Titanium elastic nails for pediatric tibial shaft fractures

Purpose  The purpose of our study was to investigate the safety and efficacy of elastic stable intramedullary nailing for unstable pediatric tibial shaft fractures using titanium elastic nails (TENs). To our knowledge, this is the largest series reported in the literature of this specific fixation technique. Methods  We reviewed all children with tibial shaft fractures treated operatively at our tertiary care children's hospital to find those patients who underwent fixation with TENs. Between 1998 and 2005, we identified 19 consecutive patients who satisfied inclusion criteria. The average age of the patients in our series was 12.2 years (range 7.2–16 years), and mean follow-up was 15.7 months (range 6–28 months). Patient charts and radiographs were retrospectively reviewed to gather the clinical data. Outcomes were classified as excellent, satisfactory, or poor according to the Flynn classification for flexible nail fixation. Results  All patients achieved complete healing at a mean of 11.0 weeks (range 6–18 weeks). At final follow-up, mean angulation was 2° (range 0°–6°) in the sagittal plane and 3° in the coronal plane (range 0°–9°). Five patients (26%) complained of irritation at the nail entry site; there were no leg length discrepancies or physeal arrests as a result of treatment. Two patients required remanipulation after the index procedure to maintain adequate alignment. According to the Flynn classification, we had 12 excellent, six satisfactory, and one poor result. Conclusion  Although the indications for operative fixation of pediatric tibial shaft fractures are rare, occasionally surgical treatment is warranted. Based on our results, elastic stable intramedullary nailing with titanium elastic nails is an effective surgical technique which allows rapid healing of tibial shaft fractures with an acceptable rate of complications. No authors received any financial support or compensation for this study.     

Treatment for distal tibial fractures with intramedullary nails and blocking screws

Introduction

This retrospective study was designed to define the technical details for the treatment for distal tibial fractures with intramedullary nails and blocking screws, and to assess the effectiveness of the method based on our clinical practice.

Materials and methods

Twenty-one patients in whom adequate reduction could not be achieved with distal tibial intramedullary nailing, blocking screws were inserted under fluoroscopy. Blocking screws were inserted from the medial side in eighteen patients, in the medial and anterior side in one patient, and in the posterior side in two patients. Patients were followed up clinically and radiologically. Fracture alignment and union were monitored by X-ray, and complications were noted.

Results

Neutral alignment with union in both coronal and sagittal plane was achieved in all patients. None of the patients experienced infection. The only complication of the blocking screws was fissure in one patient in the location of the screw during surgery. In another patient, nonunion was developed with 8° flexion angle. Union was achieved in this patient at 9?months with auto grafting.

Conclusion

Blocking screws helped to achieve better reduction and alignment with intramedullary nailing of distal tibial fractures by decreasing the effective diameter of the medullary canal. The use of blocking screws enabled to use the intramedullary nailing as an alternative while treating distal tibial fractures.     

Angle stable locking nails versus conventionally locked intramedullary nails in proximal tibial shaft fractures: a biomechanical study

Introduction  

A tibial nail with fixed-angle locking screws intends to combine the advantages of angular stability and intramedullary stabilization in extraarticular proximal tibial fractures. The goal of this study is to analyze if the angle stable tibial nail (ASN) is biomechanically more stable than an established conventional standard nail (CN).     

Intramedullary locking nails for femoral shaft fractures in elderly patients

Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient.     

In-vitro evaluation of fatigue failure of locking screws in solid tibial nails

Unreamed nailing with solid tibial nails is an accepted method of treatment for open tibial shaft fractures up to grade III and of closed tibial fractures with severe soft tissue damage. However, fatigue failure of the distal locking bolts is a frequent complication. We report a mechanical study investigating the fatigue limit of six different types of locking bolts used in solid tibila nails (Biorigid Tibial nail/aap, UTN/ace, STN/Howmedica, TLN/Howmedica, delta R & T Tibial nail/Smith & Nephew, AO/ASIF UTN/Synthes). Our results prove a direct correlation between the bolt's diameter and mechanical properties. Further more we found that bolts with a continuing thread were weaker than bolts of the same diameter with only a short thread and an increased diameter at the nail's aperture. Our results suggest that mobilization with half of the average body weight (350N) allows osseous consolidation without fatique failure of any of the tested locking bolts. Some of the tested locking bolts may even withstand full wieght-bearing in a physiological walking cycle, but will not withstand the stress of a running cycle.     

Intramedullary locking nails in the management of femoral shaft fractures

Intramedullary locking nails have proved to be of considerable advantage when treating complex, comminuted or segmental femoral shaft fractures. We have reviewed 117 patients with 120 femoral shaft fractures treated with the Strasbourg device. These included 20 compound fractures, 13 pathological fractures and two non-unions. Rehabilitation and union rates have been very satisfactory and there have been no serious infections in the series. Comminution of the proximal femur has occurred in six patients and there have been three femoral neck fractures, but all of these have healed without further complications.     

