the disadvantages of each.     

Femur fractures and lung complications: a prospective randomized study of reaming

Reaming the intramedullary canal during fixation of femoral shaft fractures may contribute to pulmonary morbidity in patients with trauma. The purpose of our study was to compare acute and late pulmonary complications after reamed or nonreamed nailing of femur fractures. Patients who had femoral shaft fractures were randomized prospectively to a reamed (n = 41) or nonreamed (n = 41) femoral nailing group. Arterial blood gases were measured before and after femur fixation. Ratios of PaO2/FiO2 and alveolar arterial gradients were calculated. Pulmonary complications (acute respiratory distress syndrome) (ARDS), pneumonia, and respiratory failure) were monitored. Age, gender, fracture site, fracture type, time to nailing, length of operation, Injury Severity Score, and Abbreviated Injury Scale-thorax were similar for the two groups. No significant differences were observed in the ratio of PaO2/FiO2 ratios or alveolar arterial (A-a) gradients before and after nailing. The overall incidence of pulmonary complications was 14.6% (eight patients who had reamed nailing and four patients who had nonreamed nailing), and given the sample size, definitive conclusions could not be reached because of inadequate statistical power. We were unable to document differences in pulmonary physiologic response or clinical outcome between patients having reamed and nonreamed femoral nailing. This study may serve as a pilot investigation for other clinical investigations.     

Femoral and tibial fractures

Femoral shaft fractures have a bimodal distribution with high energy injuries in young patients and an increasing incidence of osteoporotic fractures in elderly patients. Adult diaphyseal fractures are invariably managed operatively and the procedure most commonly performed is stabilisation with antegrade reamed intramedullary nailing. Retrograde nailing is also used for specific indications. Plating is still used for more distal fractures. External fixation and non-operative treatment by traction are seldom used now due to high risk of complications. Tibial shaft fractures are the most common long bone fracture and the most common open long bone fracture (21%). Reamed intramedullary nailing is the most common treatment for unstable fractures. Low energy undisplaced fractures can be treated non-operatively in a cast or brace. Plating is not often used for diaphyseal injuries but is useful for metaphyseal fractures. External fixation is still commonly used for some severe open injuries or to correct deformity. Complications of femoral and tibial fractures include nonunion, malunion and infection in association with open fractures. Compartment syndrome complicates 2-10% of tibial fractures. For closed fractures the incidence of all of these complications should be less than 5%. Open fractures have a greater risk of complication which is generally proportional to the energy of the injury.