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1.
Alvin Chao-Yu Chen Chun-Ying Cheng Ying-Chao Chou 《Journal of orthopaedics and traumatology》2017,18(1):37-42
Background
Post-traumatic deformity of the distal radius may lead to multiple sequelae and severe functional impairment. Intramedullary fixation is a novel technique for treatment of distal radius fractures. The present study aimed to evaluate the functional and radiographic outcomes of intramedullary nailing for correction of post-traumatic deformity in late-diagnosed fractures of the distal radius.Materials and methods
From July 2009 to February 2011, 16 patients with late-diagnosed displaced fractures of the distal radius were included. Eligible inclusion was extra-articular fracture for more than 4 weeks. Surgical correction and internal fixation with intramedullary nailing was performed for treatment of ten AO type A2 and six AO type A3 fractures. All patients were followed up radiographically and clinically for an average of 20.3 months.Results
All fractures achieved bone union without major complications. Functional status and radiographic alignment significantly improved postoperatively. There was no significantly secondary displacement comparing early postoperative and final radiographic parameters. The functional results according to the Mayo wrist scoring system were good or excellent in 94 % of patients. The mean score was 83.8.Conclusion
Surgical correction and internal fixation with the intramedullary nail is a feasible and less invasive technique with few complications in the treatment of post-traumatic deformity of the distal radius.Level of evidence
IV.2.
Babis GC Benetos IS Zoubos AB Soucacos PN 《Archives of orthopaedic and trauma surgery》2007,127(10):905-908
Introduction
Intramedullary nailing has become a popular and effective procedure for the treatment of most fractures of the tibial diaphysis. However, distal interlocking screw placement under fluoroscopic control is responsible for the majority of the radiation exposure and a significant loss of surgical time in the entire nailing procedure. To limit fluoroscopy use, during distal interlocking screw placement, Orthofix® has developed a distal targeting device which compensates for the inevitable deformation of the nail in the sagittal plane during its insertion. This prospective clinical study evaluates the efficacy of this distal targeting device for distal locking.Materials and methods
One hundred and fifteen fresh tibial fractures in the same number of patients with a mean age of 37.5 years (17–85 years) were treated with operative stabilization using the Orthofix tibial nailing system.Results
The mean duration of the operation was 38 min (20–55 min). A mean of four intra-operative plain X-rays (2–6 X-rays) were used in 103 cases to confirm guide wire placement, final nail insertion and accuracy of screws placement. The mean duration of the use of the image intensifier utilized in the remaining 12 fractures was 5 s (3–8 s). The distal targeting device failed in 12 (5.2%) distal locking screws.Conclusion
This study demonstrates that distal locking can be performed easily and successfully with minimal exposure to radiation, once the surgeon develops a reasonable experience with the use of this distal targeting device.3.
4.
Darren Grimwood Jane Harvey-Lloyd 《European journal of orthopaedic surgery & traumatology : orthopedie traumatologie》2016,26(8):867-876
Background
Intramedullary nailing is the standard surgical treatment for mid-diaphyseal fractures of long bones; however, it is also a high radiation dose procedure. Distal locking is regularly cited as a demanding element of the procedure, and there remains a reliance on X-ray fluoroscopy to locate the distal holes. A recently developed electromagnetic navigation (EMN) system allows radiation-free distal locking, with a virtual on-screen image.Objective
To compare operative duration, fluoroscopy time and radiation dose when using EMN over fluoroscopy, for the distal locking of intramedullary nails.Method
Consecutive patients with mid-diaphyseal fractures of the tibia and femur, treatable with intramedullary nails, were prospectively enrolled during a 9-month period. The sample consisted of 29 individuals, 19 under fluoroscopic guidance and 10 utilising EMN. Participants were allocated depending on the type of intramedullary nail used and surgeon’s preference. These were further divided into tibial and femoral subcategories, relative to the fracture site.Results
EMN reduced fluoroscopy time by 49 (p = 0.038) and 28 s during tibial and femoral nailings, respectively. Radiation dose was reduced by 18 cGy/cm2 (p = 0.046) during tibial and 181 cGy/cm2 during femoral nailings when utilising EMN. Operative duration was 11 min slower during tibial nailings using EMN, but 38 min faster in respect of femoral nailings.Conclusions
This study has evidenced statistically significant reductions in both fluoroscopy time and radiation dose when using EMN for the distal locking of intramedullary nails. It is expected that overall operative duration would also decrease in line with similar studies, with increased usage and a larger sample.5.
