Retrograde dynamic locked nailing for aseptic nonunion of femoral supracondyle after antegrade locked nailing

Introduction  

Using antegrade exchange locked nailing to treat femoral supracondylar aseptic nonunion may sometimes have some limitations. Using retrograde locked nailing to treat such situations may achieve great advantages. The feasibility of such a technique was investigated.     

Retrograde dynamic locked intramedullary nailing for aseptic supracondylar femoral nonunion after dynamic condylar screw treatment

Objective

Supracondylar femoral nonunions after dynamic condylar screw (DCS) treatment are uncommon, and few studies have addressed an optimal treatment technique for this disorder. Re-insertion of a new plate may not be secure because of bony defects in the distal fragment, created by the lag screw of the DCS.

Materials and methods

Forty-two consecutive adult patients with 42 supracondylar femoral nonunions were treated with removal of the DCS, re-alignment of the knee axis, and insertion of a retrograde dynamic traditional femoral locked nail. When necessary, a humeral plate was augmented to reinforce rotational stability.

Results

A final group of 36 patients with 36 nonunions were followed for an average of 2.8 years (range 1.1–6.2 years). All nonunions healed with a union rate of 100 %, and the average time to union was 4.2 months (range 2.5–5.5 months). Complications included two malunions. There were no instances of nonunion or deep infection. Satisfactory knee function among 36 patients improved from 8.2 % preoperatively to 86.1 % at the last follow-up (p < 0.001). All 36 patients could walk without aids.

Conclusion

The described technique may be an excellent alternative treatment for an aseptic supracondylar femoral nonunion after DCS treatment. The technique is not difficult, and the union rate and satisfactory rate are high.

     

Retrograde femoral nailing: a focus on the knee

A consecutive series of 23 patients with reamed retrograde femoral nails was reviewed. Nails were placed through the intercondylar notch with a minimal incision. Nineteen patients with retrograde femoral nails were available at an average follow-up of 19.3 months. The union rate was 100% with no infections or malunions. No second surgeries were required for union. Knee range of motion averaged 109 degrees and was greater in those patients with shaft fractures (117 degrees) than in those with supracondylar-intercondylar fractures (91.3 degrees) (P=.02). Pain (0-3 scale) averaged 0.36. Hospital for Special Surgery knee scores averaged 80.4 (90% good or excellent results). Minor knee pain (55%) and secondary surgeries (35%) were common. The only fair or poor results were in patients with preexisting osteoarthritis. A literature review of 14 papers and abstracts was conducted. Exposure, often extensive initially, is more recently percutaneous. The infection rate is acceptable (0-14%), with knee sepsis uncommon. Lower union rates were observed for supracondylar femur fractures (80%-84%) than for femoral shaft fractures (85%-100%) after a single surgery. Second surgeries are common (14%-60%). Varus/valgus malunion, common (12%-29%) with the initial extrarticular entry site, occurs less with the intercondylar entry site. The antegrade femoral nail allows for better control of proximal shaft fractures, while the retrograde femoral nail is more reliable in controlling distal shaft fractures. Rotational malunion still remains a problem. Mild knee pain is common (13%-60%). The treatment of supracondylar femur nonunions with retrograde femoral nailing is disappointing.     

顺行锁定髓内钉和动力加压钢板治疗肱骨干骨折的系统评价

[目的]对比顺行锁定髓内钉和动力加压钢板治疗肱骨干骨折的临床结果,并为以后此类骨折的治疗提供更可信的证据。[方法]计算机检索Cochrane library、Medline、Embase、CNKI等数据库网站,检索2016年12月以前有关顺行锁定髓内钉和动力加压钢板治疗肱骨干骨折的文献,筛选文献后采用Revman 5.0软件进行分析,获得两种方法治疗肱骨干骨折的临床结果。[结果]最初搜索文献472篇,经过筛选后最终有8篇纳入研究,共计完成随访患者373例,其中顺行髓内钉治疗者187例,动力加压钢板治疗者186例。Meta分析表明,顺行锁定髓内钉组患者术后感染率明显低于动力加压钢板组[OR=0.34,95%CI(0.12,0.98),P=0.05],但前者肩部撞击征与再次手术率明显高于后者[OR=7.81,95%CI(2.51,24.33),P<0.001;OR=2.61,95%CI(1.19,5.72),P=0.02],术后桡神经损伤与骨折不愈合率,两者之间差异无统计学意义。[结论]与顺行锁定髓内钉相比,动力加压钢板治疗肱骨干骨折可以降低肩部撞击征与再次手术发生率,但却增加了术后感染的发生率;术后桡神经损伤及骨折不愈合方面,两者差异无统计学意义。     

Tibial shaft malunion treated with reamed intramedullary nailing: a revised technique

