Extending the Indication of Intramedullary Nailing of Tibial Fractures

Abstract Intramedullary nailing is an effective and well-established method for the treatment of a wide spectrum of tibial fractures. Nevertheless, the handling of metaphyseal and open fracture remains challenging. Surgical and technical advancements have opened up new possibilities to broaden the indication of intramedullary nailing in these areas.     

有限扩髓交锁髓内钉治疗胫骨闭合性粉碎性骨折

目的：探讨有限扩髓交锁髓内钉治疗胫骨粉碎性骨折的治疗效果。方法：对38例胫骨闭合性粉碎性骨折病人行有限扩髓交锁髓内钉治疗，全部应用静力性固定。结果：平均随访时间12个月(6～22个月)，采用Johner-Wruh评分标准，治疗结果：优30例，良6例，一般2例，骨折平均愈合时间16周(12～36周)，3例延迟愈合，无深部感染、骨髓炎、畸形愈合及骨不连。结论：有限扩髓交锁髓内钉是治疗胫骨粉碎性骨折较理想的方法，可促进骨折愈合，并发症较少。     

大众健康评分下的胫骨髓内钉术后疗效

目的使用大众健康评分及骨科专业关节评分,对单一胫骨干骨折髓内钉治疗的患者进行评分研究,比较两种方法之间的异同。方法选用自2005年3月至2006年3月,因胫骨干骨折在我院骨科取胫骨髓内钉的患者作为研究对象。骨折类型为单一下肢胫骨骨折及胫腓骨骨折。入选后收集其X片、了解受伤机制、骨折类型、手术切口入路、骨折愈合时间及并发症,同时对其进行临床评价,包括视觉评分法（VAS）、Iowa膝关节及踝关节评分、SF-36生活质量表,利用Spearman检验对部分变量进行相关性分析。结果本组共162例患者,术后平均随访38个月。60例患者休息时存在膝关节周围疼痛;103例患者由于进钉点疼痛而影响膝关节活动;31例患者出现不同程度踝关节周围疼痛;19例患者仍感骨折部位疼痛。膝关节与踝关节的VAS评分存在明显相关性（r=0．38）,而两者与骨折部位的VAS评分均无相关性。膝、踝关节的Iowa评分与SF-36生活质量表的躯体总分及心理总分也存在极大的相关性。结论胫骨骨折髓内钉治疗术后,尽管医生认为手术效果较为肯定,但根据患者自身的评价,仍有较大比例的“不满意”率。     

Comparison of Radiological and Clinical Outcomes in Patients Treated with Standard Plating versus Intramedullary Nailing in Distal Tibial Fracture

ObjectiveTo evaluate clinical and radiological outcomes including hindfoot alignment after plate vs intramedullary nailing (IMN) for distal tibia fracture and to define radiologic parameters that influence changes in hindfoot alignment.MethodsAmong 92 patients with distal tibia metaphyseal fractures treated from 2002 to 2015, 39 cases of intramedullary nailing and 53 cases of standard plate osteosynthesis were performed. Union rate and complication rate were compared in both groups. Radiographic measurements including hindfoot angulation, moment arm, calcaneal pitch angle, and Meary angle were evaluated at a minimum of 1‐year follow‐up. Hindfoot alignment changes after surgery were compared between both groups using student t‐test. Correlation and regression were analyzed between fracture alignment parameters and hindfoot alignment.ResultsAll patients ultimately healed, with an average union period of 26 weeks in both groups. The AOFAS and VAS scores were not significantly different between the two groups. Complications were similar between the two groups. Hindfoot alignment angle, calcaneal pitch, and Meary angle showed no significant differences between the groups. The hindfoot moment arm increased with valgus in the IMN group. A low correlation was detected between angulation at the fracture site in the coronal view and hindfoot alignment (angulation and moment arm) changes (R = 0.38). A significantly high correlation was noted only between transverse rotation and hindfoot alignment changes (R = 0.79).ConclusionsRotation in the transverse plane notably influenced changes in hindfoot alignment. And this suggests that patients with distal tibia fracture should be closely monitored for hindfoot alignment changes caused by intraoperative transverse rotation regardless of the fixation method.     

