Closed retrograde retrieval of the distal broken segment of femoral cannulated intramedullary nail using a ball-tipped guide wire

Background:

Extracting broken segments of intramedullay nails from long bones can be an operative challenge, particularly from the distal end. We report a case series where a simple and reproducible technique of extracting broken femoral cannulated nails using a ball-tipped guide wire is described. This closed technique involves no additional equipment or instruments.

Materials and Methods:

Eight patients who underwent the described method were included in the study. The technique involves using a standard plain guide wire passed through the cannulated distal broken nail segment after extraction of the proximal nail fragment. The plain guide wire is then advanced distally into the knee joint carefully under fluoroscopy imaging. Over this wire, a 5-millimeter (mm) cannulated large drill bit is used to create a track up to the distal broken nail segment. Through the small knee wound, a ball-tipped guide wire is passed, smooth end first, till the ball engages the end of the nail. The guide wire is then extracted along with the broken nail through the proximal wound.

Results:

The method was successfully used in all eight patients for removal of broken cannulated intramedullary nail from the femoral canal without any complications. All patients underwent exchange nailing with successful bone union in six months. None of the patients had any problems at the knee joint at the final follow-up.

Conclusion:

We report a technique for successful extraction of the distal fragment of broken femoral intramedullary nails without additional surgical approaches.     

微创髓内钉插入技术治疗股骨干骨折的初步结果

目的探讨采用微创髓内钉固定技术治疗股骨干骨折的近期疗效。方法自2002年9月～2004年12月应用小切口闭合复位、微创髓内钉插入固定技术治疗股骨干骨折23例,根据AO分型:A2型3例,A3型4例,B2型6例,B3型4例,C1型5例,C2型1例。记录手术时间、输血量和术后并发症以及术后住院时间。结果平均手术时间90min(60～150min),平均输血量60mL(0～400mL)。无明显的术中和术后并发症。平均住院时间4d(3～7d)。结论采用微创顺行髓内钉插入固定技术治疗股骨干骨折具有创伤小、不输血、恢复快、并发症少的优点,是治疗股骨干骨折的一种微创技术。     

A technique for extraction of the distal segment of a broken femoral nail using a flexible reamer

IntroductionExtraction of broken femoral nails in peri-implant fractures is becoming an increasingly common problem faced by orthopaedic surgeons. Different closed and open techniques for removal of broken nails have been previously described but due to variations in equipment and fracture configurations these methods are not always easily reproducible. We describe an open surgical technique using simple equipment that can be utilised when other methods of extraction have failed.Case presentation and surgical techniqueWe present a case of a peri-implant fracture secondary to non-union involving a short cephalomedullary nail where the broken distal segment of nail was significantly more distal to the femoral fracture site. After multiple failed attempts at extraction with previously described closed techniques a rectangular cortical window was created 2 cm distal to the tip of the broken nail using a saw. An antegrade guide wire was passed through the nail and pulled out of the bony window. A flexible intramedullary reamer was subsequently passed in retrograde fashion over the guide wire and a simple pushout technique was used to push both segments of the broken nail through the original insertion site. An exchange nailing was performed and the cortical window was reattached using a cable.DiscussionThis is a simple technique that does not require any specialist equipment and does not require the fracture site to be disturbed. The use of a flexible reamer as a pushout device is ideal as there are multiple size options allowing the surgeon to match the size of the medullary canal with the reamer. Furthermore, the flexibility of the reamer allows easy access through a lateral bone window.ConclusionBroken femoral nail extraction can be technically challenging and when other closed methods have failed we believe our technique offers a simple alternative that can be added to the armamentarium of solutions.     

Failure of intertrochanteric nailing due to distal nail jamming

Nail impingement against the anterior femoral cortex during nail insertion, or anterior cortex penetration, has been described in the literature as a worrying complication. We describe a previously unreported surgical failure due to a compromised dynamic distal locking caused by distal jamming of the nail. An 80-year-old male suffered a closed right intertrochanteric femoral fracture. Due to the presence of a long medial fragment, a 240 mm long titanium trochanteric nail was chosen to stabilize the fracture. Dynamic distal locking was performed by placing the distal screw at the inferior rim of the elliptical locking hole to allow compression of the fracture site during weight-bearing. Six-month X-ray follow-up revealed a broken nail and nonunion of the fracture due to failed dynamization of the distal locking screw. The nail was removed and replaced by a total arthroplasty. Due to the femoral anterior bow of the shaft, anterior cortical impingement of the distal tip of a nail may result in the failure of the nail to slide within the diaphyseal canal when using a medium-length nail preventing compression of the fracture. Dynamic distal locking can be ineffective if the ability of the distal nail to slide within the diaphyseal canal is hindered. This type of scenario can represent an opportunity for anterior nail impingement. Distal jamming of the nail can thus compromise dynamic compression at the fracture site during loading, thus inducing nonunion of the fracture, and leading to breakage of the osteosynthesis device. For these reasons, caution is recommended when using medium-length trochanteric nails for unstable trochanteric fractures.     