Thirty-seven consecutive adult tibial shaft malunions which had not undergone surgical treatment were prospectively treated with reamed intramedullary nailing. Indications for this treatment modality included a malunion of a tibial shaft which had only been conservatively treated, lesion level fitting for traditional or locked reamed intramedullary nail fixation, less than 2 cm shortening, and without evidence of deep infection at present. The malunions were treated with fibulotomy, closed wedge tibial osteotomy, open reaming of the marrow cavity, stable reamed intramedullary nail stabilization with or without supplementation, and cancellous bone grafting. Thirty-four (92%) patients were followed up for at least 1 year (range 1.0–4.3 years), and all achieved a solid union. The union period was 5.8±0.8 months. Complications included 2 (6%) patients with deep infection and 1 (3%) with cortical perforation. However, all 3 patients recovered completely after adequate management. In conclusion, a reamed intramedullary nail is an ideal instrument for tibial shaft malunions in indicated cases. Good exposure of the bony segments to ream the marrow cavity precisely can avoid cortical perforation. Gentle dissection of the soft tissues may lower the infection rate. Concomitant cancellous bone grafting can improve the union rate. Received: 13 April 1999     

Retrograde nailing of femur: surgical technique with tibial traction

A modified surgical technique for femoral retrograde nailing is described. A tibial skeletal traction in the proximal metaphysis is placed to obtain fracture reduction during surgery. This technique enables fracture control during the procedure, avoiding the need of an assistant.     

Retrograde suction decompression of paraclinoid aneurysm--a revised technique

BACKGROUND: Aneurysms of the ophthalmic segment of the carotid artery are difficult lesions to handle. Batjer and Samson described the technique of suction decompression of the aneurysm by inserting a needle and aspirating blood from the internal carotid artery in the neck. However, this method carries a risk of arterial dissection and distal embolization. METHOD: We describe a revised technique for suction decompression of paraclinoid aneurysms. The method makes use of the anatomical advantage of the carotid bifurcation. Instead of direct clamping of the internal carotid artery, we isolated the common and external carotid arteries and decompressed the aneurysm via the external carotid artery. We also saved the aspirated blood for autotransfusion. RESULTS: We have used this technique in two elderly patients with good results. CONCLUSION: This technique avoids dissection of the internal carotid artery and minimizes the risk of embolization.     

Retrograde femoral nailing of periprosthetic fractures around total knee replacements

IntroductionThe incidence of primary total knee replacement (TKR) is increasing with a resultant rise in those patients sustaining distal femoral periprosthetic fractures around TKRs. The management of these fractures pose a significant challenge. The compatibility of retrograde femoral intramedullary (IM) nails with femoral TKR components needs to be considered preoperatively when this complex pathology is addressed. The aim of this study was to update the literature and assess the compatibility of the most commonly used primary TKR prostheses and retrograde femoral IM nails using a Sawbone anatomical model.Methods and materialsEight of the most commonly used primary TKR prostheses and four of the most commonly used retrograde femoral IM nails were identified. The femoral components of the TKRs were implanted onto left sided femoral Sawbones using the manufacturer's guides and cutting blocks and positioned appropriately. The retrograde IM nails were inserted using the conventional entry point and a nail was deemed compatible if this was possible through the femoral prosthesis. Details of whether a posterior entry point was required to allow insertion, whether the femoral nail was scratched by the femoral TKR prosthesis on insertion and whether excess force was required to insert the retrograde femoral IM nail were recorded.ResultsThe Biomet AGC Cruciate Retaining (CR) and Posterior Stabilised (PS) TKR were the only prostheses that were compatible with all the nails used. The other TKR prostheses were not compatible because of the force required to gain entry, scratching of the retrograde femoral IM nail or because a posterior entry point was required to gain entry through the intercondylar notch.ConclusionThe majority of standard sized retrograde femoral nails are technically feasible for insertion through most femoral TKR components but this study has found that they are not compatible due to excessive force required for insertion, damage to the nail during insertion or the risk of anterior cortex perforation. Further studies are required to update the compatibility table and cadaveric studies would confirm the findings and allow further mechanical testing.     

MRI of the knee after locked unreamed intramedullary nailing of tibia

We analysed the reason for knee pain after intramedullary (IM) nailing with standard MRI sequences at a mean of 27 months (range 2–45) after nail removal in eleven patients with a mean age of 30 years (range 15–52). Knee pain was assessed in four grades. All our patients had signal changes of fluid in the nail channel, areas of low signal intensity in Hoffa’s fat pad and subcutaneous low signal nodes in front of a thickened patellar ligament. Ten patients had low signal adhesions from the nail insertion towards the patellar ligament. Six patients had severe knee pain and even marked adhesions. Two patients had no knee pain; one of these two had minimal adhesions and the other one no adhesions. Five of the patients had a meniscal tear and/or local cartilage reduction. The degree of adhesions from the nail insertion in the tibia towards the patellar ligament was proportional to the degree of knee pain. No sign of acute inflammation was found. Abstract presented, in part, at the European Society of Musculoskeletal Radiology Annual Meeting, 13–14 June 2003, Aarhus, Denmark.     

