Development of intramedullary nailing and the interlocking nail

Development of practically feasible methods for intramedullary stabilisation of fragments is inseparably linked to the name of Gerhard Küntscher. The principle of elastic transverse fixation of the nail in the medullary cavity permits its use only in fractures in the median diaphyseal range of tubular bones. For multiple and comminuted fractures Küntscher recommended a so-called "detention" or "locking" nail. This was developed further by Klemm and Schellmann, thus extending the range of indication for intramedullary fragment stabilisation. The origins and phases of development of this method are shown.     

Radiation exposure to the surgeon during closed interlocking intramedullary nailing

During interlocking intramedullary nailing of twenty-five femoral and five tibial fractures, the primary surgeon wore both a universal film badge on the collar of the lead apron and a thermoluminescent dosimeter ring on the dominant hand to quantify the radiation that he or she received. When distal interlocking was performed, the first ring was removed and a second ring was used so that a separate recording could be made for this portion of the procedure. At the conclusion of the study, all of the recorded doses of radiation were averaged. The average amount of radiation to the head and neck during the entire procedure was 7.0 millirems of deep exposure and 8.0 millirems of shallow exposure. The average dose of radiation to the dominant hand during insertion of the intramedullary nail and the proximal interlocking screw was 13.0 millirems, while the average amount during insertion of the distal interlocking nail was 12.0 millirems. Both of these averages are well within the government guidelines for allowable exposure to radiation during one-quarter (three months) of a year. Precautions that are to be observed during this procedure are recommended.     

Olecranon anatomy: Use of a novel proximal interlocking screw for intramedullary nailing,a cadaver study

AIM: To define the optimum safe angle of use for an eccentrically aligned proximal interlocking screw (PIS) for intramedullary nailing (IMN).METHODS: Thirty-six dry cadaver ulnas were split into two equal pieces sagitally. The following points were identified for each ulna: the deepest point of the incisura olecrani (A), the point where perpendicular lines from A and the ideal IMN entry point (D) are intersected (C) and a point at 3.5 mm (2 mm safety distance from articular surface + 1.5 mm radius of PIS) posterior from point A (B). We calculated the angle of screws inserted from point D through to point B in relation to D-C and B-C. In addition, an eccentrically aligned screw was inserted at a standard 20° through the anterior cortex of the ulna in each bone and the articular surface was observed macroscopically for any damage.RESULTS: The mean A-C distance was 9.6 mm (mean ± SD, 9.600 ± 0.763 mm), A-B distance was 3.5 mm, C-D distance was 12.500 mm (12.500 ± 1.371 mm) and the mean angle was 25.9° (25.9° ± 2.0°). Lack of articular damage was confirmed macroscopically in all bones after the 20.0° eccentrically aligned screws were inserted. Intramedullary nail fixation systems have well known biological and biomechanical advantages for osteosynthesis. However, as well as these well-known advantages, IMN fixation of the ulna has some limitations. Some important limitations are related to the proximal interlocking of the ulna nail. The location of the PIS itself limits the indications for which intramedullary systems can be selected as an implant for the ulna. The new PIS design, where the PIS is aligned 20°eccentrically to the nail body, allows fixing of fractures even at the level of the olecranon without disturbing the joint. It also allows the eccentrically aligned screw to be inserted in any direction except through the proximal radio-ulnar joint. Taking into consideration our results, we now use a 20° eccentrically aligned PIS for all ulnas. In our results, the angle required to insert the PIS was less than 20° for only one bone. However, 0.7° difference corresponds to placement of the screw only 0.2 mm closer to the articular surface. As we assume 2.0 mm to be a safe distance, a placement of the screw 0.2 mm closer to the articular surface may not produce any clinical symptoms.CONCLUSION: The new PIS may give us the opportunity to interlock IMN without articular damage and confirmation by fluoroscopy if the nail is manufactured with a PIS aligned at a 20.0° fixed angle in relation to the IMN.     

