Oxygen saturation during reaming and intramedullary nailing of the femur.

Oxygen saturation was monitored during the reaming and intramedullary nailing of 15 femoral fractures (three impending) to assess the relationship between intramedullary reaming and nailing and the production of hypoxemia. There were no statistically significant drops in oxygen saturation during this procedure in either the fractured or intact (impending fractures) femora.     

Porosity of rat femora following intramedullary reaming and nailing

The present study evaluated cortical porosity and thickness of intact rat femora 12 weeks after intramedullary reaming and nailing. The right femora were reamed and received either flexible polyacetal nails or rigid stainless steel nails. A third group was reamed but not nailed. The left femora were used as controls. The anterior cortical wall was analyzed at the mid-diaphyseal level. Neither reaming nor reaming combined with nailing influenced porosities with a diameter less than 10 microns. For larger pores, polyacetal nailing doubled the porosity, whereas steel nails increased porosity by a factor of 4.5. A slightly increased porosity was observed for the reamed group. Reduced cortical thickness was found in both nailed groups, whereas cortical thickness was increased in the reamed group compared with the control side. Implantation of rigid and flexible intramedullary nails in rat femora increased porosity along the anterior cortical wall.     

Effects of intramedullary reaming and nailing of rat femur. A mechanical and chemical study.

This study was undertaken to explore the association between mechanical and chemical effects of intramedullary reaming and nailing. The right femora of 80 rats were reamed and nailed with steel nails. Forty rats were evaluated from 3 days to 24 weeks postoperatively. The other 40 rats had the nail removed after 12 weeks, and they were then followed from 3 days to 24 weeks after nail extraction. Evaluation consisted of in vivo strain recording, geometric measurements, mechanical three-point bending test, and chemical analyses of hydroxyproline and calcium contents. Reaming and nailing caused immediate weakening of the bone as measured by in vitro mechanical tests, but within 3 weeks the mechanical properties were fully restored, whereas in vivo strain remained reduced throughout the experimental period in rats with nails. Removing the nail increased in vivo strain to a level close to that of the intact femur. Remodeling of the bone resulted in greater external anteroposterior diameter, cross-sectional area, area moment of inertia, and amount of hydroxyproline and calcium in the operated on femur as compared with the intact side. This indicates that the repair processes resulted in greater bone mass of the operated on femur than of the intact femur. Thus, there is evidence that nailing techniques effectively assist tissues by repair and remodeling.     

Flexible intramedullary nailing of subtrochanteric fractures of the femur. A multicenter analysis

In a retrospective, multicenter analysis, 79 subtrochanteric fractures of the femur were treated with flexible intramedullary nails. Seventy fractures were traumatic in origin, three were pathologic, and six occurred in spinal cord patients. All of the fractures healed, and there were no fixation failures. Thirteen patients (16%) required adjunctive internal fixation, bone grafts, or postoperative traction. Shortening greater than 1 cm occurred in four patients (5%). Reoperation with one week of surgery was necessary in eight patients (10%). The single greatest complication was knee complaints, which occurred in 17 patients (21.5%). However, only six of these patients required revision prior to fracture union. In one patient a deep wound infection developed, which eventually healed without evidence of osteomyelitis. All patients who were ambulatory before their fracture were able to bear weight.     

Effects of intramedullary reaming and nailing of rat femur: A mechanical and chemical study

This study was undertaken to explore the association between mechanical and chemical effects of intramedullary reaming and nailing. The right femora of 80 rats were reamed and nailed with steel nails. Forty rats were evaluated from 3 days to 24 weeks postoperatively. The other 40 rats had the nail removed after 12 weeks, and they were then followed from 3 days to 24 weeks after nail extraction. Evaluation consisted of in vivo strain recording, geometric measurements, mechanical three-point bending test, and chemical analyses of hydroxyproline and calcium contents.

Reaming and nailing caused immediate weakening of the bone as measured by in vitro mechanical tests, but within 3 weeks the mechanical properties were fully restored, whereas in vivo strain remained reduced throughout the experimental period in rats with nails. Removing the nail increased in vivo strain to a level close to that of the intact femur. Remodeling of the bone resulted in greater external anteroposterior diameter, cross-sectional area, area moment of inertia, and amount of hydroxyproline and calcium in the operated on femur as compared with the intact side. This indicates that the repair processes resulted in greater bone mass of the operated on femur than of the intact femur. Thus, there is evidence that nailing techniques effectively assist tissues by repair and remodeling.     

