Current treatment of infected non-union after intramedullary nailing.

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

The role of the intramedullary implant in limb lengthening.

Limb lengthening is now an accepted practice in orthopaedic surgery. The principles of distraction osteogenesis have become well established with the use of external fixators, utilizing both monolateral and ring fixators. Corticotomy technique, frame stability, lengthening rate and rhythm all contribute to the formation of bone regenerate and tissues. Complications are however common including pin-site infection, soft tissue tethering from the pins and wires resulting in pain, regenerate deformity from soft tissue forces or fracture following frame removal and patient intolerance of the frames during treatment. Surgical techniques have changed to try and minimise these complications. The use of intramedullary nails have been used in conjunction with an external fixator or inserted after lengthening has been achieved, to reduce fixator time and prevent regenerate deformity. Implant innovation has led to the production of intramedullary lengthening nails. The initial devices used ratchet mechanisms with rotation of the bone fragments to achieve lengthening (Bliskunov, Albizzia and ISKD). More accurate control of lengthening and a reduction in pain, resulting from the manual rotation of the leg required to achieve the ratchet progression, was achieved by the use of a transcutaneous electrical conduit powered by external high frequency electrical energy (Fitbone). The most recent implant uses an external remote controller which contains two neodymium magnets. These are placed over the nail on the skin and rotate which in turn rotates a third magnet within the intramedullary nail (Precice). This magnet rotation is converted by a motor to extend or retract the extendible rod. There are multiple nail sizes and lengths available, and early results have shown accurate control with few complications. With such promising outcomes the use of this lengthening intramedullary nail is now recommended as the implant of choice in femoral lengthening. This article is an historical account of the intramedullary device and the impact on limb lengthening.

Distal tibial fractures: evaluation of different fixation techniques.

PURPOSE: The purpose of this study was the comparison of the most commonly used surgical techniques (external fixation, intramedullary nailing, and plate fixation) for the treatment of distal tibial fractures (AO/OTA classification 42-A, B, C or 43-A, B1). METHODS: A retrospective cohort study of patients who underwent surgical treatment for distal tibial fractures between 1992 and 2011 was performed. RESULTS: A total of 93 patients (52 male/41 female) met inclusion criteria. Statistically significant differences were found regarding the consolidation time of the intramedullary-nailing (147.32 ± 91.16 days) and the plate-fixation group (135.75 ± 110.75 days) versus the external-fixation group (163.12 ± 96.79 days; P = 0.001; P = 0.01). Significant differences were also observed in the range of motion (ROM) of the ankle joint in the intramedullary-nailing and plate-fixation group versus the ROM in the external-fixation group (P = 0.044; P = 0.025). The overall complication rate was 13/93 (14 %). Out of 66 patients treated with intramedullary nailing, 8 (12 %) suffered from complications. Out of the 15 patients treated with plate and 12 patients with external fixation, 2 (13 %) and 3 (25 %) showed complications, respectively. CONCLUSION: Our results demonstrate advantages in terms of shorter mobilization time and a better ROM of the ankle joint for intramedullary nailing and plate fixation compared with external fixation. Due to our results, we suggest internal fixation (intramedullary nailing or plate fixation) whenever patient's condition and the local fracture situation allow it.

A minimally invasive fixation technique for selected patients with fifth metacarpal neck fracture.

OBJECTIVE: The objective of this study was to compare the short-term results of treatment of fifth metacarpal neck fractures using a minimally invasive surgical fixation technique and the gold standard splinting method in a selected patient group of office workers with high expectations. PATIENTS AND METHODS: Twenty-four male patients (mean age: 28 years, range: 18-46 years) satisfying the inclusion criteria were enrolled in the study in two groups: surgical treatment and splinting (U-shaped ulnar gutter) groups. Hygienic interactions during daily activities and the use of keyboard and pens were allowed in the posttreatment period. The Short Form-Disabilities of the Arm, Shoulder and Hand Score (DASH) questionnaire was used to assess patient satisfaction and functionality of the extremity on the 30th and 45th days. Joint ranges of motion were measured on the 45th day. Functional and radiological evaluation data were analyzed statistically. RESULTS: In the conservative treatment group, initial palmar angulation was measured to be 42.6°, whereas a mean of 13.5° was noted and metacarpal shortening of 5.6mm decreased to 2mm after treatment, respectively. In terms of total joint range of motion (ROM), flexion of the treated side was at 91.25% and extension at 92.5% when measured versus the healthy-side values at the final follow-up. The mean time for return to work in this group was 33.6 days. The mean Quick-DASH score on the 30th-day follow-up was 69.5, whereas it was 39.3 at the 45th-day follow-up. The radiological findings showed a correction of the mean palmar angulation from 43° to 8° at follow-up in the surgically treated group. The initial metacarpal shortening of 9.3mm improved to 0.5mm at final examination. In terms of total joint ROM, flexion of the treated side was at 94% and extension at 95.5% when measured versus the healthy-side values on the 45th-day follow-ups. The mean time for return to work was 3.9 days. The mean Quick-DASH score on the 30th-day follow-up was 2.96, whereas it was noted as 0.69 at the 45th-day follow-up. CONCLUSIONS: We recommend antegrade intramedullary K-wire fixation as a reliable method, which minimizes the functional loss and allows for early return to daily activities in office workers who sustained a fracture of the fifth metacarpal neck.