胫骨髓内钉术后膝关节痛的临床观察

目的通过胫骨髓内钉术后膝关节痛的临床观察,探讨膝关节痛的病因.方法回顾在我院应用闭合复位交锁髓内钉治疗新鲜胫骨干骨折129个(126例病人).结果膝关节痛的共有17例,其中4例是由于钉尾突出胫骨近段,引起局部疼痛.另13例疼痛原因不详;所有病人膝关节活动均>110°,其中7例<110°时有痛(包括4例钉突出的),10例在极度屈膝活动时自觉有膝关节痛;除4例钉尾突出外,13例中在非扩髓组6/55例,扩髓组7/70例,统计学分析无差异;膝关节痛与髓内钉的品牌无统计学差异;经髌韧带入路关节痛发生率(11/44)明显高于髌韧带内侧入路(2/72),统计学上有显著差异.结论建议使用髌韧带周围入路;胫骨交锁髓内钉后出现的膝关节痛虽然比较少,其原因还需进一步观察与研究.     

胫骨骨折--髓内钉与石膏固定治疗的比较

许多研究表明,对于闭合性或I度开放性胫骨骨折,髓内钉的治疗效果可能比石膏固定治疗效果要好。在髓内钉治疗组中,骨折愈合时间和返回工作岗位时间较短,且骨折延迟愈合和不愈合的情况要更少。与石膏固定治疗组相比,髓内钉治疗组疼痛更强烈些,虽然患者对疼痛的抱怨较多,然而一些与健康相关生活质量方面的治疗结果仍然比石膏固定治疗组优秀。     

Grosse—Kempf带锁髓内钉治疗股骨、胫骨骨折

本文对我院1988年7月—1994年11月间用带锁髓内钉治疗股骨、胫骨骨折进行总结,共施行手术62例,随访7个月以上的58例.结果:死亡3例(均与骨折无关),2例骨折未愈合,1例骨转移癌术后仍存活,其余52例骨折全部愈合.关节功能恢复良好.术后并发症:钉断裂2例,伤口感染1例,近端锁钉断裂1例,远端锁钉断裂2例,均未影响骨折愈合及功能的恢复.带锁髓内钉应用范围广,骨折愈合率高,手术失败率低,拔钉后不会出现再骨折,是一种比较好的内固定方法.     

扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的疗效比较

目的　比较扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的临床疗效。方法　对 6 4例共 6 7侧开放性胫骨骨折采用带锁髓内钉治疗 ,其中非扩髓组 36侧 ,扩髓组 31侧。伤口愈合拆线后扶拐下地活动 ,术后定期随访 6个月～ 1年。结果　非扩髓组与扩髓组局部感染率分别是 13 9%和 12 9% (P >0 0 5 ) ,无全身感染 ;非扩髓组 5例锁钉断裂 ,扩髓组无断钉 ;非扩髓组与扩髓组平均骨折愈合时间分别为 2 2 5周和 17 2周 (P <0 0 5 )。延迟愈合分别为 5例、 3例 ,非扩髓组有 1例骨折不愈合。结论　与非扩髓组比较 ,扩髓带锁髓内钉具有骨折固定强度大、骨折愈合快、延迟愈合或不愈合少 ,感染率没有明显升高     

胫骨、股骨干骨折合并同侧膝关节内骨折的髓内钉治疗

目的　评价胫骨、股骨干骨折合并同侧膝关节内骨折的髓内钉治疗。方法　股骨髁间骨折合并股骨干骨折采用螺栓、松质骨螺钉及逆行髓内钉治疗 2 3例。胫骨平台骨折合并胫骨干骨折 1 2例 ,应用松质骨螺钉、髓内钉固定。结果　 30例解剖复位 ,5例功能复位。股骨、胫骨干骨折愈合平均 4 5～ 5个月。按Neer膝关节功能评分标准 ,优良率 85 7%。术后膝关节平均活动度 1 1 2 5°。结论　胫骨、股骨干骨折合并膝关节内骨折螺栓及松质骨螺钉固定后应用髓内钉治疗效果良好 ,膝关节功能恢复满意。     