阻挡螺钉技术在闭合复位髓内钉内固定治疗股骨干骨折中的应用

[目的]探讨和评估阻挡螺钉技术在闭合复位、髓内钉内固定治疗股骨干骨折中的临床疗效和注意事项.[方法]2006年10月～2009年2月,应用闭合复位、髓内钉内固定结合阻挡螺钉技术治疗股骨干骨折15例,根据AO分型:3281型1例,3282型2例,3283型3例,32C1型5例,32C2型4例.骨折部位:股骨干峡部9例,中下1/3交界处6例.术后通过随访评估骨折复位质量以及愈合情况.[结果]本组15例共应用阻挡螺钉20枚,其中13例获得随访,随访时间12～28个月,平均14.2个月.股骨骨折对线在冠状面成角平均为1.5°,矢状位成角平均2.1°.所有骨折均获得骨性愈合,平均愈合时间为5.8个月.阻挡螺钉及整个内固定系统位置稳定,未出现内固定物松动、变形、移位、断裂等并发症.[结论]阻挡螺钉技术在闭合复位、髓内钉治疗股骨干骨折中能够有效提升骨折复位的质量、增加骨折固定的稳定性,从而扩大髓内钉的应用范围.     

分叉式交锁髓内钉治疗肱骨干骨折

目的报告肱骨分叉式交锁髓内钉(BLIN型钉)治疗肱骨干骨折的疗效。方法用BLIN型钉治疗肱骨干骨折20例,钢板治疗肱骨干骨折29例,分别从手术情况、并发症、生物力学、骨折愈合情况、功能恢复等方面进行比较。结果随访4～16个月,钢板组平均骨折愈合时间4.2月,术后桡神经麻痹4例,螺钉松动、钢板弯曲1例,骨不连2例。BLIN型钉组平均骨折愈合时间9.6月,术后无一例发生桡神经麻痹,无一例钢钉折弯或断裂,骨折愈合牢固可靠,功能恢复良好。结论肱骨分叉式交锁髓内钉治疗肱骨干骨折,虽然骨折愈合时间较钢板长,但其他方面均优于钢板。     

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。     

Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures

Background

Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking.

Methods

All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations.

Results

Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6–54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18–68 min) for tibial fractures and 55 min (range 47–150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity.

Conclusion

The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.     

Treatment of tibial shaft fractures by intramedullary locking nailing]

Authors analyzed consecutive series of 56 tibial shaft fractures (43 men and 13 women) treated by intramedullary locking nails in years 1993-2004. Age of patients ranged from 17 to 83 years (mean 38 years). The final result was analyzed in 51 patients (91%). The bone union was observed in 50 patients. Fractures united within 6 months in 45 patients (88%), between 8 and 15 months in 5 patients. Operative treatment of non-union was necessary in one patient. The fractures united in anatomical axis in 45 cases, small (less than 10 degrees) valgus deviation was noticed in four patients, whereas five patients with fractures localized in distal part of the tibia had 11-30 degrees valgus deviation. The limb length inequality more than 1 cm was noticed in one case. There was neither infection nor compartment syndrome. One patient died because of fatal pulmonary embolism.     

The use of Ender nails in fractures of the tibial shaft

Between November 1979 and January 1983, we treated fifty-one severe fractures of the tibial shaft with multiple intramedullary Ender nails. Thirty-six fractures were treated within two weeks after injury. Forty-one fractures united in less than four months and eight, in four to eight months. Only two were not united after eight months. An anatomical reduction was maintained in all but three of the fractures, in which the tibia shortened. Two tibiae united with an angulation of 7 degrees and one with 6 degrees, as measured in two planes. There were two infections, both after an open fracture. It has been our experience that Ender nails provide excellent rotational stability, allow early full weight-bearing, and markedly decrease the duration of need for immobilization. Ender nailing was of value both for the acute management of complicated high-energy fractures of the tibial shaft with extensive soft-tissue damage and as a salvage procedure to maintain reduction of a fracture when other techniques had failed.     

空心钉结合髓内钉固定治疗同侧胫骨平台伴胫骨干骨折

目的探讨空心钉结合髓内钉固定治疗同侧胫骨平台伴胫骨干骨折的方法和疗效。方法采用空心钉结合髓内钉固定治疗同侧胫骨平台伴胫骨干骨折12例,先以空心钉固定胫骨平台骨折,部分关节面粉碎塌陷较严重、怀疑合并半月板及韧带损伤者使用关节镜辅助探查及复位胫骨平台关节面,再以髓内钉固定胫骨干骨折。结果本组获平均17（8～33）个月随访,均获得骨性愈合,胫骨平台骨折平均愈合时间为12周,胫骨干骨折平均愈合时间为23周。疗效根据Lowa膝关节功能评价标准评定：优8例,良3例,可l例。结论空心钉结合髓内钉既有效固定了两处骨折。又充分保护了软组织,是治疗同侧胫骨平台伴胫骨干骨折的有效方法。     

Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws

OBJECTIVES: To describe the technique and results of using blocking screws and intramedullary nails to treat patients with fractures of the proximal third of the tibial shaft. DESIGN: Prospective. SETTING: Level I trauma centers. PATIENTS: Twelve consecutive patients treated with intramedullary nailing and blocking screws for fractures of the proximal third of the tibial shaft. INTERVENTION: Patients were treated with intramedullary nails and blocking screws. MAIN OUTCOME MEASURE: The alignment of fractures was determined using standard anteroposterior and lateral radiographs after surgery and at each follow-up examination. One patient was lost to follow-up. All other patients were followed at regular intervals until union or establishment of a nonunion. Changes in alignment and complications were noted. RESULTS: Postoperatively, all patients had less than 5 degrees of angular deformity in the planes in which blocking screws were used to control alignment. One patient had postoperative malalignment (6 degrees of valgus), but a lateral blocking screw to control valgus deformity was not used in this patient. One patient was lost to follow-up. Eleven patients were followed up to union (n = 10) or establishment of a nonunion (n = 1). Ten of eleven patients maintained their postoperative fracture alignment at their last follow-up examination (average follow-up of thirty-three weeks). One patient progressed from 6 degrees of valgus immediately after surgery to 10 degrees of valgus at union. This patient did not have a blocking screw to control valgus angulation. CONCLUSIONS: Blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.     

Treatment of the femoral and tibial fractures with Grosse and Kempf locking nails.

In a series of 104 femoral and 50 tibioendomedullary nailings using Grosse-Kempf (G-F) locking nails, 24% of femoral fractures and 12% of tibial fractures were comminuted; 48% of the patients had multiple injuries. The nail was locked at proximal and distal levels in 54% of the cases for the femur. Dynamization of the nail was carried out at an average of 12 weeks. Nonweight-bearing was imposed for both series from three weeks to three months. Bone healing was achieved before six months in 100% of tibial fractures. Following Thoressen criteria, the results of femoral cases were all excellent and good; the percentage reached 96% for tibial cases. The G-F nail is suitable for high-energy, comminuted fractures.     

The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails

Intramedullary nailing of metaphyseal fractures may be associated with deformity as a result of instability after fixation. Our aim was to evaluate the clinical use of Poller screws (blocking screws) as a supplement to stability after fixation with statically locked intramedullary nails of small diameter. We studied, prospectively, 21 tibial fractures, 10 in the proximal third and 11 in the distal third in 20 patients after the insertion of Poller screws over a mean period of 18.5 months (12 to 29). All fractures had united. Healing was evident radiologically at a mean of 5.4+/-2.1 months (3 to 12) with a mean varus-valgus alignment of -1.0 degree (-5 to 3) and mean antecurvatum-recurvatum alignment of 1.6 degrees (-6 to 11). The mean loss of reduction between placement of the initial Poller screw and follow-up was 0.5 degrees in the frontal plane and 0.4 degrees in the sagittal plane. There were no complications related to the Poller screw. The clinical outcome, according to the Karstr?m-Olerud score, was not influenced by previous or concomitant injuries in 18 patients and was judged as excellent in three (17%), good in seven (39%), satisfactory in six (33%), fair in one (6%), and poor in one (6%).     

Radiographic predictors of symptomatic locking screw removal after treatment of tibial fractures with intramedullary nails

IntroductionThe purpose of this study was to determine the radiographic parameters associated with symptomatic locking screw removal after intramedullary tibial nail insertion. Our hypothesis was that locking screws located closer to joints and those extending longer than the width of the bone result in more symptomatic implant removal.MethodsWe conducted a retrospective cohort study at our Level I trauma center. Seventy-five patients underwent surgical removal of symptomatic locking screws from 2007 to 2014 and were compared with a control group of 122 patients from the same time period who did not undergo symptomatic locking screw removal. Our main outcome measures were radiographic and demographic factors associated with implant removal.ResultsMultivariable regression indicated that a proximal locking screw that started anterolateral and was directed posteromedial was the strongest radiographic predictor of symptomatic removal (odds ratio [OR], 2.83; p = 0.03). An Injury Severity Score <11 (OR, 3.10; p < 0.001) and a body mass index <25 kg/m² (OR, 2.15; p = 0.02) were also associated with locking screw removal. The final prediction model discriminated patients requiring symptomatic locking screw removal with moderate accuracy (area under the receiver operating characteristic curve = 0.73).ConclusionsThe strongest radiographic predictor for symptomatic locking screw removal after tibial nail insertion was the direction of the most proximal locking screw. In contrast to previous research on retrograde femoral nails, tibial locking screws that were closer to the joints were not associated with an increased likelihood of symptomatic screw removal. Clinicians can use these data to help counsel patients regarding the likelihood of symptomatic screws and perhaps to help guide screw placement in cases with multiple options.     

Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union

Distal third tibial fractures are prone to non-union following tibial nail insertion. The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws. Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed. Our results showed that 80% of non-unions in distal third fractures had only one distal locking screw compared to 20% who had two distal locking screws. This is statistically significant (p<0.01). We therefore conclude that two distal locking screws are essential for distal third fractures.