Tibial shaft fracture after removal of an ACE tibial nail

Intramedullary interlocking nailing is the gold standard method for treatment of tibial shaft fractures. Thus, the growing use of the intramedullary nailing resulted in an increased number of tibial nails removal procedures in daily clinical practice. Despite adequate surgeon experience, the removal of tibial intramedullary nails is not without complications. One of the commonly used nails is the ACE (DePuy Orthopaedics, Inc., Warsaw, IN, USA). The purpose of this paper is to report such a complication following the removal procedure and review the pertinent literature. A 39-year-old female who had sustained a lower-third tibial fracture was treated with an intramedullary nail 5 years ago. Despite her unremarkable follow-up, for personal reasons, a removal procedure was planned. Two undisplaced fractures were observed in the postoperative radiological evaluation. The potential complications of the removal of intramedullary nailing of the tibia should be considered by both physician and patient.     

Recommendation of use of checklists in tibial intramedullary nail removal: Retrospective study of mechanical complications related to nail removal

BackgroundThe removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication.MethodsThis is a retrospective seven-year (2010–2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital’s orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed.ResultsA total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail’s distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula.ConclusionNail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. Iatrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws.     

阻钉技术对交锁髓内钉断钉的影响

目的探讨阻钉技术对交锁髓内钉断钉的预防作用。方法2003年1月~2005年8月,采用交锁髓内钉固定长骨干骨折56例,男32例,女24例。年龄21~65岁,平均34岁。其中股骨骨折26例,胫骨骨折30例,均为新鲜、闭合性骨折。骨折类型:中部横断骨折10例,中部短斜形骨折11例,中部长斜形或螺旋形骨折20例,远、近1/3骨干骨折15例。前期32例患者采用常规的交锁髓内钉固定骨折(组),后期24例中部长斜形或螺旋形骨折及远、近1/3骨折患者采用交锁髓内钉配合阻钉固定骨折(组)。结果获随访12~21个月,平均16个月。组3例患者骨折未愈合,其中1例股骨中部长斜形骨折主钉在骨折线附近断裂,另2例胫骨远1/3骨折主钉在靠近骨折端的第1个锁钉孔处断裂;其余患者术后6~12个月获骨性愈合,但骨折处出现较多骨痂。组患者于术后3~8个月获骨性愈合,骨折对位、对线良好,无断钉发生。结论阻钉技术配合交锁髓内钉应用可明显增强骨折断端稳定性,减少断钉发生。     

Is routine removal of intramedullary nails justified.

This study investigates the outcome of 100 cases of lower limb intramedullary nail removal. 12 femoral and 25 tibial nails were removed for pain and 4 tibial nails for infection. For 22 tibial nails and 38 femoral nails there was no recorded indication. There where 3 operative complications, 2 abandoned procedures and 1 tibial fracture (nail extraction without prior removal of the distal locking screw). In 9 out of 16 cases anterior knee pain improved after tibial nail removal. 4 patients, previously asymptomatic, developed anterior knee pain following tibial nail removal. 40 patients who were discharged without crutches returned in pain and had to be given crutches to alleviate leg pain. 62 patients took a mean of 11 days sick leave. We conclude that all complications were avoidable. Intramedullary nail removal is safe. Patients with anterior knee pain should be told that their pain may persist and that knee pain may even arise. Most patients will require crutches and an average of 2 weeks away from work.     

胫骨骨折术后骨不连治疗方法的疗效比较

[目的]探讨带锁髓内钉固定后胫骨骨折骨不连治疗方法的选择和疗效。[方法]348例带锁髓内钉固定胫骨骨折中发生骨不连36例。采用冲击波治疗lO例；髓内钉动力化8例；髓内钉动力化加自体植骨6例；单纯自体植骨5例；改钢板固定加自体植骨3例；肥大型骨不连更换髓内钉4例。[结果]所有病例平均随访28个月。6个月内再手术者较6个月后再手术者愈合时间明显缩短（P〈0.05）。冲击波治疗10例中1例不愈合，经2次冲击波治疗后愈合。髓内钉动力化8例中2例不愈合，经冲击波治疗后愈合，其中2例发生骨缩短；髓内钉动力化加自体植骨6例均愈合；单纯自体植骨5例中2例8个月未愈合，更换髓内钉加自体植骨后愈合；改钢板固定加自体植骨3例均愈合；肥大型骨不连更换髓内钉4例均愈合。【结论】早期治疗带锁髓内钉固定后胫骨骨折骨不连效果肯定。髓内钉动力化可促进骨愈合，但有引起骨缩短的可能；更换髓内钉或钢板加自体植骨治疗骨不连效果满意；冲击波有促进骨不连愈合的作用。     