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   

Retrograde nailing of a femoral supracondyle

Because standard femoral supracondylar nails have certain disadvantages, they are often replaced by traditional femoral or tibial locked nails. The purpose of this study was to make a biomechanical comparison between both types of traditional locked nails to determine which technique was more suitable for treating unstable femoral supracondylar fractures. Fourteen left Sawbones femurs (Pacific Research Laboratories, Vashon, Washington) were osteotomized in the femoral supracondylar area. One centimeter of the medial cortex in the proximal fragment was obliquely removed to simulate an unstable fracture without shortening. Seven specimens were treated with traditional retrograde dynamic femoral locked nails, and the other 7 with traditional retrograde dynamic tibial locked nails. All specimens were tested with a servohydraulic materials testing machine to compare their relative stability. Static compression, dynamic cyclic compression, and static compression to failure were tested. An extensometer was used to measure the displacement of fragments. Displacement between the fragments increased following the increment in loads in both nails. The load-displacement curve was nearly linear up to 1000 N for both nails. The femoral nail had a greater stiffness compared with the tibial nail at 100 and 200 N (P=.02 and P=.04, respectively) in static compression and at 700 to 1000 N (P=.01 in each case) in dynamic cyclic compression, as well as larger loads in static compression to failure (8663 vs 7547 N, respectively; P<.001). Clinically, a traditional femoral locked nail may be more suitable to replace a standard femoral supracondylar nail in a retrograde fashion to treat an unstable femoral supracondylar fracture.     

Retrograde locked nailing of humeral shaft fractures using the unreamed humeral nail (UHN)

Objectives  

Bony consolidation of humeral fractures in anatomical reduction.     

An improved surgical technique to treat femoral shaft malunion: revised reamed intramedullary nailing technique

Twenty-four consecutive adult patients who sustained a femoral shaft angular or rotational deformity, with or without significant shortening, were treated with skeletal traction of the femoral condyle, transverse femoral osteotomy, realignment of the shaft axis with or without lengthening, stable reamed intramedullary nail stabilization, and corticocancellous bone grafting. Twenty-one patients who underwent the treatment were followed-up for at least 1 year (range 1.0–4.5 years), and all achieved a solid union. The union rate was 100% (21/21) with a union period of 4.9 ± 0.5 months. There were no significant complications. All patients achieved a satisfactory outcome as indicated by patient satisfaction and physician assessment of outcome (p < 0.001, Fisher’s exact test). In the present series, the use of this revised reamed nailing technique resulted in a high success rate and a low complication rate. It provides an effective alternative treatment in indicated cases. Received: 23 March 2000     

Upper eyelid ptosis correction by a revised tarsal resection technique

Many techniques have been developed for the correction of eyelid ptosis. A new tarsal plate resection technique is described for use in cases of minimal ptosis with fair to good levator function. The procedure involves a horizontal lenticular excision of the tarsal plate, placed so that equal amounts of tarsus remain above and below the excision. The height of the excision is equal to the amount of ptosis correction desired, as determined in the preoperative examination. This precision in surgical correction is the chief advantage of the procedure. The technique also spares Müller's muscle, thus retaining the lid-elevating action of that muscle. Good results have been achieved in 6 patients, some showing excellent results after nine years.     

肱骨自锁髓内钉逆行插钉技术治疗肱骨骨折

目的探讨自锁髓内钉逆行插钉技术治疗肱骨干骨折的临床应用效果。方法采用逆行插钉技术髓内钉固定治疗14例肱骨干骨折。根据术后肩关节活动范围进行效果评价。结果随访12例,时间3~20个月,平均8·7个月,骨折均愈合。肩关节功能评价:优11例,良1例。结论采用肱骨自锁髓内钉逆行插钉技术治疗肱骨骨折在术后肩关节功能恢复上比顺行插钉技术具有优势。     

Antegrade locked nailing for humeral shaft fractures

Treatment results of antegrade locked nailing of acute humeral shaft fractures, including union rate and recovery of shoulder function, have been inconsistent. This led the current authors to hypothesize that implant design and surgical techniques might account for this inconsistency. In the current study, 47 fractures (38 acute; nine pathologic) in 47 patients achieved union with the techniques of closed nailing, short to long segment nailing, and fracture compression. Satisfactory recovery of shoulder function occurred because of minimal surgical trauma, prevention of impingement by the nail or locking screws, and prevention of axillary nerve injury or comminution of the humeral head. Forty-seven patients with 38 acute fractures and nine pathologic fractures were treated with humeral locked nails. Mean followup time was 21.4 months. With a single operation, all 38 acute fractures proceeded to eventual union; the average time to union was 7.8 weeks. Thirty-five patients had excellent or satisfactory recovery of shoulder function. Complications included slipout of the proximal screw, nail breakage, fragment displacement, and transient postoperative radial nerve palsy. All nine patients with pathologic fractures had substantial pain relief and increased arm function after surgery. The current study shows the reliability of antegrade locked nailing for proximal and middle third fractures of the humeral shaft.