Overlapping intramedullary nailing after failed minimally invasive locked plating for osteoporotic distal femur fractures--Report of 2 cases.

Minimally invasive plate osteosynthesis (MIPO) using a locking plate has been widely used for distal femur fractures in the elderly with osteoporosis and yielded favourable results. However, implant failure and subsequent periplate fracture have still occurred owing to the controversy of concepts regarding locked plating. The treatment after failed MIPO in elderly patients is very challenging and has been not yet addressed definitely in the literature, although several options can be considered. We report the successful outcomes of two cases treated with overlapping intramedullary (IM) nailing for implant failure and periplate fracture after MIPO for osteoporotic distal femur fracture, along with simple tips of distal interlocking of IM nail.

Complications after interlocking intramedullary nailing of humeral shaft fractures.

INTRODUCTION: IM nails have gained popularity for stabilization of humeral shaft fractures (HSF). The initial enthusiasm was tempered by a number of specific complications and thus indications need to be re-evaluated. PATIENTS AND METHODS: This retrospective study includes 111 patients with HSF subjected to a treatment protocol of IM fixation with first and second generation of humeral nails. Antegrade approach was used in 105 (94.5%) and retrograde in 6 (5.5%) patients. Reaming was performed in 51 (45.9%) fractures. The study covers a period of 10 years. Mean follow-up time was 3.5 (1-6) years. This investigation is directed at technical errors and complications, especially those corrected by secondary surgery. RESULTS: We registered 52 (46.85%) intra-operative complications in 40 (36.04%) patients, on average 1.3 per patient. The most common were: distraction n=5 (4.5%), long proximal locking screws n=9 (8.1%), additional diaphyseal fracture n=7 (6.3%) and countersinking of the nail in the humeral head n=8 (7.2%). The number of postoperative complications was 40 (36.0%) related to 19 (17.1%) patients. Technical errors, such as distraction, longer nail and additional fractures have affected time to union and resulted in chronic shoulder pain. 36 (32.5%) secondary surgeries were needed to address these problems. When first generation nails are used, the intra-operative complication related risk increases 1.58 times, and the postoperative complication related risk is 1.67 times higher compared to second generation nails. According to Constant-Murley score excellent and very good functional results were achieved in 93 (83.78%) patients. While reaming did not influence the clinical results for both nail generations, overall better results were achieved with second generation nails. Postoperative shoulder pain has been registered in 18 (16.2%) patients. CONCLUSION: We registered a number of technical errors and complications, which we consider technique specific. The analysis and avoidance of these complications, related only to IM nailing of the humerus, will allow IM nails to successfully bridge the gap between functional bracing and plating.

Functional and radiological outcome of Intramedullary nailing vs. plate fixation for humeral shaft fractures. Does treatment method bring any difference?

BACKGROUD: Operative Management of Humeral shaft fractures may be accomplished with the help of Plate fixation or IM Nails. Controversy exists as to which modality is superior to the other in terms of fewer complications and better functional and radiological outcome. OBJECTIVE: To compare the differences in radiological and functional outcome of humeral shaft fractures managed by platefixation and antegrade intramedullary nails. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of Patients managed surgically for uncomplicated humeral shaft fractures between 2007 and 2012. The patients were followed up for one year at clinic, and radiographs and clinical assessment were used to complete the Quick Disabilities of the Arm, Shoulder and HandQuestionnaire. SPSS 19 was used for statistical analysis. RESULTS: Of the total 61 patients, 39(64%) underwent plating and 22(36%) had intramedullary nailing. There was no significant difference in terms of mean age and mean duration of surgery in the two groups (p>0.05 each). Also, no significant difference was noted in the duration of healing with either of the two methods (p>0.05). Mean Questionnaire score for plating was 23.9±17.7, while for intramedullary nailing it was 21.7±19.8 (p>0.05). CONCLUSIONS: There was no significant difference in the radiological and functional outcome of patients in the two groups.