Background
Limb lengthening and deformity correction with motorized intramedullary lengthening nails is a more comfortable and equally safe procedure than the use of external fixators. While this treatment is a well-established method in adults, intramedullary nailing for skeletally immature patients remains a challenge and is the focus of current clinical investigations.Objective
Elucidation of the indications for the application of femoral and tibial lengthening nails in skeletally immature patients, presentation of essential characteristics and limitations of the treatment.Material and methods
Treatment of skeletally immature patients up to 16 years old who had a lengthening nail inserted was retrospectively clinically and radiologically evaluated (2016–2018).Results
A total of 60 procedures were performed on 54 patients. Mean age at the time of surgery was 13.6 years and the mean follow-up time was 10 months. Different nailing approaches were used: antegrade femoral (n?=?42), retrograde femoral (n?=?10) and antegrade tibial (n?=?8). The average amount of lengthening was 45?mm. In 58 of the 60 cases (96.7%) the desired amount of lengthening was achieved, while 2 patients experienced complications that required interruption of the treatment. None of the patients developed growth disorders associated with the nailing approach.Conclusion
Different approaches for intramedullary lengthening nails can be used in children and adolescents to correct leg length discrepancy with or without concomitant deformities. The treatment is limited by the size of the available nails, the residual growth and extent of the deformity. Larger trials will be needed to further validate the application of lengthening nails in skeletally immature patients.6.
Erik J. Kramer David W. Shearer Elliot Marseille Billy Haonga Joshua Ngahyoma Edmund Eliezer Saam Morshed 《World journal of surgery》2016,40(9):2098-2108
Background
Femoral shaft fractures are one of the most common injuries seen by surgeons in low- and middle-income countries (LMICs). Surgical repair in LMICs is often dismissed as not being cost-effective or unsafe, though little evidence exists to support this notion. Therefore, the goal of this study is to determine the cost of intramedullary nailing of femoral shaft fractures in Tanzania.Methods
We used micro-costing methods to estimate the fixed and variable costs of intramedullary nailing of femoral shaft fractures. Variable costs assessed included medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. Fixed costs included costs for surgical instruments and administrative and ancillary staff.Results
46 adult femoral shaft fracture patients admitted to Muhimbili Orthopaedic Institute between June and September 2014 were enrolled and treated with intramedullary fixation. The total cost per patient was $530.87 (SD $129.99). The mean variable cost per patient was $419.87 (SD $129.99), the largest portion coming from ward personnel $144.47 (SD $123.30), followed by implant $134.10 (SD $15.00) medical personnel $106.86 (SD $28.18), and medications/supplies $30.05 (SD $12.28). The mean fixed cost per patient was $111.00, consisting of support staff, $103.50, and surgical instruments, $7.50.Conclusions
Our study provides empirical information on the variable and fixed costs of intramedullary nailing of femoral shaft fractures in LMICs. Importantly, the lack of surgical capacity was the primary driver of the largest cost for this procedure, preoperative ward personnel time. Our results provide the cost data for a formal cost-effectiveness analysis on this intervention.7.
S. Lotzien C. Hoberg M. F. Hoffmann J. Gessmann D. Seybold T. A. Schildhauer M. Königshausen 《Trauma und Berufskrankheit》2017,19(4):216-221
Background
Fractures of the humeral shaft occur with an incidence of 2–4% among all fractures in humans. With both non-operative treatment and surgical treatment, such as open reduction, internal fixation or intramedullary osteosynthesis, good results can be achieved; however, a gold standard has not yet been identified in the literature or in practice.Objective
The purpose of this article is to summarize the available evidence and to propose an algorithm for the treatment of humeral shaft fractures.Material and methods
Included were a selective literature search in the Medline database and the clinical experience of the authors.Conclusion
Surgical treatment options for humeral shaft fractures with proven high success rates are open reduction with subsequent plate osteosynthesis and intramedullary nail osteosynthesis. Despite a great deal of research on minimally invasive surgical options and optimized design of implants, non-operative treatment is still an option for treatment of fractures of the upper arm.8.
