Nail Fit: Does Nail Diameter to Canal Ratio Predict the Need for Exchange Nailing in the Setting of Aseptic, Hypertrophic Femoral Nonunions?

OBJECTIVES: To evaluate patient-independent risk factors for aseptic femoral hypertrophic nonunion requiring exchange nailing, with particular reference to the fit of the nail at the isthmus within the canal. DESIGN: Retrospective case control study. SETTING: Level 1 trauma center. MAIN OUTCOME MEASUREMENTS: Between 2008 and 2012, 211 patients without any patient-dependent risk factors for nonunion were treated with a locked reamed intramedullary nail for a femoral shaft fracture. Twenty-three cases went on to hypertrophic nonunion requiring exchange nailing (treatment group) and 188 cases went on to union (control group). Patient-independent risk factors for exchange nailing were documented. RESULTS: Patient-independent risk factors for exchange nailing were poor fracture reduction [Odds ratio (OR): 11.5, 95% confidence interval (CI), 4.0-33.4, P < 0.001], open fracture (OR: 7.6, 95% CI, 3.0-19.6, P = 0.004), Winquist classification of 4 (OR: 4.4, 95% CI, 1.9-6.7, P = 0.016), and poor nail fit (OR: 10.3, 95% CI, 5.1-28.4, P < 0.001). Multivariate analysis revealed nail fit as an independent predictor of femoral nonunion requiring exchange nailing (OR: 11.4, 95% CI, 6.9-15.2, P < 0.001). Moreover, we found a direct relationship between increasingly poor nail fit and increased risk of exchange nailing, with the criterion occurring at a nail fit ratio <70%. CONCLUSION: When proceeding to femoral fracture reamed intramedullary nailing, we recommend a minimum nail fit of 70% at the isthmus and ideally 90% or more, to avoid surgical reintervention. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cancellous bone graft and Kirschner wire fixation as a treatment for cavitary-type scaphoid nonunions exhibiting DISI.

BACKGROUND: Cavitary-type scaphoid non-unions represent one of the most difficult treatment challenges amongst all scaphoid non-unions as they exhibit bone loss, scaphoid shortening, flexion ('humpback') deformity and dorsal intercalated segmental instability (DISI), creating altered carpal mechanics which may proceed to the degenerative changes of scapholunate advanced collapse of the wrist. Our technique and its rationale are presented in the largest-to-date series on cavitary scaphoid non-unions exhibiting DISI. METHODS: Our technique for treatment of these cavitary non-unions is presented through a series of 27 patients. RESULTS: Union was achieved in (26/27) 96% of cases, with no complications. Carpal mechanics was restored, with an average carpal height index of 1.52 ± 0.06, and an average scapholunate angle was 46 ± 9°. Average follow-up was 2.2 years. CONCLUSION: In this subset of patients, we believe this technique is less technically demanding than the use of either cortico-cancellous grafts or various compression screws. Our success equals or betters that of other published techniques, with all patients enjoying a full return to work, even in occupations demanding heavy labour. We believe that scaphoid union, coupled with the often difficult restoration of carpal height and intra-carpal angles, has produced very good functional outcomes in the management of these challenging cases.

The Australian arthroplasty thromboprophylaxis survey.

Previous surveys of orthopedic surgeons have shown considerable variation in thromboprophylaxis for venous thromboembolism after joint arthroplasty. This survey aimed to determine the current practice among Australian orthopedic surgeons. A questionnaire regarding the duration, reasons, and methods of chemical and mechanical prophylaxis for hip and knee arthroplasty patients was sent to the 1082 surgeons identified; 593 (55%) members completed the questionnaire. The survey revealed that 98% of surgeons used chemical thromboprophylaxis, mainly low-molecular-weight heparin (84% hip and 79% knee). Those who use low-molecular-weight heparin were more likely to prescribe anticoagulants in fear of litigation (19.2% vs 10.1%, P = .04) and more likely to rely on protocols or guidelines (32.2% vs 17.2%, P = .004) instead of basing their decision on their own reading (52.4% vs 71.3%, P = .001). Most orthopedic surgeons in our survey have indicated that they would welcome guidelines from their association or college regarding thromboprophylaxis in arthroplasty.

Effect of moderate pressure distention on the human saphenous vein vasomotor function.

BACKGROUND: Manual pressure distension, which is commonly applied to the human saphenous vein graft for coronary artery bypass, is believed to have detrimental consequences for the graft patency. The vasomotor function of the vein after distention during surgical preparation for grafting and after distention in laboratory conditions at pressure of 50 to 600 mm Hg was studied. The effect of a combination of vasodilative agents to prevent vasospasm was also tested. METHODS: The contractile and dilatory responses of distended and undistended human saphenous veins and those after drug treatment were examined in organ baths under isometric conditions. RESULTS: Distention at the pressure range 100 to 300 mm Hg resulted in an increased contractile response of the saphenous vein to both alpha-adrenergic activation with 50 micromol/L phenylephrine (153.73% +/- 15.69%) and depolarization with 80 mmol/L K(+) (141.03% +/- 15.13%) in comparison with the undistended vein and did not impair the relaxation. In contrast manual distention during surgical preparation abolished the contractile response and impaired the relaxation. The application of a combination of vasodilative drugs (alpha-adrenergic antagonist phenoxybenzamine, 10 micromol/L, Rho-kinase inhibitor HA-1077, 50 micromol/L, and calcium blocker nicardipine, 1 micromol/L) eliminated the contractile response of the vein to phenylephrine and 80 mmol/L K(+). This effect was sustained more than 20 hours after the washout of the drugs. CONCLUSIONS: The distention of the human saphenous vein at moderate pressure combined with the application of the effective combination of vasodilative drugs before grafting into the arterial circulation could be a beneficial alternative to the current practice of uncontrolled pressure distension.