Operative Treatment of Traumatic Humeral Shaft Fracture: Comparision of Interlocking IM Nailing and Plate Fixation by Posterior Approach

PURPOSE: To compare the results and complications of interlocking IM nailing and plate fixation by posterior approach in the treatment of traumatic humeral shaft fracture MATERIALS AND METHODS: From March 1997 to March 2003, 49 patients undergone operation due to traumatic humeral shaft fracture. Follow-up was over one year. 28 patients operated with interlocking IM nailing initially and 21 operated with plate fixation by posterior approach prospectively. Statistics were compared using clinical and radiological outcomes and complications. RESULTS: Radiologically, bone union was observed after an average of 14.3 weeks in IM nailing, and 11.7 weeks in plate fixation. So plate fixation showed earlier bone union (p=0.012). Nonunion occurred in 4 cases (14.3%) operated with IM nailing, and 1 case (4.8%), that was open shaft fracture, with plate fixation. Nonunion occurred more frequently when operated by IM nailing. 6 cases showed limitation of shoulder movement due to damage of the rotator cuff by IM nail entry site. 1 case showed radial nerve palsy, and 1 case showed axillary nerve palsy in the case of IM nailing. Also, secondary surgery due to complications was operated in 9 cases (32.1%) in IM nailing and 1 case (4.8%) in plate fixation (p=0.03). CONCLUSION: In the case of traumatic humeral shaft fracture plate fixation by posterior approach was more useful than IM nailing in the decrease of complications and bone union. Such approach is thought to be an excellent method for anatomic reduction and nerve exploration in the case of open and comminuted fracture which accompany nerve injuries

Bone Density and Mechanical Property after Locked Intramedullary Nailing of the Long Bone Fractures: Preliminary Study of QCT & Lunar of 15 Long Bone Fractures / 대한정형외과학회잡지

The decrease of bone density after fracture is a well-known phenomenon. Several studies of the changes of bone density after fracture demonstrated bone density decreased not only at the fracture site, b ut also along the whole fractured bone. Being treated with locked intramedullary (IM) nailing, 15 patients with the long bone fractures of lower limbs were examined by Quantitative Computed Tomography (QCT) or Dual-Energy X-ray Bone Densitometer (Lunar DPX-L) a few days after nail removal. In the cases of QCT (5 patients of the tibia shaft fracture), cortical bone density, cortical thickness and geometrical shape (i.e. external antero-posterior and medio-lateral diameters) of the fracture site were compared to those of the contralateral side. On the other hand, in the case of Lunar' (5 patients of the tibia shaft fracture & 5 patients of the femur shaft fracture), only cortical bone density was compared to that of the contralateral side. The results of this study were as follows: 1. When treated by the locked intramedullary nailing of the long bone fractures, the bone density of the tibia & femur shaft fractures measured from the fracture site, proximal and distal sites to mid-fracture decreased. 2. There was a difference in the bone density of the uninjured long bone diaphysis of the tibia & femur shaft fractures. That is, in the case of the tibia shaft fracture, the bone density of the ipsilateral femur diaphysis measured by QCT increased 2 %, and increased 7 % when measured by Lunar. But, in the case of the femur shaft fracture, the bone density of the ipsilateral tibia diaphysis measured by Lunar decreased 4%. 3. In the case of the tibia shaft fracture, the cortical thickness in the fracture site measured by QCT increased 72 %, and external antero-posterior and medio-lateral diameters increased 7 % and 63 %. It seemed to be the formation of peripheral callus due to medullary reaming preceding intramedullary nail insertion. Therefore, this clinical study demonstrated that the mechanical property of the long bone fractures was restored and restricted weight bearing hardly needs to recommended when the nail was removed after the fracture union. 4. The bone densities of the tibia shaft fratures measured by QCT were not different with those measured by Lunar.