Purpose
The purpose of this systematic review was to analyse the available evidence regarding nonunions of the fibula. We focussed on the incidence, risk factors, evaluation, and treatment modalities for fibular nonunions as evident in the current literature and propose a treatment algorithm.Methods
This was an Institutional Review Board (IRB) exempt study performed at a level one trauma centre. We systematically reviewed the published evidence on fibular nonunion or delayed union from 1950 to February, 2011.Results
Twelve articles were included in this systematic review. In summary, nonunion of the fibula is becoming increasingly more common in association with intramedullary nailing of concomitant tibial shaft fractures. A treatment algorithm for nonunion of the fibula has been proposed.Conclusions
The suspicion for nonunion of the fibula should be heightened in lower leg fractures if the patient is symptomatic, and the progression of healing is not as expected. Ideally, prospective, multicentre studies would be performed to provide more rigorous data on the incidence, risk factors, and optimum treatment.9.
Purpose
Subtrochanteric fractures have a bimodal age distribution. They usually require open reduction and internal fixation. Closed reduction and intramedullary nail fixation rate are increased for this type of fracture. As a result, the hardware breakage and non-union rate is high among such patients. Our purpose is to evaluate the outcomes of the role of blade plate and bone strut allograft in the management of subtrochanteric non-union by femoral nailing.Materials and methods
We reported a group of 22 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail with medial femoral allograft bone and lateral blade plate and wire (PS) s; and a group of 13 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail treated with lateral blade plate and screws (CG). The chosen criteria to evaluate the two group during the clinical and radiological follow-up were the quality of life, measured by The Short Form (12) Health Survey (SF-12), the hip function and quality of life related to it, measured by the Harris Hip Score (HHS), bone healing, measured by Radiographic Union Score (RUS) by XR and CT at 1 year after the surgery, and postoperative complications. The evaluation endpoint was set at 12 months.Results
The Bone healing measured by RUS occurred and also the full recovery before the first trauma measured by SF-12 and HHS are better in PS group. We only had three unimportant complications in PS while four breakage hardware in CG.Conclusion
We conclude that in complicated non-unions, the use of blade plate and bone strut allograft has a definite positive role in the management of such cases.10.
Boris A. Zelle Antonio J. Webb Christopher Matson Michael Morwood Khang H. Dang Samuel S. Ornell Gabrielle Gostigian Cody M. Ramirez Hassan Mir 《Patient safety in surgery》2018,12(1):31
Introduction
Recent advances have led to the design of a new cephalomedullary nail, which aims to decrease the risk of failures in patients with intertrochanteric hip fractures by allowing for insertion of two interdigitating screws into the head segment. The goal of this study is to evaluate the safety and efficacy of this two-screw cephalomedullary nailing system.Patients/participants
Patients 18 years of age and older who underwent intramedullary nailing of their intertrochanteric femoral fracture using the InterTAN nailing system (Smith and Nephew, Memphis, TN) from 2012 to 2016 were included in this retrospective study which was performed at two urban certified level-1 trauma centers and one urban certified level-3 trauma center. The study data was collected through a retrospective chart review and review of the existing radiographic studies. Primary outcome measure was mechanical hardware failure and screw cutout. Secondary outcome measures included nonunion, malunion, medical and surgical complications.Results
A total of 264 patients were included in this analysis. Two patients (0.75%) were found to have a screw cut out requiring revision surgery. Two other revision surgeries were performed for malrotation (n?=?1) and malunion (n?=?1). Other implant-related complications occurred in 19 cases (7.9%), which included broken distal screws (n?=?9), distal screw loosening (n?=?8), and loose lag screws (n?=?2). There was a total of 10 (3.8%) surgical wound complications, including four deep and six superficial infections.Discussion
This modified cephalomedullary nail is a reliable, safe, and effective implant for management of intertrochanteric hip fractures. Surgical treatment of patients with intertrochanteric hip fractures can be performed in a safe fashion using this implant.11.