闭合复位经皮微创动力内固定架治疗股骨转子部骨折

目的 探讨微创动力内固定架治疗股骨转子部骨折的疗效. 方法 2005年1月至2007年1月在C形臂X线机透视下闭合复位,小切口微创手术入路,经皮微创动力内固定架治疗转子部骨折16例,其中男11例,女5例;年龄25～78岁,平均48.6岁.按股骨转子间骨折改良的Evan's分型:Ⅰ型1例,Ⅱ型2例,Ⅲ型4例,Ⅳ型3例,Ⅴ型2例;股骨转子下骨折4例. 结果 本组手术时间38～70 min,平均45 min;手术切口 3.5～4.5 cm,平均3.9 cm;术中出血量50～90 mL,平均68.6mL;临床愈合时间55～92 d,平均68.9 d;住院时间14～19 d,平均15.6 d;自由负重时间为术后36～78 d,平均43.6 d.所有患者获得6～36个月(平均14.7个月)随访.根据X线评价:16例骨折均达骨性愈合.按照董纪元疗效评价标准评定疗效:优14例,良1例,可1例,优良率93.8%. 结论 经皮微创动力内固定架治疗转子部骨折,手术简便快速、创伤少、固定牢、愈合快、术后并发症少,是对转子部骨折有效的内固定方法.     

半层甲床瓣局部转移修复甲床部分缺损

目的探讨应用半层甲床瓣局部转移一期修复甲床部分缺损,并综合评价其功能恢复情况。方法2009年4月～2011年4月,对外伤引起的38例38指甲床部分或大部分缺损病例,采用半层甲床瓣局部转移修复甲床缺损。结果术后随访5-24个月,以最后1次结果进行评估。38例患指外形及功能恢复较满意。结论半层甲床瓣局部转移修复甲床部分缺损手术操作简单,指甲生长良好,效果满意,是治疗外伤性甲床部分缺损的有效方法。     

辅助钢板与钢丝加固髓内钉治疗不稳定股骨转子部骨折的比较

[目的]比较股骨近端髓内钉辅助股骨近端外侧锁定钢板与环扎钢丝内固定治疗不稳定股骨转子部骨折的临床疗效。[方法]回顾分析本院于2015年3月~2017年1月收治的83例不稳定性股骨转子部骨折行股骨近端髓内钉固定并辅助外侧壁固定手术患者的资料。根据辅助固定方法不同分为钢板组39例和钢丝组44例。比较两组患者临床效果。[结果]两组手术均顺利完成。钢板组手术时间显著长于钢丝组(P<0.05),两组患者在平均失血量、平均住院天数的差异无统计学意义(P>0.05),钢板组平均住院费用显著高于钢丝组(P<0.05)。随访12~24个月,平均(16.81±2.92)个月。钢板组平均完全负重时间显著早于钢丝组(P<0.05)。随时间延长,两组患者Harris评分显著增加(P<0.05);术后3个月钢板组的Harris评分显著高于钢丝组(P<0.05),至术后6、12个月时,钢板组的Harris评分仍高于钢丝组,但差异无统计学意义(P>0.05)。影像评估方面,钢板组骨折复位质量优秀率为71.79%,钢丝组为45.45%,差异有统计学意义(P<0.05)。钢板组骨折愈合时间显著早于钢丝组(P<0.05)。末次随访时两组患者颈干角差异无统计学意义(P>0.05)。至末次随访时,钢板组内固定松动2例,髋内翻2例;钢丝组股骨头坏死1例,髋内翻3例。[结论]对不稳定性转子部骨折髓内钉辅助固定,钢丝环扎手术时间短、费用相对低。锁定钢板则有助于缩短完全负重及骨折愈合时间,并早期改善髋关节功能,骨折复位质量相对好。     