Retrograde Intramedullary nailing of the Fractures of the Femoral shaft in Adult / 대한정형외과학회잡지

Femoral fractures in adults frequently need an extensive dissection for attainment of adequate internal fixation, frequently leading to nonunion, infection and derangement of joint motion. Retrograde IM nailing, compared to the conventional methods, has advantages of reducing periarticular soft tissue dissection and establishing a load sharing construct reducing hardware failure. The purpose of this study is to verify the advantages of retrograde IM nailing by retrospective evaluation of the results of adult femoral fractures treated by this technique. The matrials were 17 femoral fractures in 15 patients treated by retrograde IM nailing and followed up for more than 1 year. The fracture was located in the middle third of the shaft in 5 and distal third in 12. The latter consisted nf 6 cases of type Al, 4 cases of type A2 and 2 cases of type A3 by Miiller's classification. The results were as follows; 1) Fracture union was achieved at an average of 17.5 weeks. 2) Full range of knee motion was gained in 15/17 knees (88%). 3) Complication occurred in 2 knees. One nonunion and one angulatory malunion. 4) There was no infection, no femoral shortening or implant failure. In conclusion, retrograde IM nailing of adult femoral fracture is an effective method in selected cases such as far distal femoral fracture, ipsilateral femur neck and shaft fractures, floating knee, post-TKR femoral fracture and so on. The merits of this technique are rigid fixation which is difficult to obtain with others, no need of fracture table, short operative time and mimium blood loss. However, It has potential problems such as difficulty in insertion of proximal locking screw and need for an arthrotomy to remove hardware.

Closed Intramedullary Nailing of Femoral Fracture without a Fracture Table / 대한정형외과학회잡지

The standard treatment of adult femoral shaft fractures is the closed intramedullary nailing using a fracture table, but in polytraumatized patients, this method may be difficult due to concomitant adjacent injury. So, we report on the technique of closed intramedullary nailing without a fracture table for adult femoral shaft fracture using "joystick" technique on radiolucent table in supine position. Among 15 cases, two were open fractures, three were proximal 1/3, seven were middle 1/3, two were distal 1/3, and theree were segmental fractures. According to the Winquist Hansen classification, five type I, four type II, three type III, three were type IV. The eleven patients out of the fifteen were operated within 48 hours. The average operation time was 105 minutes, and the amount of bleeding was below 300cc. Forty-seven percent was anatomically reduced, forty percent had below five degree of angular deformity or below five milimeter of shortening, thirteen percent had above five degree of angular deformity of above five milimeter of shortening. The closed intramedullary nailing of femoral shaft fractures without fracture table using radiolucent table and "joy stick" technique is an effective and safe method in multiple injuries. And it reduced the operation time by reducing the preoperation time including preparing of a fracture table.

Management of Tibia Fracture by Closed Intramedullary Nailing / 대한정형외과학회잡지

161 patients with tibia fracture were treated by closed intramedullary nailing at the department of Orthopedic Surgery, Eul-Ji General hospital, Dae Jeon, during 5 years from January, 1988 to April, 1993. 134 of these patients were performed with Kiintscher IM nailing and 27 patients with Ender nailing. Rigid IM nailing is the method of choice in tibia shaft fracture with rigid fixation, low complication, wide indication and early weight bearing, but the treatment of segmental fracture of the tibia will have many difficulties because of severe displacement, severe comminution, massive soft tissue damage and lack of blood supply at fracture site. Either antegrade or retrograde Ender nailing was of value for the management of segmental fracture which was too proximally or too dixtally located to insert interlocking screws, open fracture and soft tissue injury around Kiintscher insertion site. The result as fllows; 1. 43 fractures were open and 118 were closed. 69 fractures involved the distal portion, 55 fractures the middle portion, 13 fractures the proximal portion of the tibia and 24 fractures were segmental. 2. Among the 161 eases, 114 cases were male and 47 cases were female, the most common ages were ranged from 21 year to 30 year, involving 44 cases. 3. The most common cause was traffic accident. 4. Average intervals from injury to operation were 6.34 days(closed fracture) and 9.84 days(open fracture). 5. The mean durations of the bone union were 18.90 weeks(closed fracture) and 16.46 weeks(open fracture). 6. Complication included 7 cases delayed union, 3 cases nonunion, 8 cases superficial infection, 4 cases joint stiffness, 3 cases nail migration, 2 cases angular deformity, 2 cases rotational deformity, 1 cases osteomyelitis.