髓内扩张自锁钉治疗胫骨骨折的生物力学研究

目的对髓内扩张自锁钉(IESN)的生物力学性能进行实验研究,为临床应用提供理论依据。方法采用新鲜成人胫骨标本18根,制成中段斜行骨折模型;梅花针、交锁钉、IESN固定胫骨后进行抗屈伸、抗侧弯、抗短缩、抗扭转、抗疲劳方面的生物力学测试,评价IESN的内固定稳定性;同时比较三种内固定稳定程度的差异。结果IESN在抗侧弯、抗短缩、抗扭转、抗疲劳刚度方面明显强于梅花针(P<0.01),在抗屈伸方面与梅花针、交锁钉相当(P>0.05);在抗侧弯方面强于交锁钉(P>0.05);在抗扭转方面稍差于交锁钉(P>0.05);在抗短缩方面明显弱于交锁钉(P<0.01)。结论髓内扩张自锁钉具有良好的生物力学性能,有较强的固定作用和稳定性。     

微创交锁钉治疗胫骨干长节段粉碎性骨折46例分析

[目的]阐明闭合或有限切开复位交锁髓内钉内固定微创治疗胫骨干多节段粉碎性骨折的优越性和手术要点。[方法]选取46例胫骨干长节段粉碎性骨折使用微创交锁髓内钉固定为治疗组,随机选取同时期普通钛板治疗多节段骨折46例为对照组,对两组术中情况及术后疗效进行比较,其中治疗组采用闭合复位穿钉,有限切开复位螺钉固定,瞄准器锁定骨折远、近端。[结果]两组术后均随访12个月以上,两组在手术时间、住院时间、术中出血量及骨折愈合时间、远期功能疗效满意度方面均有显著性统计学差异。[结论]闭合或有限切开复位交锁髓内钉治疗胫骨干长节段粉碎性骨折较钛板有着微创、手术时间短、伤口愈合快、住院时间短,更符合胫骨生物力学、更高骨折愈合率、更少并发症等优越性。微创交锁钉为该类骨折提供了最佳骨折愈合时机、良好功能恢复,可避免关节僵硬,大部分患者可重返工作岗位。     

胫骨骨折的交锁髓内钉治疗

目的：观察交锁髓内钉在胫骨骨折中的治疗效果。方法：1997年2月－2000年2月对37例胫骨骨折采用交锁髓内钉治疗,男30例,女7例,年龄18－65岁,闭合性骨折28例,开放性骨折6例,陈旧性骨折2例,胫骨骨不连2例,开放性骨折采用非扩髓髓内钉,闭合性骨折采用扩髓髓内钉。结果：37例得到随访,骨折全部愈合,无锁钉及髓内钉松动、断裂,膝踝关节功能正常,迟发性感染1例。结论：交锁髓内钉在治疗胫骨骨折中具有创伤小、固定坚强、骨折愈合率高、能早期活动、感染率低等优点,是一种较好的内固定方法。     

交锁髓内钉远端锁入可吸收螺钉治疗胫骨骨折

目的比较交锁髓内钉远端锁入可吸收螺钉与锁入金属锁钉静力型固定在治疗胫骨骨折中的临床效果。方法采用交锁髓内钉远端锁入可吸收螺钉固定治疗25例胫骨骨折患者（试验组）,检测骨折愈合及并发症情况,并与同期锁入金属锁钉静力型固定28例胫骨骨折（对照组）的随访结果进行比较。结果患者均获得随访,时间4~13个月。骨折愈合时间：试验组为13~16（14.28±0.94）周,对照组为14~18（15.89±1.13）周,差异有统计学意义（P〈0.01）。结论交锁髓内钉远端锁入可吸收螺钉比锁入金属锁钉静力型固定更有利于胫骨骨折愈合。     

Comparative study on treatment of midshaft tibial fracture with expandable and interlocking intramedullary nails