两种髓内钉固定股骨干骨折合并同侧髋部骨折的疗效比较

目的比较防旋型股骨近端髓内钉(proximal femoral nail antirotation,PFNA)与重建钉微创治疗青壮年股骨干骨折合并同侧髋部"囊外型"骨折的疗效。方法回顾性分析2000年1月-2010年8月采用PFNA和重建钉微创治疗的69例青壮年股骨干骨折合并同侧髋部"囊外型"骨折患者临床资料,其中重建钉组44例,PFNA组25例。两组患者性别、年龄、体重、致伤原因、骨折类型及受伤至手术时间比较,差异均无统计学意义(P>0.05),具有可比性。对两组手术时间、术中失血量、骨折愈合时间、并发症及髋、膝关节功能等进行比较。结果 PFNA组手术时间及术中失血量均明显少于重建钉组,差异有统计学意义(P<0.05)。69例均获1年以上随访,PFNA组随访时间12～38个月,平均20个月;重建钉组随访时间12～48个月,平均22个月。两组均无伤口感染、深静脉血栓形成、肺栓塞、内固定断裂、股骨头缺血性坏死及肢体严重旋转与短缩畸形等并发症发生。术中PFNA组植钉困难1例,重建钉组近端锁钉技术困难7例;术中PFNA组医源性股骨干骨折3例,重建钉组6例;术后PFNA组股骨干骨折延迟愈合1例,重建钉组2例;PFNA组和重建钉组并发症发生率分别为20%(5/25)和34%(15/44),比较差异无统计学意义(χ2=1.538,P=0.215)。两组各部位骨折愈合时间比较差异均无统计学意义(P>0.05)。末次随访时,两组髋关节Harris评分和膝关节Evanich评分比较差异均无统计学意义(P>0.05)。结论 PFNA与重建钉固定股骨干骨折合并同侧髋部"囊外型"骨折的临床疗效均满意,但PFNA具有操作简便等优点。     

高龄粗隆间骨折的微创治疗应用探讨

目的 探讨小切口微创技术治疗高龄股骨粗隆间骨折的方法及其疗效。方法 收集近2年来65岁以上高龄粗隆间骨折病例33例，其中小切口DHS治疗18例，微创Gamma钉治疗15例，对手术切口大小、操作时间、术中术后出血量、并发症、术后髋关节功能评定进行临床随访分析。结果 33例均得到随访，小切口DHS组：切口长度为4cm（3～5cm），平均手术时间70min（60～100min），平均出血100mL（50～200mL）；微创Gamma钉：切口长度为3cm（2．5～4．5cm），平均手术时间50min（40～70min），平均出血65mL（30～100mL）。对两组进行术后功能评定，优30例（90．9％），良3例（9．1％）。结论 小切口技术治疗股骨粗隆骨折创伤小，是高龄患者一种理想的治疗方法。     

交锁髓内钉治疗股骨干骨折(附45例报告)

目的: 探讨使用交锁髓内钉治疗股骨干骨折的应用、手术方式选择及疗效。方法: 对使用交锁髓内钉治疗 45例 (48肢) 股骨干骨折的疗效进行回顾性分析。手术采用闭合、小切口或有限切开复位, 用三维瞄准器锁定骨折远、近端。结果: 48例患者平均随访 13. 5个月, 肢体、关节功能恢复优良率 91. 1%(41 /45), 一期骨折愈合率 89. 6% (43 /48 )。平均骨临床愈合时间 6. 8个月。感染率 2. 1% ( 1 /45 )。1例髓内钉断裂。结论: 交锁髓内钉是目前治疗股骨干骨折的首选方法, 术中应常规静力固定, 不剥离或少剥离骨膜, 不强求解剖复位, 尽量闭合复位、有限扩髓。     

交锁髓内钉治疗股骨干骨折及相关问题探讨(附106例报告)

目的:探讨使用交锁髓内钉治疗股骨干骨折的最佳手术方式选择。方法:对1998年6月～2002年10月使用交锁髓内钉治疗106例(118肢)股骨干骨折的疗效进行回顾性分析。手术采用闭合或小切口开放复位,用三维瞄准器锁定骨折远、近端。结果:平均随访14.4个月,肢体、关节功能恢复优良率95.3％,一期骨折愈合率94.0％,平均骨临床愈合时间5.7个月。2例软组织感染,感染率1.9％,2例髓内钉断裂。结论:交锁髓内钉治疗股骨干骨折应常规闭合复位、扩髓、静力固定,不强求解剖复位,本组取得了满意疗效,认为是目前治疗股骨干骨折的首选方法。     

The new technique of precise insertion of lag screw in an operative treatment of trochanteric femoral fractures with a short intramedullary nail