Clinical Evaluation of Complications of Interlocking Nail for Femoral Shaft Fracture / 대한정형외과학회잡지

The intramedullary nailing is one of the most available method in treatment of femoral shaft fracture. Since the development of Kuntscher naukl in 1940, new design such as Grosse-Kempf IM nailing became widely used by more applicable level of femoral shaft fracture. Therefore, complications of intramedullary nailing was rarely seen. The authors analysed complications in 7 cases of intramedullary nailing for treatment of femoral shaft fracture in Koryo General Hospital from Jan. 1991 to Jan. 1993., and the results were as follows; 1. The average age was 40.5 years and all patient's sex were male. 2. Among 7 cases, complications were delayed union in 4 cases, metallic failure in 2 cases and femoral neck fracture in 1 case. 3. Among 4 cases of delayed union, 3 cases treated by weight-bearing after dynamization and 1 case treated by bone graft after dynamization. 4. Metallic failure occurred in 2 cases, 1 case developed metallic corrosion in medullary canal, the other case developed metal failure at fracture. 5. Fomoral neck fracture in 1 case was treated by multiple Knowles' pins.

Operative Treatment of Femoral Shaft Fracture in Adult: Compression Plate Versus Intramedullary Nailing for Femoral Shaft Fracture / 대한정형외과학회잡지

The authors studied 54 patients (55 cases) of femoral shaft fractures treated by compression plate fixation and IM nailing from August 1986 to December 1991. The purpose of this study is to analyse comparatively the radiological and clinical results between the compression plate fixation and IM nailing in femoral shaft fracture of adult. The obtained results were as follows: 1. Among the 54 patients, the ratio of male and female was 44: 10, and the highest in cidence of age was between 3rd and 4th decades. 2. The main cause of injury was traffic accident in 38 cases. 3. The most common fracture type was B1-② in ten cases by AO-ASIF classification. 4. The mean duration of union was 13 weeks in compression plate fixation by the Koostra's criteria and the average 23 weeks in IM nailing by the Bjorens criteria. 5. The clinical result according to Margerl et al, was good in 25 cases (80.6%) with compression plate fixation and good in 20 cases (83.3%) with intramedullary fixation. 6. Complications of compression plate fixation were metal failure in 2 cases and deep wound infection in 1 case, and 1 case of femur neck fracture during operation and 1 case of metal failure in intramedullary fixation.

Interlocking Intramedullary Nailing Versus conventional Kuntscher Intramedullary Nailing for Fracture of the Femoral Shaft / 대한정형외과학회잡지

We studied 75 cases of conventional Kuntscher intramedullary nailing and 52 cases of interlocking intramedullary nailing from July 1980 to October 1988 for femur shaft fractures. The conventional Kuntscher intramedullary nailing was used for fresh fracture and the interlocking intramedullary nailing was used not only fresh fracture, but also unstable fracture, nonunion and pathologic fracture. The conventional Kuntscher intramedullary nailing was frequently used in middle one-third level, but the interlocking intramedullary nailing could be applied widely from subtrochanteric area to supracondylar level in femur. The average operation time in patient who had no associated injury was 3.6 hours in conventional Kuntscher intramedullary nailing and 3.25 hours in interlocking intramedullary nailing. Time period for union was much less in interlocking intramedullary nailing than conventional Kuntscher intramedullary nailing. Some kinds of immobilization was needed shortly in conventional Kuntscher intramedullary nailing but immediate postoperative ambulation was possible in interlocking intramedullary nailing. Interlocking intramedullary nailing can prevent the angulation, shortening and trochanteric bursitis due to migration of the intramedullary nail.

The Interlocking Kuntscher IM Nailing for Femur Shaft Fracture / 대한정형외과학회잡지

The intramedullary nailing is a good method of treatment in femur shaft fracture but it is not available in some fracture pattern or fracture level. And it is very difficult with conventional Kiintscher nailing to prevent torsional stress and fix rigidly in unstable fracture of the femur shaft. The unstable fracture by comminuted fracture or segmental fracture, nonunion and pathologic fracture needed the rigid fixation. Interlocking Kuntscher IM nailing can provide antitorsional stability, good axial alignment and prevent shortening of the fracture site, also allow early ambulation and joint exercise. We analysed 51 patients 52 cases of interlocking Kiintscher IM nailing from May 1981 to March 1988. The interlocking Kuntscher IM nailing prevents the rotational and axial roading. The interocking Kuntscher IM nailing has expanded its application in fracture pattern and fracture site. The interlocking IM nailing provides rigid fixation in severe comminuted fracture. segmental fracture, long spiral fracture, and other several unstable fractures and eliminates splinting or external supports, so it is possible doing early joint exercise. The interlocking Kuntscher IM nailing was also considered best internal fixation method in pathologic fracture or sever osteoporosis. The static interlocking for rigid fixation and the dynamic interlocking method for axial compression to fracture site during weight bearing can be adapted appropriately to fracture pattern. Radiation hazard during the interlocking nailing is not considerable.