Successful use of reaming and intramedullary nailing of the tibia

The records and radiographs of 87 patients with 88 fractures of the tibial diaphysis who underwent intramedullary reaming and nailing were retrospectively reviewed. The mean patient age was 37 years. Seventy fractures were closed, and 18 were open. The indications for nailing were failures of closed treatment (n = 48), nonunions (n = 24), multiple injuries (n = 14), and fixation of osteotomy (n = 2). Seventy-six patients with 77 nails who were followed for an average of 26.2 months were studied. For acute fractures, the average time to complete clinical and radiographic union was 5.3 months. For established nonunions, the average healing time was 9 months. The only fractures that failed to unit were nonunions developing from previously open Type III injuries. Angular deformities greater than 5 degrees did not occur. Significant tibial shortening occurred in only one fracture. Decreased motion in the ankle or knee was present in six patients. Major complications as a result of tibial nailing occurred in three patients: two deep infections and one patellar tendon rupture. Minor complications included 10 patients with pain at the nail insertion site necessitating removal in four patients, three patients with transient sensory peroneal nerve dysesthesias, and one patient with a superficial wound infection that cleared with local care. Nine patients required reoperation. Intramedullary reaming and nailing of the tibia can be used advantageously in the treatment of difficult fractures of the tibial shaft and their sequelae. Attention to the technical details of nail insertion will minimize the most frequent complications.     

Assessment and correction of femoral malrotation following intramedullary nailing of the femur

Rotational deformity is a more common problem than one might expect in the treatment of femoral shaft fractures. This review presents two cases of femoral malrotation following intramedullary nailing of the femur. The presentation, importance of early recognition, investigation with a CT scan, and the technique of correction is discussed in detail. The importance of intra-operative assessment to avoid this complication is highlighted and a review of the current literature on this problem and its treatment is presented.     

Treatment of tibial fractures by reaming and intramedullary nailing

We treated 112 fractures of the tibia by manipulative reduction, reaming of the medullary canal, and fixation of the fracture fragments with an intramedullary nail. Seventy-six of the fractures were acute, and eight of these were second or third-degree open fractures. The other thirty-six fractures had a non-union, osteotomy for malunion, or failure of other types of treatment. Follow-up of 100 fractures showed union in all but one, which was in a drug abuser who had an amputation due to infection. The main complication was infection, which was successfully treated in six of seven fractures. The method of treatment, employing either closed or open technique and recently making use of interlocking bolts to stabilize one or both principal fracture fragments on the nail, is an excellent one for unstable acute fractures and for secondary procedures in fractures that are not associated with infection. The infection rate was increased with the open surgical technique. The few contraindications to its use are described.     

Coagulation, fibrinolysis and cytokine responses to intramedullary nailing of the femur: An experimental study in pigs comparing traditional reaming and reaming with a one-step reamer-irrigator-aspirator system

Introduction

Operations in trauma patients represent a second insult and the extent of the surgical procedures influences the magnitude of the inflammatory response. Our hypothesis was that a reamer-irrigator-aspirator (RIA) system would cause a lesser inflammatory response than traditional reaming (TR).

Materials and methods

Coagulation, fibrinolysis and cytokine responses were studied in Norwegian landrace pigs during and after intramedullary nailing (IMN) with two different reaming systems using ELISA and chromogenic peptide substrate assays. The TR (n = 8) and the RIA (n = 7) reaming systems were compared to a control group (n = 7). The animals were followed for 72 h. Arterial, mixed venous and femoral vein blood were withdrawn simultaneously peroperatively and until 2 h after the nail was inserted for demonstration of local, pulmonary and systemic activation of the cascade systems. At 6 h, 24 h, 48 h and 72 h postoperatively arterial blood samples were withdrawn.

Results

Significantly procedure-related increased levels were found for thrombin-antithrombin (TAT) and tissue plasminogen activator (t-PA) in the TR group and TAT in the RIA group. The local and the pulmonary activation of coagulation and fibrinolysis were more pronounced in the TR than in the RIA group, the difference reached significance for plasminogen activator inhibitor-1 (PAI-1) (arterial blood). The cytokine response, mainly represented by IL-6 increase, was more pronounced in the TR than the RIA group, and was significant for IL-6 in femoral vein blood. The arterial levels of IL-6 exceeded the mixed venous levels indicating an additional pulmonary activation of IL-6. Two animals in the TR group, who died of pulmonary embolism (PE) prior to planned study end point, had a more pronounced response compared to the rest of the TR group.

Conclusion

A procedure-related coagulation and fibrinolytic response was demonstrated in both reaming groups, with more pronounced response in the TR than in the RIA group. Elevated levels of cytokines were demonstrated related to reaming and nailing, with significantly higher IL-6 levels in the TR than in the RIA group.     