In order to reduce the incidence of cut-out, which is one of the serious postoperative complications of trochanteric femoral fractures, we paid special attention to the placement of lag screw in the femoral head. As a result, we devised a new technique that allows insertion of the lag screw at the first attempt into the optimal position on both planes, inferior half on the antero-posterior view and exactly central on the lateral view, without the need for any special devices other than the basic original set, using a trochanteric nail.For this technique, we have evaluated the proximal femoral profile under image intensifier, on the true lateral view projected parallel to the axis of the femoral neck and not on the conventional lateral view (Lauenstein view) with the projection parallel to the axis of the femoral shaft in a coronal plane.With the X-ray beam lying in the same plane with the targeting device including the nail and the guide sleeve, the guide pin is intended to pass through the guide sleeve and the middle of shadow of the proximal end of the targeting device, so that it can be inserted in the optimal position without fail, aligned with the middle axis of the femoral head.The deviation angle between the axes of the lag screw and the femoral head was measured on every postoperative lateral radiograph. The mean deviation angle of 1.6° in the 39 fractures after the introduction of the new insertion technique was compared with 4.8° in the 44 fractures before the introduction, which showed a significant difference between these groups (p < 0.0001, Welch's t-test).When the lag screw can be placed exactly in the centre of the femoral head on the true lateral view, it can be set forward as closest to articular surfaces as possible on the postero-anterior view without a risk of penetration, so that the tip-apex distance could be easily achieved under 20 mm, which leads to a reduction of postoperative cut-outs.This technique can be applied in other similar trochanteric nails, which gives them an advantage over the sliding hip screws.     

Submuscular plating of pediatric femur fracture

Currently, surgical management of pediatric femur fracture consists of intramedullary nailing with flexible nails or rigid trochanteric entry nails. Rigid trochanteric entry nails are the implant of choice for femoral fractures in adolescents, whereas titanium elastic nails are popular for the management of length-stable diaphyseal femoral fractures in school-age children. However, higher complication rates have been reported in children with length-unstable diaphyseal femoral fractures treated with titanium elastic nails. These complications may require unplanned surgery. Fracture shortening or angulation can lead to nail prominence or exposure that may require nail shortening or removal. Recently, submuscular plating has been found to be a successful alternative option for management of length-unstable femoral fractures in school-age children. Submuscular plating can also be used in older and/or heavier children who have a femoral canal that is too small to accommodate a rigid intramedullary nail.     

Removal of broken solid femoral nail: a modified bent tip guide wire technique

A broken solid femoral nail can be challenging to remove. We describe a modified bent tip guide wire technique for extraction of a broken solid retrograde femoral nail from the proximal femur. The broken nail was removed successfully through the original retrograde entry point to allow for an exchange femoral nailing in a patient with a hypertrophic non-union. This novel technique avoids any additional exposure other than that required to remove and insert the nail.     

小型钛板联合颌间牵引钛钉在下颌骨骨折中的应用

目的探索小型钛板联合颌间牵引钛钉在下颌骨骨折复位内固定术中的应用及临床效果。方法回顾分析小型钛板联合颌间牵引钛钉,行下颌骨骨折复位内固定术186例的临床资料和应用经验。采用颌间牵引钛钉行颌间牵引,恢复咬牙合关系,经隐蔽微创切口或原开放性创口将下颌骨骨折断端解剖复位,小型钛板骨间固定。结果所有患者创口Ⅰ期愈合,张口度正常,咬牙合关系正常,面部外型、咀嚼功能恢复良好。临床治愈率100%。X线片示:骨折愈合良好,未见钛板螺钉松动、移位、断裂,周围骨质无疏松及吸收现象。结论小型钛板联合颌间牵引钛钉行骨间坚强内固定术,治疗下颌骨骨折,微创,复位准确,简便快捷,效果满意,值得临床推广应用。     

Russell-Taylor重建钉内固定治疗股骨干多节段骨折并同侧股骨颈骨折

目的 探讨使用Russell-Taylor股骨重建钉内固定治疗股骨干多节段骨折并同侧股骨颈骨折的临床疗效、手术要点和围手术期注意事项。方法 对1998年6月～2002年10月使用股骨重建钉静力固定治疗7例的疗效进行回顾性分析。手术采用闭合穿钉、小切口切开复位。结果 平均股骨颈骨折临床愈合时间5.2个月、股骨干骨折7.3个月,一期骨折愈合率达到71.4％(5/7),其中2例术后12、15个月远端骨折段骨延迟愈合改为动力固定,4～6个月后骨折愈合。无股骨头坏死征象。1例浅表感染。结论 股骨颈骨折强调不切开复位,并争取解剖复位;股骨干骨折则常规闭合穿钉、小切口复位、有限扩髓、静力固定。认为股骨重建钉是目前治疗股骨干多节段骨折并同侧股骨颈骨折的最佳方法。     