Femoral shaft fracture callus formation after intramedullary nailing: a comparison of interlocking and Ender nailing

 Intramedullary nailing is widely used for the operative treatment of femoral fractures. Recently, the biologic healing of fractures has become better understood from fundamental investigations. However, there has been no clinical comparison between the fracture healing process with these two fixation methods. The purpose of this study was to use radiographs to compare callus formation with two types of intramedullary nailing for femoral shaft fractures: reamed interlocking (IL) nails and Ender nails. Femoral shaft type A fractures (AO classification) were studied. Twenty-seven fractures were treated with reamed IL nailing, and 81 fractures were treated with Ender nailing. The callus area was calculated from the maximum cross-sectional area on the anteroposterior and lateral radiographs. The callus appeared at a mean of 3.9 weeks after surgery in the IL group, and at a mean of 2.8 weeks in the Ender group (P < 0.05). In the IL and Ender groups, fracture healing was noted at a mean of 3.4 and 2.0 months, respectively. The mean area of callus formation in the IL and Ender nailing groups was 439.5 mm² and 699.4 mm², respectively (P < 0.02). Ender nailing results in abundant callus, which forms at an earlier stage after the procedure than in patients treated with IL nailing. Dynamization at the fracture site is reported to increase external callus formation. Our results indicate that the elasticity of the fixation obtained with Ender nailing promotes callus formation. Received: November 9, 2001 / Accepted: February 13, 2002     

Shielding of the patient's gonads during intramedullary interlocking femoral nailing

Levels of exposure to radiation were recorded at sixty sites in fifteen patients during intramedullary interlocking femoral nailing. Radiation film dosimeters were placed at four gonadal sites on each subject. A standard male-gonad cup or a pelvic drape of 0.5-millimeter-thick lead-equivalent was put in place to shield the gonads. A second set of four dosimeters was placed external to the shield to approximate unprotected exposure. The total duration of the fluoroscopy averaged five minutes (range, thirty seconds to fourteen minutes). The total exposure to radiation external to the shield was 35 +/- 34 millirems at the male gonadal sites and 17 +/- 11 millirems at the female gonadal sites. With use of the gonadal shield, exposure to radiation was not measurable in thirteen of the fifteen patients. The differences between the exposures of the shielded and unshielded sites to radiation were statistically significant (p less than 0.001). The highest level of gonadal exposure was found with the treatment of proximal femoral fractures and with the use of statically locked nails. Regardless of the conditions, and for all types of fractures and locations, our results demonstrated that gonadal shielding is justified.     

Treatment of diaphyseal forearm fracture with interlocking intramedullary nailing: A pilot study

IntroductionThe present study was done to assess the functional outcome and complications of interlocking intramedullary (IM) radius ulna nailing to treat radio-ulna fractures in adults.MethodologyThirty adult patients with diaphyseal or segmental fractures of radius and ulna were included and treated with IM nailing. Grace and Eversmann rating system was used to assess functional evaluation and grip strength was measured using grasp dynamometer.ResultsMean age of the 30 eligible patients was 33.5 years, and males comprised 77% of the study population. Intra-operative complications like nail impaction and proximal screw locking problem for radius was present in one patient each. Increased swelling in three patients (10%) and posterior interosseous nerve palsy in one patient (3%) were observed post-operatively. In the post-operative period, all patients were able to move fingers, had 100° elbow range of motion and good grip strength. Pronation and supination till 80° was present in 80% and 57% of the patients respectively. Wrist flexion and dorsiflexion till 90° was present in 80% and 57% of the patients. Fracture union was confirmed radiologically in all cases at a mean of 3.6 weeks. Functional outcome was excellent in 73% and good in 13%. Grip strength was judged to be excellent in all cases.ConclusionsExcellent and good functional outcomes were obtained in 86%, and no case developed mal-union or delayed union. Based on our results, IM nail for surgical treatment of radial and ulnar diaphyseal fractures can be used.     