Mubashir Maqbool Wani Mubashir Rashid Riyaz Ahmad Dar Arshad Bashir Asif Sultan Iqbal Wani Shakir Rashid Mark O’Sullivan 《European journal of orthopaedic surgery & traumatology : orthopedie traumatologie》2016,26(2):223-230
Purpose
Although external fixation and flexible intramedullary nailing have been extensively used in the management of pediatric femur fractures, there are very few studies, which have compared the results. The purpose of the study was to compare the results of external fixation and flexible intramedullary nailing in pediatric femur fractures.Methods
Two groups of patients were treated by external fixator (EF) and flexible intramedullary nailing (FIN) over two different but successive time periods and results compared. The first group (EF) consisted of 45 patients, and the second group had 50 patients.Results
The age in EF group ranged from 6 to 14 years (average 9.93 years), and the age in FIN group ranged from 6 to 11 years (average 7.66 years). In the EF group, fixator was removed at an average of 12.23 weeks. In the FIN group, radiographic union was evident at an average time of 10.06 weeks. Pin-site infection was common in EF group. One patient had a re-fracture in EF group, and one patient had to be re-operated in FIN group after he developed anterior angulation of more than 30°.Conclusion
We believe that it is the discretion of the surgeon to operate on the femur fracture using either of the treatment modalities. Further randomized studies need to be conducted between these two treatment modalities.12.
P. Persiani M. Gurzi O. Moreschini G. Di Giacomo C. Villani 《Musculoskeletal surgery》2017,101(1):19-23
Purpose
The current techniques used to lock distal screws for the nailing of long bone fractures expose the surgeons, radiologists and patients to a hearty dose of ionizing radiation. The Sureshot? Distal Targeting System is a new technique that, with the same results, allows for shorter surgery times and, consequently, less exposure to radiation.Materials and methods
The study was performed on 59 patients (34 males and 25 females) with a simple humerus fracture diagnosis, type 1.2.A according to the AO classification, who were divided into two groups. Group 1 was treated with ante-grade intramedullary nailing with distal locking screws inserted with a freehand technique. Group 2 was treated with the intramedullary nail using the Sureshot? Distal Targeting System. Two intra-operative time parameters were evaluated in both groups: the time needed for the positioning of the distal locking screws and the time of exposure to ionizing radiations during this procedure.Results
Group 2 showed a lower average distal locking time compared to group 1 (645.48″ vs. 1023.57″) and also a lower average time of exposure to ionizing radiation than in group 1 (4.35″ vs. 28.96″).Conclusion
The Sureshot? Distal Targeting System has proven to be equally effective when compared to the traditional techniques, with the added benefits of a significant reduction in both surgical time and risk factors related to the exposure to ionizing radiation for all the operating room staff and the patient.13.
Introduction
We studied the safety and incidence of complications from the treatment of gunshot-induced femur diaphysis fractures with locked intramedullary nailing in comparison to external fixation.Methods
Patients who had femoral diaphysis fracture operations due to gunshot injuries (107 femurs of 99 patients) between 2003 and 2014 were retrospectively reviewed, and 66 femurs of 60 patients were place into two groups (Group A: intramedullary nailing—38 femurs of the 36 patients; Group B: external fixator—28 femurs of 24 patients). The mean follow-up was 76.3 months (22–131). The study outcomes were patient complications, infection rate, union time, need for secondary surgery, functional assessment with lower extremity functional scale, and radiological evaluation with orthoroentgenograms.Results
The mean age of the patients was 37.3 ± 7.4 years in Group A and 39 ± 6.1 years in Group B. There was no significant difference between the two groups in age, gender or follow-up. There were two deep infections (5.2%) in Group A and one deep infection (3.5%) in Group B. Delayed union was observed in four patients (10.5%) in Group A and in two patients (7.1%) in Group B. There was one non-union (2.6%) and one non-union (3.5%) in Group A and Group B, respectively. There was no significant difference between the two groups in incidence of union, delayed union or deep infection. The mean union time was 3.1 ± 2.5 months in Group A and 5.8 ± 1.4 months in Group B. The union time was significantly lower in the intramedullary nailing group (p = 0.023). There were no significant differences between the two groups in regards to radiological and functional evaluation.Discussion
This study showed similar complication rates and functional results both for external fixator and intramedullary nailing for the treatment of femoral diaphysis fractures due to gunshot injuries.Level of evidence
Level 3 retrospective comparative clinical study.14.