手部外伤性异物的治疗体会

目的探讨手部外伤性异物取出术中易忽略的几个问题。方法 10年来对126例手部外伤性异物患者进行了异物取出术。术前、术后均行X线检查,部分患者术前行B超检查。术后随访时间为1~8个月。结果 65例甲下异物患者中,18例行拔甲后,新生指甲欠平整,外形欠佳;47例采用了指甲部分切除,术后指甲生长良好。1例鱼刺伤异物取出(2枚)术后X线复查,仍可见1枚异物残留。1例患者长期(2年以上)针状异物存留,致生锈,取出时断裂。15例仙人掌刺伤异物患者,取出术后有5例局部仍有红肿症状。2例火药爆炸伤患者中,有1例术后经X线复查仍有部分异物残留并导致局部感染。结论甲下异物取出时应尽量避免拔甲,以免甲床长期暴露而变得毛糙,造成指甲畸形;金属异物存留时间较长时间者,取出时应尽可能与周围软组织同时切除,避免异物断裂;对于仙人掌刺存留患者,术中应扩大切除范围;火药爆炸伤应清创彻底。     

体表精确定位微创股骨近端防旋髓内钉固定治疗老年股骨转子间骨折

目的 探讨体表精确定位微创股骨近端防旋髓内钉(PFNA)固定治疗老年股骨转子间骨折的临床疗效.方法 采用体表精确定位微创PFNA固定治疗28例老年股骨转子间骨折患者.记录切口长度、手术时间、术中出血量、住院时间及并发症情况,采用Harris髋关节功能评分标准评定疗效.结果 手术时间45～90 min,术中出血量10～8...     

Effectiveness of distally slotted proximal femoral nails on prevention of femur fractures during and after intertrochanteric femur fracture surgery

IntroductionIntra- and post-operative femoral shaft fractures related with nailing remain of concern. Although manufacturers have sought to solve the problem by providing distally slotted nails, it is not clear that these implants reduce fractures.We compare two distally slotted proximal femoral nails [trochanteric nail (TRON) and proximal femur intramedullary nail (PROFIN)].Patients and MethodsThe medical records of 195 hips treated with TRONs (distally slotted in four places in the sagittal and coronal planes) and 583 hips treated with PROFINs (distally slotted in two places in the coronal plane) in two institutes were retrospectively evaluated. The inclusion criteria were follow-up for at least 6 months; pertrochanteric fractures and age over 55 years.ResultsIn total, 161 hips in the TRON group and 512 hips in the PROFIN group were included. The mean follow-up time was 28.5 (range: 6–84) months in whole group. The demographic characteristics of the groups were similar. Only 2 intraoperative shaft and 3 proximal lateral cortex fracture was detected in PROFIN group, there wasn’t any postoperative fracture. Four proximal lateral cortex and 2 femur shaft fractures were detected in TRON group (one during operation and one at postoperative 8th month after a fall at pedestrian way).ConclusionsDistal cephalomedullary nail slotting prevented intra- and post-operative femoral fractures. A distal slot 50 mm in length may increase nail elasticity and reduce nail tip stress to a greater extent than a 30-mm slot. Distal slotting in both the sagittal and coronal planes afforded no advantage compared to coronal slotting only.Level of evidenceLevel III retrospective study     

How much is too much? A guide to appropriately bending ball tip guide wires when using intramedullary nails for the treatment of lower extremity long bone fractures

IntroductionThis study was to determine the angle of bend that can be placed in a ball-tip guide wire while still allowing passage of reamers and nails of several commonly utilized nailing systems.MethodsBall-tip guide wires, opening reamer tips, femoral nails, and tibial nails were collected from several manufacturers. Guide wires were incrementally bent 3 cm from the tip and passed through the reamer tip, tibial nail, and femoral nail until unable to pass.ResultsAll systems tested demonstrated that the reamer, with its relative smaller diameter cannula as compared to the nails themselves, determined the smallest tolerable bend to be able to pass the bent guide wire. The bend angle tolerated by reamer tips was on average 7° (4–9°). The bend angle tolerated by femoral nails was more consistent between the tested systems and was on average 15.5° (12–18°). The bend angle tolerated by tibial nails had the most variability between manufacturers and was on average 16° (13–21°).DiscussionKnowing the degree of guide wire bend which is tolerated can save time in equipment preparation as well as allow one to pre-bend the guide wire and know the intramedullary nail and/or reamers will likely pass. We hope the information provided in this work increases awareness of the potential technical issues with guide wire over-bending and that surgeons may err on the side of minimizing the bend in order to save time in the OR, decrease frustration and eliminate intraoperative complications that can occur.