扩髓带锁髓内钉治疗胫骨干骨折不愈合

目的：探讨使用扩髓带锁髓内钉治疗胫骨干骨骨折不愈合的临床治疗效果。方法：回顾本院自2000年1月～2003年6月应用扩髓带锁髓内钉治疗胫骨干骨折不愈合病人38例。其中钢板固定术后21例，普通髓内针8例，石膏固定6例，外固定架3例。均采用有限切口切开复位并扩髓，静力锁定加植骨术。结果：平均髓访时间18．5个月(7～30个月)。骨折均愈合，骨折愈合时间3．5～13．5个月，平均5．5个月。临近关节功能较术前明显改善，无感染、断钉等并发症。结论：扩髓带锁髓内钉治疗胫骨干骨折不愈合，具有稳定性可靠、利于骨折愈合及早期关节活动的优点，是治疗胫骨干骨折不愈合的有效方法之一。     

A new intramedullary nailing system for long bone fractures--biomechanical evaluation and animal study of a new intramedullary nail]

Interlocking intramedullary nails have expanded their application to the fixation of long bones especially for unstable or comminuted fractures. However, there are certain drawbacks in this method: prolongation of operative time and increased radiation hazard to the patient as well as to the surgical staff, the latter of which is especially a problem in the distal interlocking under fluoroscopic control. In order to solve the problem a new intramedullary nail (J-type) was developed and tested in vitro with Hiprox femur models as well as in vivo using canine models. The nail made of Ti-6Al-4V alloy is composed of an inner nail and an outer cylinder. The proximal portion is transversely fixed with two screws, while the distal portion is fixed into the cancellous bone with four expandable blades. The strength of fixation with this nail was compared to those with four other commercially available interlocking nails as to bending, tortional and compression stiffness as well as to the durability against repeated compression. In the present in vitro and in vivo experiments, a newly developed intramedullary nail (J-type) provides evidence for satisfactory mechanical strength. The use of J-type nail also contributes to shorter operative time and reduction of radiation hazard.     

非扩髓带锁髓内钉治疗粉碎性胫腓骨骨折

目的 总结非扩髓带锁髓内钉治疗粉碎性胫腓骨骨干骨折的临床经验、方法使用非扩髓带锁髓内钉治疗粉碎性胫腓骨骨干骨折47例,其中闭合性骨折36例,开放性骨折11例。结果患行5个月内骨折完全愈合,膝关节、踝关节功能均正常。2例开放性多段骨折患者,术后患肢红肿热痛经切开引流和应用抗生素,感染得到控制。结论 非扩髓带锁髓内钉能有效地稳定胫腓骨粉碎性骨折,减少骨折局部血运的破坏,有利于骨折的愈合。     

非扩髓带锁髓内钉治疗开放性胫腓骨骨折

2004年3月~2005年11月,我科使用非扩髓带锁髓内钉治疗开放性胫腓骨骨折18例,效果满意。1材料与方法1.1病例资料本组18例,男12例,女6例,年龄21~65岁。胫骨的解剖分区:Ⅲ~Ⅴ区17例,Ⅵ区1例;骨折类型按Gustilo评定系统分为:Ⅰ型7例,Ⅱ型5例,ⅢA型5例,ⅢB型1例。急诊手术8例,10例伤     

可膨胀髓内钉与带锁髓内钉治疗胫骨骨折的疗效分析

目的 观察可膨胀髓内钉与带锁髓内钉治疗胫骨骨折的临床效果,探讨可膨胀髓内钉治疗胫骨骨折的方法及临床适应证.方法 72例胫骨骨折患者随机分为2组, A组:34例,行可膨胀髓内钉内固定术;B组:38例,行带锁髓内钉内固定术.从手术时间、术中出血量、骨折愈合时间和并发症等方面进行比较分析.结果 随访5～13个月,平均7个月.两组疗效比较:手术时间、术中出血量、X线透视时间、骨折愈合时间差异有显著性(P＜0.05),术后并发症差异无显著性(P＞0.05).结论 可膨胀髓内钉内固定治疗胫骨骨折能显著减少手术时间和术中出血量,缩短骨折愈合时间,减少并发症,掌握好手术指征,是治疗胫骨骨折的一种较好方法.     