Distal Tibial Fractures: Intramedullary Nailing

The tibia is an exposed bone with vulnerable soft tissue coverage and is therefore predisposed to local soft tissue problems and delayed bone healing. The objective in distal tibial fracture treatment is to achieve stable fixation patterns with a minimum of soft-tissue affection. Thus, the risk of soft tissue breakdown and bone healing complications is more likely related to open reduction and plating. Percutaneous, minimally invasive intramedullary nailing is a proven fixation mode for fracture stabilization in tibial shaft fractures. Anticipating the pitfalls, intramedullary nailing meets the requirements of the method of choice in distal tibial fracture fixation. In conclusion, intramedullary nailing of distal tibial fractures is a reliable method of fixation, possessing the advantages of closed reduction and symmetric fracture stabilization of an area with a delicate soft tissue situation, but prospective randomized trials are needed to compare modern intramedullary fracture fixation with modern plate fixation in distal tibial fractures.     

胫骨干骨折髓内钉治疗术后膝关节痛的临床观察

目的通过对胫骨干骨折髓内钉内固定治疗后膝关节痛的临床观察,探讨膝关节痛的发生和病因。方法回顾研究1996年5月～2006年4月应用交锁髓内钉内固定治疗胫骨干骨折685例,所有病例在骨折愈合后均有1次以上的随访,平均随访时间为24.2个月。结果共有165例术后发生膝关节痛,经髌韧带入路组膝关节痛发生率为34.5%,髌韧带内侧入路组为14.6%,两组有显著性差异。结论髌韧带旁入路能减少胫骨干骨折髓内钉治疗术后膝关节痛的发生,建议使用髌韧带周围入路,髓内钉固定后膝关节痛的原因尚需进一步研究。     

Tibial Nailing During Pregnancy: A Safe Option

Abstract We present a case of a distal tibial fracture in a pregnant patient treated with an intermedullary device. The risks associated with operative treatment of fractures in pregnancy are discussed. The patient underwent a successful procedure using a novel tibial nail which reduced both operative time and radiation exposure. Surgical intervention allowed the mother to have a normal delivery. The patient had an excellent outcome with no adverse effects reported by either mother or baby.     

Bilateral Low-Dose Computed Tomography Assessment for Post-Operative Rotational Malalignment After Intramedullary Nailing for Tibial Shaft Fractures: Reliability of a Practical Imaging Technique

IntroductionThe purpose of this study is to evaluate the intra- and inter-observer reliability of low-dose protocolled bilateral postoperative Computed Tomography (CT)-assessment of rotational malalignment after intramedullary nailing (IMN) of tibial shaft fractures.Materials and methods156 patients were prospectively included with tibial shaft fractures that were treated with IMN in a Level-I Trauma Centre. All patients underwent post-operative bilateral low-dose CT-assessment (effective dose of 0.03784 – 0.05768 mGy) as per hospital protocol. Four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. The Intra-Class Coefficient (ICC) was calculated to evaluate intra- and inter-observer reliability. The intra- and inter-observer reliability was categorized according to Landis and Koch.ResultsIntra-observer reliability for quantification of rotational malalignment on post-operative CT after IMN of tibial shaft fractures was excellent with 0.95 (95% CI = 0.92-0.97).The overall inter-observer reliability was 0.90 (95% CI = 0.87-0.92), also excellent according Landis and Koch.ConclusionFirstly, bilateral post-operative low-dose –similar radiation exposure as plain chest radiographs– CT assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following IMN of tibial shaft fractures and it allows for early revision surgery. Secondly, it may contribute to our understanding of the incidence-, predictors- and clinical relevance of post-operative tibial rotational malalignment in patients treated with IMN for a tibial shaft fracture, and facilitates future studies on this topic.     