Infection after intramedullary nailing of the femur

BACKGROUND: The management of infection after intramedullary nailing of the femoral shaft fracture remains a challenge to orthopedic surgeons. The dilemma confronting surgeons concerns the removal or retention of the nail in the presence of infection. METHODS: The authors treated 23 infections after intramedullary nailing for femoral fractures. All fractures were unhealed at presentation. All patients were followed for at least 1 year after the infection. Acute infection occurred in 13 patients, subacute infection in 5, and chronic infection in 5. The patients were divided into two groups on the basis of the method of the initial treatment. In group I (12 patients), the intramedullary nails were retained, and there were 11 men and 1 woman, with an average age of 36 years (range, 15-55 years). In group II (11 patients), the nails were removed at the time of debridement and the fractures were stabilized with external fixation, and there were nine men and two women, with an average age of 44 years (range, 25-69 years). RESULTS: In group I, all fractures healed within an average period of 9 months (range, 5-15 months) after surgical debridement. There was no recurrence of infection at an average follow-up of 25 months (range, 12-76 months). In group II, seven fractures healed within an average of 10 months (range, 4-24 months) after treatment. At an average follow-up of 33.8 months (range, 12-79 months), infected nonunion was noted in two patients. More complications occurred in group II patients in comparison with group I patients. Limited range of motion of the knee joint was usually encountered if a fracture was stabilized with external fixation for a prolonged period of time. CONCLUSION: Retention of the intramedullary nail is performed if the fixation is stable and the infection is under control. External fixation is most suitable for uncontrollable osteomyelitis or infected nonunion. Staged bone grafting is usually necessary when a bone defect is present.     

The effects of reaming and intramedullary nailing on fracture healing

Most closed fractures of the shaft of the femur and tibia can be treated successfully with internal fixation with medullary or interlocking nails. Unlike plate fixation, intramedullary nailing does not provide absolutely rigid fixation, so that some motion at the fracture site exists. The process of reaming causes circulatory disturbances in the inner two-thirds of the diaphyseal cortex. However, this does not impede the formation of external callus. The parts of bone that have sustained vascular damage by trauma or surgery are revascularized. Delay in the healing process due to disruption of the blood supply to fracture fragments is not known. The majority of patients are able to weight-bear a few days after surgery.     

Pudendal nerve palsy complicating intramedullary nailing of the femur.

A prospective study of 106 patients who had static interlocking nailing of the shaft of the femur was performed to determine the relationship between the duration and magnitude of intraoperative traction and the development of a pudendal nerve palsy. A strain-gauge, mounted in the countertraction post, measured the magnitude of the perineal pressure over time. All nailings were performed with the patient in the supine position. Postoperatively, the patients were interviewed by one of us, who had been blinded from the results of the recordings of intraoperative pressure, for a history of erectile dysfunction and changes in labial, scrotal, or penile sensation. A light-touch sensory examination of the genitalia was performed on all patients. Ten patients (six men and four women) had a pudendal nerve palsy: nine had sensory changes only, and one complained of erectile dysfunction. The symptoms had resolved at the three-month follow-up evaluation in all patients except one man who complained of dysesthesia six months postoperatively. The patients in whom a palsy did not develop had been positioned on the fracture-table and the perineal post for an average of 2.6 hours (range, 1.4 to 5.2 hours) compared with an average of 2.8 hours (range, 2.0 to 4.3 hours) for those in whom a palsy did not develop (p = 0.15). The magnitude of the total traction forces averaged 34.9 kilogram-hours for the patients who did not have a palsy compared with 73.3 kilogram-hours for those who did (p < 0.03). Adduction of the hip, as well as manipulations for reduction of the fracture, significantly increased the traction forces.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ender nailing of acute fractures of the humerus. A study of closed fixation by intramedullary nails without reaming

A prospective study of closed intramedullary fixation of fractures of the shaft of the humerus, using Ender nails, was performed over a six-year period. Eighty-nine fractures in eighty-eight patients were treated with no immobilization postoperatively. Three patients were lost to follow-up. Eighty-five of the remaining eighty-six fractures healed, the average time to clinical union being 7.2 weeks. Non-union of one fracture occurred and there were no infections or malunions. Six of the nine preoperative and two postoperative radial-nerve palsies were lesions in continuity and healed spontaneously. The remaining three radial nerves that had been severed by a missile needed further attention. One of the nails backed out in eight patients, requiring revision in five. The average lack of complete extension of the elbow was 4 degrees and flexion of the elbow was 132 degrees. Abduction of the shoulder averaged 91 degrees; external rotation, 54 degrees; and internal rotation, 68 degrees. We conclude that closed intramedullary Ender nailing can be performed safely and effectively in selected fractures of the humeral shaft. However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment.     

Intraarticular heterotopic ossification in the knee following intramedullary nailing of the fractured femur using a retrograde method.

The cases of a forty-five-year-old woman and a twenty-year-old man who developed severe intraarticular and periarticular heterotopic ossification around the knee following intramedullary nailing of a femur fracture using a retrograde technique. The association of musculoskeletal heterotopic ossification with closed head injuries seems well established and can occur in and around the knee following retrograde intramedullary nailing. This complication may occur more often than has been reported.