Alexander Eickhoff Maximilian Fischer Florian Gebhard Christian Ehrnthaller 《Der Unfallchirurg》2018,121(10):810-816
Background
Operative treatment of clavicle fractures by intramedullary nailing with titanium elastic nailing (TEN) has been established as an alternative to plate osteosynthesis for many years. The main complication after TEN osteosynthesis is nail migration. The goal of this study was evaluation of predictors for medial nail migration and comparison with plate osteosynthesis.Material and methods
A retrospective analysis of electronic patient charts, surgical protocols and radiographs of all operatively treated clavicle shaft fractures between 2010–2014 (n = 141) was performed. When evaluating the patient charts and the surgical protocols special attention was paid to the fracture type, the duration of the operation, the need for an open reduction and the onset of complications as well as the duration until implant removal. Radiographs were analyzed concerning the implant location and an implant migration.Results
Surgery time (39 vs. 83?min) as well as the time to implant removal (226 vs. 495 days) were significantly reduced (p = 0.00), while complication (39% vs. 21.4%) as well as reoperation rates (15% vs. 7.1%; p = 0.033) were increased in TEN compared to plate osteosynthesis. The main complication was medial nail migration. The following predictors regarding medial migration could be identified: open or closed reduction (p = 0.021), multifragmentary fractures (p = 0.049), oblique fractures (p = 0.08) and TEN thickness (33% at 2?mm, 0% at 3?mm).Discussion
Advantages of TEN are a shorter surgery time as well as a shorter duration until implant removal. The TEN osteosynthesis led to a significantly increased complication rate, with nail migration representing the major reason. When predictors for medial TEN migration are considered, type B and C fractures can also be sufficiently treated by a large diameter TEN.15.
A. Pautasso S. Lea A. Arpaia G. Ferrero E. Bellato F. Castoldi 《Musculoskeletal surgery》2018,102(1):67-74
Background
Proximal and shaft humeral fractures are very common worldwide; surgical treatment can be a viable option to reduce limb immobilization and to allow the patient an earlier return to daily activities. The aim of our study was to evaluate the outcomes of patients treated with intramedullary nail in our Institute from January 2010 to December 2016.Materials and methods
This is an observational cohort study. Inclusion criteria were: traumatic proximal and diaphyseal humeral fractures treated with antegrade nail; a minimum follow-up of 6 months. We evaluated the fracture healing time, the functional recovery (using the Constant score) and postoperative complications (need of blood transfusion, infections and need of re-intervention). The t test was used for statistical analysis.Results
Ninety-five patients were included (20 proximal and 75 diaphyseal fractures). Bone callus formation was evident a mean of 57 days after surgery. In all patients, there was an improvement in the functional recovery over time, but those younger than 65 years had better outcomes. The type of fracture and patients’ gender did not affect these results at one and 6 months of follow-up. In 18 cases, blood transfusions were needed; infections never occurred; finally, revision surgery was performed in 10 cases (two reverse total shoulder arthroplasties, one open reduction and internal fixation with plate and screws and seven nail removals for intolerance).Conclusion
In our study, intramedullary nail proved to be a minimally invasive technique with a rapid improvement in range of motion, an earlier rehabilitation and acceptable pain.16.
Jason Wong Jared M. Newman Konrad I. Gruson 《Journal of orthopaedics and traumatology》2016,17(2):113-122
Background
While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been advocated as an effective and less invasive surgical technique. The purpose of this study is to elucidate the demographics, outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures.Materials and methods
Multiple computerized literature databases were used to perform a systematic review of English-language literature. Studies that met our stated criteria were further assessed for the requisite data, and when possible, similar outcome data were combined to generate frequency-weighted means.Results
Fourteen studies with 448 patients met our inclusion criteria. The frequency-weighted mean age was 64.3 years, and mean follow-up was 22.6 months. Females accounted for 71 % of the included patients. Three-part fractures (51 %) were most commonly treated. The overall frequency-weighted mean Constant score was 72.8, and American Shoulder and Elbow Surgeons (ASES) score was 84.3. Frequency-weighted mean forward elevation, abduction, extension, and external rotation were 137.3°, 138.4°, 33.8°, and 43.1°, respectively. The Constant score for two- and three-part fractures was significantly higher than for four-part fractures (p = 0.007 and p = 0.0009, respectively). The reoperation rate for two-, three-, and four-part fractures was 13.6, 17.4, and 63.2 %, respectively.Conclusions
Intramedullary nailing of acute, displaced two- and three-part proximal humerus fractures yields satisfactory clinical outcomes, although reoperation and complication rates remain high. Use of this implant for four-part fractures cannot be recommended until further clinical studies with larger patient numbers are available.Level of evidence
Level IV, Systematic review.17.