Nonreamed Intramedullary Nailing of Open Tibial Fractures

The development of small-diameter interlocking intramedullary nails that can be inserted without reaming provides a fixation option for open tibial-shaft fractures. Nonreamed intramedullary nailing of these injuries facilitates soft-tissue management without an increase in infection or nonunion rates relative to external fixation. Reaming is not required, which means less injury to the tibial endosteal blood supply. Proximal and distal interlocking maintains better bone alignment than is possible with semirigid or noninterlocking intramedullary nails. The technique of using these devices with static interlocking is described, as are some suggested techniques for avoiding complications.     

Intramedullary Pressure in Reamed Femoral Nailing with Two Different Reamer Designs

Background and Objective: Reaming increases intramedullary pressure and can cause fat intravasation. A new generation of reamers have been developed to minimize these effects. This prospective consecutive nonrandomized clinical trial compares the intramedullary pressure changes of a modern reamer with a conventional one. Objective was to investigate whether intramedullary pressures are different in the use of a new Howmedica reamer compared to a conventionel AO reamer. Patients and Methods: Intramedullary pressures were measured in the distal femoral fracture fragment at the supracondylar region in nine patients and in the intact femur with an impending fracture in two patients with metastatic disease. Monitoring was carried out in 5 AO and 6 Howmedica intramedullary reaming procedures. Results: Significant differences between the two treatment groups could be shown for 9.5 mm, 10 mm, 10.5 mm, 11 mm and 13.5 mm reamers. Analysis of variance for repeated measurements of all diameters showed signigficant more increase of intramedullary pressure with the use of the AO compared to the Howmedica reamer. No clinical symptoms of fat embolism could be detected in both groups. Conclusions: The intramedullary pressures increased substantially with the use of both reamer designs but the highest peak pressures were measured during the reaming of an intact femur. Intramedullary pressure increased significantly with the AO reamer more than with the Howmedica reamer.     

Tibial fractures Reamed versus unreamed intramedullary nailing

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

胫骨骨折--扩髓和不扩髓髓内钉比较

关于这个主题的文献质量不高，因此很难得出一个结论，究竟是扩髓钉还是不扩髓钉的效果更好。这个报告提示：对于开放或闭合性胫骨骨折，两种治疗方法在骨愈合率和并发症上没有统计学差异，建议对患者的功能和生活质量进行更深入和详细的评价和分析研究。     

Quantification of Reaming Debris at the Fracture Gap of Diaphyseal A2 and A3 Fractures After Reamed Intramedullary Nailing of the Sheep Tibia

Background  The aim of this study was to visualize the intramedullary bone debris after reamed nailing of long bones. To date, there is no protocol to quantify bone debris in the fracture gap. The hypothesis was to show if there are differences between A2 and A3 fractures. Methods  In this trial 17 sheep tibiae were used. On the medullary isthmus eight A2 und nine A3 fractures were produced. Afterwards, reposition, closure of the soft tissue and reaming procedure up to 10% of the bonecortex were done. For internal fixation, a plastic implant was used. The region of interest was scanned with the Micro-CT 80 and the fracture gap was contoured from a special software (SCANCO Medical AG, Switzerland). The threshold for the reaming debris was set at 549.9 mgHA/cm³. The analysis of the bone debris located at the fracture gap was measured by percent of debris volume to gap volume. For statistical analysis the Wilcoxon test was used and a level of significance of p < 0.05 was chosen. Results  The fracture gap width ranged from 0.3 to 1.7 mm in both groups. Comparing A2 and A3 fractures there was no significant difference concerning the percentage of reaming debris at the fracture gap. The Median of A2 fractures was 20.5 and 21% for A3 fractures. Conclusions  The results show reaming produces intramedullary bonegrafting. Despite different fracture planes of A2 and A3 fractures, no significant differences in the amount of reaming debris located at the fracture gap could be found. However the percental rate of reaming debris at the fracture gap of plain fractures is negligible. This research shows that there is potential for reaming debris to be applied effectively as a prophylactic and osteogenetic autograft. Together with the high stability of the intramedullary nail an all embracing concept of osteosynthesis could be established.