股骨骨折闭合复位髓内固定后骨折端旋转移位的CT测量

[目的]通过CT测量股骨骨折髓内钉固定术后骨折端旋转移位程度,探讨术中纠正旋转畸形的方法。[方法]CT扫描测量56例股骨骨折闭合复位髓内钉固定后的前倾角值,并与健侧对照,计算双侧前倾角的差值,借此判断骨折远端旋转畸形的程度。前倾角增大表明骨折远端内旋,反之代表骨折远端外旋。根据AO分类标准,股骨粗隆下A3型骨折9例,股骨干A型骨折12例,B型骨折15例,C型骨折7例,股骨髁上A型骨折13例。[结果]所有入选病例的伤侧前倾角均发生变化,股骨干骨折的前倾角变化最大,为-13.35°~47.21°。粗隆下骨折的前倾角变化最小,为-7.12°~36.35°,髁上骨折的前倾角变化居中,为-11.10°~39.22°。骨折远端内旋移位的程度和发生率均大于外旋移位。内旋移位占60.71%,外旋移位占39.29%。股骨干骨折远端内旋移位的变化最大,为1.37°~29.82°,平均12.34°。粗隆下骨折远端内旋移位的变化最小,为0.81°~23.21°,平均8.32°。髁上骨折居中,为1.72°~27.11°,平均8.38°。骨折远端外旋移位仍以股骨干骨折表现最明显,为1.11°~21.12°,平均9.33°。粗隆下骨折变化最小,为1.31°~16.23°,平均7.71°。股骨髁上骨折变化居中,为0.97°~17.96°,平均8.22°。分别对3个骨折部位的健侧和伤侧配对t检验,P<0.001,差异显著。[结论]股骨骨折闭合复位髓内钉固定术后,骨折端旋转移位的发生率非常高,术中影像监测可有效控制旋转移位。     

Closed interlocking nailing of the femur complicated by an intramedullary calcified lesion

The interlocking intramedullary nail has greatly expanded the indications for closed intramedullary nailing of the femur. We describe a complication caused by the presence of a calcified lesion located at the proximal metaphyseal-diaphyseal junction of the femur. This lesion could not be penetrated by hand reamers. We used a long 3.5-mm drill bit to place a hole in the infarct, which then allowed passage of the hand reamer. The operation then proceeded in the standard fashion without complications.     

逆行交锁髓内钉治疗股骨髁间粉碎性骨折12例

目的探讨股骨逆行交锁髓内钉治疗股骨髁间粉碎性骨折的效果。方法应用股骨逆行交锁髓内钉治疗12例股骨髁间粉碎型骨折,随访全部病例并进行临床效果评定。结果经6~20个月随访,12例骨愈合良好。结论股骨逆行交锁髓内钉具有操作简便、固定牢靠等优点,是治疗股骨髁间粉碎性骨折较理想的内固定器械。     

External jig-aided intramedullary interlocking nailing of diaphyseal fractures: experience from a tropical developing centre

Intramedullary interlocking nailing for diaphyseal fractures is a standard treatment option in affluent societies. These procedures are often performed under image intensifier guidance. The cost of these gadgets precludes their common use in resource poor regions. External jig-aided intramedullary interlocking nailing is relatively cheap and offers the chance for performing these procedures in resource poor regions. The aim of this study was to document the advantages, challenges and outcome of this form of treatment in a resource poor setting. The Surgical Implant Generation Network (SIGN) implants and instrumentation were used for this study. Thirty-seven limbs in 35 patients were included. There were 30 males and five females giving a ratio of 6:1. The mean age was 35 ± 11.9 years with a range of 15–61 years. The femur and tibia were the bones studied with a total of 23 and 14 fractures, respectively (ratio 1.6:1). There were 14 comminuted fractures, two segmented fractures, six mal-unions, eight non-unions and seven simple fractures. Road traffic accidents were the most common cause of injuries with motorcycle accidents accounting for 19 (57.4%) cases. The mean follow-up period was 22 ± 5.32 months, mean time to union was 16.9 ± 5.4 weeks and the major complication was osteomyelitis (10.8%). We conclude that this is a viable treatment option for musculoskeletal injuries in resource poor regions. Education to encourage early acceptance of surgical intervention and reduced patronage of traditional bone setting for injudicious interventions can reduce the infective complication rates.     

A simple, rapid and economical method of distal interlocking nailing in upper and lower leg intramedullary nailing

Distal interlocking of intramedullary nails is associated with a relatively high radiation exposure. For the reduction of fluoroscopy time and surgeon's hands irradiation, many devices have been developed so far. In this paper, a simple free-hand-technique is presented. The mean fluoroscopy time in 30 femur and 10 tibia interlocking intramedullary nailing procedures was one minute. The technique avoid the central beam of the fluoroscope and does not require specific instruments. The technique is based on the axial placement of a 2 mm K-wire in the interlocking screw holes. A centrally perforated 4.5 mm drill is placed over the K-wire. Therefore in this technique a perfect centrally placement of the K-wire is not necessary. The drill is guided by the K-wire thereby avoiding complications such as drill failure or deviation of the drill direction.     