Objective ： To evaluate the clinical results of treatment of midshaft tibial fracture with expandable intramedullary nails compared with interlocking intramednilary nails. Methods： From June 2003 to August 2005, 46 patients （27 males and 19 females, aged 20-74 years, mean =38.4 years ） with midshaft tibial fracture were treated surgically in our department. The causes of fractures were traffic injury in 21 patients, fall injury in 6, tumbling injury in 11 and crushing injury in 8. According to AO/ ASIF classification, Type A fracture was found in 16 patients, Type B in 11, Type C1 in 5, and Type C2 in 2. Open fractures were found in 12 patients, according to Gustilo classification, Type Ⅰ in 9 patients and Type Ⅱin 3 patients. Based on the patients＇consent, 24 patients were treated with expandable intramedullary nails （Group A ） and 22 with interlocking intramedullary nails （Group B ）. The operation time, blood loss during operation, X-ray fluoroscopic times, hospitalization time, weight bearing time after operation, healing time of fracture and complications of all the patients were recorded. The clinical effects of all the cases were evaluated according to the criteria of Johner-Wruhs. Results： All the patients were followed up for 12,34 months （ mean = 16.2 months）. The time of operation, the blood loss, X-ray fluoroscopic times, hospitalization time and healing time of fracture of Group A significantly decreased （P 〈 0.05 ） compared with those of Group B, but the time for weight bearing after operation, the Johner- Wruhs degree of clinical effects and complications had no significant difference between Group A and Group B （P〉0.05）. Conclusions： Expandable intramedullary nail can shorten operation time, decrease blood loss and reduce invasion, which is a safe and effective treatment method for tibial midshaft fracture.     

静力交锁髓内钉治疗胫骨多段骨折

目的观察静力交锁髓内钉在胫骨多段骨折中的治疗效果。方法2000年2月至2003年2月对28例胫骨多段骨折采用静力交锁髓内钉治疗，男21例，女7例，年龄21～61岁，全部为闭合性骨折，伴有腓骨骨折25例，骨折距上、下胫腓联合7cm内，作相应内固定处理。结果28例得到随访，骨折全部愈合，无锁钉及髓内钉松动、断裂。膝踝关节功能正常。迟延愈合1例。结论静力交锁髓内钉在治疗胫骨多段骨折中具有创伤小、固定坚强、骨折愈合率高、能早期活动、感染率低等优点，是胫骨多段骨折一种有效的内固定方法。     

Modified tibial nails for treating distal tibia fractures.

OBJECTIVE: To determine the biomechanical consequences of cutting one centimeter off the tip of a tibial nail when treating distal tibia fractures with intramedullary nails. DESIGN: Randomized laboratory investigation using matched pairs of cadaveric tibias with osteotomies made to resemble distal tibia fractures extending to four and five centimeters from the tibiotalar joints. INTERVENTION: The smaller (four-centimeter) distal tibias were stabilized using ten-millimeter diameter tibial nails that had been modified by removing the distal one centimeter of the nail. The five-centimeter distal tibias were stabilized with standard ten-millimeter diameter tibial nails. Each tibia was tested in elastic compression, rotation, and compression-bending on a servohydraulic materials testing machine. MAIN OUTCOME MEASUREMENTS: Stiffness was calculated for each type of loading to compare stability of the modified nail construct to that of the standard nail construct. RESULTS: Four-centimeter distal tibia fragments stabilized with modified nails have comparable stiffness in compression and in torsion to five-centimeter distal tibia fragments stabilized with standard tibial nails. The stiffness in compression-bending was surprisingly low in both groups and differed by only 3.7 percent. CONCLUSIONS: Removal of one centimeter from the tip of a tibial nail allows placement of two distal interlocking screws in tibial fractures located four centimeters from the tibiotalar joint. The fixation strength achieved is comparable to that of standard intramedullary nailing of tibial fractures located five centimeters from the tibiotalar joint using two distal interlocking screws. Fixation strength with these distal fractures, however, is not strong enough to resist moderate compression-bending loads. Thus, patients with distal tibia fractures treated with intramedullary nailing must follow weight-bearing restrictions until significant fracture healing occurs to prevent coronal plane malalignment of the fracture.     

Unreamed interlocking intra medullary nailing in treating tibial and fibular fractures

OBJECTIVE: To report the experience in the use of unreamed interlocking intramedullary nails. METHOD: From 1995 to 1997, 54 tibial and fibular fractures were treated with unreamed interlocking intramedullary nails they included open fractures (9 cases) and close fractures (45). RESULT: All fractures healed within 6 months and showed good knee and ankle joint functions. Slight postoperation infection was found in one of the open fractures. Incomplete injury of peroneal nerve was noted in 1 case. CONCLUSION: Unreamed interlocking intramedullary nail can be used to treat diaphyseal fractures effectively. It can protect the soft tissue envelope around the fracture and prerent local blood supply from further damaginge.     

三种交锁髓内钉治疗胫骨骨折疗效比较

目的：评价静力扩髓型、动力扩髓型和动力不扩髓型三种类型的交锁髓内钉对胫骨骨折的疗效。方法：骨折类型采用AO骨折分型法，A型18例，B型32例，C型12例，共62例，均采用切开复位内固定治疗方法。结果：62例均获得随访，平均随访时间为13个月。根据胫骨干骨折治疗最终效果的评价标准评价术后功能，优46例，良11例，一般4例，差1例。结论：A型骨折三种髓内钉比较，骨折愈合时间有非常显著性差异；B型骨折三种髓内钉愈合时间比较，其中扩髓型与不扩髓型有非常显著性差异，而扩髓型中静力型与动力型间无显著性差异；C型骨折静力扩髓型与动力不扩髓型愈合时间比较，有非常显著性差异。术中宜尽量避免扩髓，并以采用不扩髓钛合金三角形交锁钉为佳。     

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.     

Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation?

BACKGROUND: Operative treatment of tibial fractures in children requires implants that do not violate open physes while maintaining tibial length and alignment. Both elastic stable intramedullary nails and external fixation can be utilized. We retrospectively reviewed our experience with these two techniques to determine if one is superior to the other. METHODS: We retrospectively reviewed the operative records and trauma registries of three institutions within our hospital system and identified thirty-five consecutive patients with open physes who had undergone operative treatment of a tibial fracture between April 1997 and June 2004. Four patients were excluded because they had been managed with locked intramedullary nails or with pins and plaster. Of the thirty-one remaining patients, sixteen had been managed with elastic stable intramedullary nails and fifteen had been managed with unilateral external fixation. The clinical and radiographic outcomes were compared. The functional outcomes were compared with use of the Pediatric Outcomes Data Collection Instrument. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment also were compared. RESULTS: Thirty-one patients with thirty-one operatively treated tibial fractures were available for evaluation. Fifteen patients had been managed with external fixation. Seven of these patients had a closed fracture, and eight had an open fracture. There were seven healing complications in this group, including two delayed unions, three nonunions, and two malunions. Sixteen patients had been managed with elastic stable intramedullary nailing. Eleven patients had a closed fracture, and five had an open fracture. The mean time to union for the intramedullary nailing group (seven weeks) was significantly shorter than that for the external fixation group (eighteen weeks) (p < 0.01). The functional outcomes for the intramedullary nailing group were significantly better than those for the external fixation group in the categories of pain, happiness, sports, and global function (the mean of the mean scores of the first four categories) (p < 0.01 for these comparisons). CONCLUSIONS: When surgical stabilization of tibial fractures in children is indicated, we believe that the preferred method of fixation is with elastic stable intramedullary nailing.     

带锁髓内钉治疗股骨、股骨干骨折的临床应用

目的 带锁髓内钉治疗股骨、胫骨干骨折临床应用研究。方法 应用带锁髓内钉治疗股骨、胫骨干骨折104例。结果 闭合复位穿钉内固定术后6－10周愈合,切开复位内固定8－12周愈合,48周后拔出内固定物。无断钉、骨折延迟愈合或不愈合、感染、脂肪栓塞、关节僵硬等并发症发生。104例均获随访,平均随访20个月,无1例再次骨折。结论 带锁髓内钉内固定治疗股骨、胫骨干骨折与传统钢板螺丝钉内固定相比,具有固定牢固,防止骨折端扭转、分离,术后不需要外固定支持,能早期负重行走,骨折愈合率高,治疗效果可靠的优点。     

Tibia fracture following removal of the ETN<Superscript>®</Superscript> (Expert Tibia Nail): a case report

We report on a patient who sustained a fracture of the tibial shaft during the removal of the newest type of an intramedullary nail (Expert Tibia Nail, Synthes^®). In this case report, we discuss the causes of this complication and possible ways to prevent this.     

Subtrochanteric Femoral Fracture during Trochanteric Nailing for the Treatment of Femoral Shaft Fracture

We report on three cases of subtrochanteric femoral fractures during trochanteric intramedullary nailing for the treatment of femoral shaft fractures. Trochanteric intramedullary nails, which have a proximal lateral bend, are specifically designed for trochanteric insertion. When combined with the modified insertion technique, trochanteric intramedullary nails reduce iatrogenic fracture comminution and varus malalignment. We herein describe technical aspects of trochanteric intramedullary nailing for femoral shaft fractures to improve its application and prevent implant-derived complications.     

非扩髓交锁髓内钉治疗胫骨骨折

目的探讨非扩髓交锁髓内钉治疗胫骨骨折的方法与疗效。方法回顾102例胫骨骨折均采用非扩髓带锁髓内钉治疗的临床资料，对有关适应证、手术时机、扩髓与否、膝前疼痛、腓骨处理问题进行讨论。结果102例胫骨骨折有98例得到随访3～18个月，平均随访7．5个月，结果评定采用Johner—wruh评分标准，优87例，良11例，差0例。以上病人均无继发性骨筋膜综合征、膝前疼痛、感染、钉体或锁钉断裂、骨折不愈合等发生。结论非扩髓胫骨髓内钉适合胫骨骨折治疗。