Fuchs T Stange R Schmidmaier G Raschke MJ 《Archives of orthopaedic and trauma surgery》2011,131(10):1419-1425
Background
The use of antibiotic-coated implants may reduce the rate of infection and facilitate fracture healing after surgical treatment of tibial shaft fractures. A new biodegradable gentamicin-loaded coating of an implant (UTN PROtect®) was CE-certified in August 2005. In this prospective, non-randomized case series, we investigated the clinical, laboratory and radiological outcomes of 21 patients who underwent surgical treatment in closed or open tibial fractures, as well as revisions with the UTN PROtect® gentamicin-coated intramedullary nail.Methods
Of 21 patients (13 men, 8 women), 19 completed the 6-month follow-up. The study population included patients with complex tibial fractures and late revision cases. Clinical outcomes comprised adverse events, including infections and the SF-36 physical score. Laboratory outcomes, including C-reactive protein and leukocyte count as inflammatory markers, haemoglobin and serum gentamicin, were measured at baseline and up to 6 months post operatively. Radiographic assessments of fracture healing and weight-bearing capacity were determined at 5 weeks, 3 and 6 months after surgery.Results
No implant-related infections occurred; one patient had superficial wound healing problems. Mean C-reactive protein levels remained below 5 mg/L throughout the study, with a peak at 4–7 days after surgery (4.4 mg/L; range 0.5–16.1 mg/L). Leukocyte counts and haemoglobin levels did not vary over time during the study. The mean SF-36 physical score at 6 months was 42.6 (range 19.4–56.7). Radiographic union defined as three or four bridged cortices was achieved in 11 patients (58%) after 6 months. The remaining eight patients showed partial fracture healing with one or two bridged cortices. Additionally, 13 patients (68%) demonstrated full weight-bearing capacity after 6 months.Conclusions
The use of the UTN PROtect® intramedullary nail was associated with good clinical, laboratory and radiological outcomes after 6 months. These preliminary results support the use of gentamicin-coated implants as a new potential treatment option for the prevention of infection in trauma patients and in revision cases.Level of Evidence
Level II.18.
Sebastian Lotzien Valentin Rausch Thomas Armin Schildhauer Jan Gessmann 《BMC musculoskeletal disorders》2018,19(1):448
Background
Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications.Methods
We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating.Results
Between 2002 and 2017, we identified 40 patients with a mean age of 65.4?years (range 34–91?years) who met the inclusion criteria. At a mean follow-up period of 26.3?months (range 6–173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63?months (± 12.4?months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery.Conclusions
The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.19.
Introduction
The anatomy of the distal tibia accounts for reduced biomechanical stability and higher complication rates when treating distal tibiofibular fractures with an intramedullary tibia nail (IMTN). The goal of this study was to identify variables that affect the stability of IMTN. We assessed the value of additional fibular fixation, angular stable interlocking screws (ASLS) and multiplanar screw configuration in IMTN.Patients and methods
A retrospective cohort study was performed including 184 distal tibial fractures and associated fibula fracture treated with IMTN. Relevant demographic, fracture-related (type and level of the tibia and fibula fracture) and operative variables (depth of the nail, screw type and configuration, use of polar screws, fibular fixation) were studied. Coronal and sagittal alignment was assessed directly and 3–6 months after IMTN. Loss of reduction (LOR) was classified as 5–9° or ≥10°.Results
48.4% of the patients showed ≥5° LOR in one or both planes. Coronal LOR 5°–9° significantly correlated with low tibial fractures (p = 0.034), AO/OTA type 43 distal tibial fractures (p = 0.049), and sagittal LOR 5°–9° (p = 0.015). Although sagittal LOR 5°–9° was associated with fibular fractures (non-fixated suprasyndesmotic, p = 0.011), conversely we could not demonstrate the added value of (suprasyndesmotic) fibula fixation in IMTN. Coronal LOR ≥10° significantly correlated with AO/OTA type 43 distal tibial fractures (p = 0.009). In contrast to multiplanar configuration, we found a clear benefit of ASLS in distal IMTN locking.Conclusions
The level of the tibial fracture (AO/OTA type) and (suprasyndesmotic) fibular fractures were the main determinants of LOR after IMTN. ASLS was found to increase the stability of IMTN. Due to heterogeneity, however, we could not demonstrate the value of fibular fixation in IMTN. Therefore, a future prospective study with uniform treatment strategy for IMTN of distal tibiofibular fractures, with or without fixation of the fibula, is mandatory.20.