可膨胀髓内钉治疗四肢长骨骨折

[目的]探讨可膨胀髓内钉Fixion^TM系统治疗长管状骨骨折的临床应用效果。[方法]自2004年9月．2006年1月，共30例患者采用Fixion^TM可膨胀髓内钉系统（Disco-O-tech Herzliya，lsreal）进行治疗；所有患者均为外伤引起的四肢长管状骨骨折，其中男17例，女12例，年龄22—82岁；开放性骨折1例，骨不连患者1例；股骨转子间骨折7例，股骨干骨折9例，肱骨骨折7例，胫骨骨折7例。可膨胀自锁髓内钉（IM）18例，可膨胀交锁髓内钉（IL）5例，股骨近端髓内钉（PF）7例。一般术后10d允许患者部分负重，若负重时患者骨折处出现明显疼痛应推迟。[结果]本组30例伤口全部I期愈合，手术时间30～140min，平均65min，术中出血50～1200ml，平均300ml。30例患者全部获得随防，随访时间12～72周，平均40周。术后根据临床和影像学平均愈合时间为：股骨转子间骨折11周，股骨干骨折12．2周，胫骨干骨折13周，肱骨骨折11周。其中1例为肱骨干骨折术后骨不连，再次手术后3个月，骨折处骨痂形成。[结论]可膨胀髓内钉应力分布均匀，避免了应力遮挡效应；一般无需扩髓和锁钉．减少了创伤和手术时间，医生和患者接受的X线剂量少和感染率低；轴相弹性动力化固定，加快了骨折愈合时间，避免了交锁髓内钉2次动力化手术给病人带来肉体和精神上的痛苦等。临床初步应用疗效满意，为长管状骨骨折的治疗提供一种新型的理念和固定技术，在掌握好适应证、正确操作的前提下，采用Fixion^TM可膨胀髓内钉系统治疗长管状骨骨折有可能获得较传统交锁髓内钉更好的效果。     

临床护理路径在交锁髓内钉治疗胫骨干骺端骨折中的应用

目的探讨临床护理路径在交锁髓内钉治疗胫骨干骺端骨折中的应用效果。方法将41例交锁髓内钉结合阻挡钉技术治疗胫骨干骺端骨折患者随机分为对照组(20例)和观察组(21例),对照组采用常规护理,观察组采用个性化的临床护理路径进行护理,即在入院当天发放住院每日护理计划单,护理人员按照当日护理路径的内容,实施相应护理技术操作、开展健康教育。结果两组住院时间、相关知识掌握得优率比较,差异有统计学意义(均P<0.05)。结论临床护理路径可有效减少交锁髓内钉治疗胫骨干骺端骨折患者的住院时间、术后并发症,提高患者满意度。     

磁力导航交锁髓内钉在治疗胫骨干骨折中的应用

目的 评价磁力导航交锁髓内钉治疗胫骨干骨折的疗效,并与普通交锁髓内钉疗效进行比较.方法 将62例胫骨干骨折患者分为两组:A组23例,使用磁力导航交锁髓内钉治疗;B组39例,使用普通交锁髓内钉治疗.记录两组远端2枚锁钉锁定成功时间,一次性锁定成功率及骨折愈合时间.用Kakar评分标准评价两组疗效.结果 远端2枚锁钉锁定成功时间:A组(6.7±2.0)min,B组(12.5±2.2)min,两组差异有统计学意义(P＜0.05);一次性锁定成功率:A组96%,B组77%,两组差异有统计学意义(P＜0.05);骨折愈合时间:A组(16.7±1.8)周,B组(16.9±1.6)周,两组差异无统计学意义(P＞0.05);Kakar评分优良率:A组91%,B组87%,两组差异无统计学意义(P＞0.05).结论 磁力导航交锁髓内钉治疗胫骨干骨折疗效满意,与普通交锁髓内钉比较有定位准确、手术时间短、创伤小的优势.