Prevention of inaccurate targeting of proximal screws during reconstruction femoral nailing

Trust But Verify: Design Differences in The Prevention of Targeting Errors in Cephalomedullary Nails

OBJECTIVES

To evaluate insertional damage on explanted cephalomedullary nails and to differentiate typical from atypical wear to characterize outliers.

DESIGN

Therapeutic.

SETTING

Level II trauma center.

PARTICIPANTS

Patients who underwent removal of an implanted cephalomedullary nail for any reason from 2015 to 2023.

METHODS

Inspection of implants was performed at ×1000 magnification with a light microscope. Benchtop testing was performed with Gamma3, Gamma4, Intertan, TFN, and TFNa instrumentation.

RESULTS

One hundred nine cephalomedullary nails were inspected. Insertional damage was observed in more than 95% of the implants recovered. In 34% (37 of 109) of implants, damage to the proximal aperture was severe enough to cause a chamfer or "notch." Chamfers were also encountered along the distal locking aperture in short stem implants in 44% (19 of 43). Guidewire chamfers to the proximal implant external to the aperture and damage to preinserted set screws were outliers. Evidence of set screw fracture or deformity was encountered in 12 specimens. Four anomalous set screw variants were encountered within 1 implant design, each variant exhibiting maltracking with deployment that could result in malfunction.

CONCLUSIONS

Insertional damage to cephalomedullary implants was encountered routinely among the explants and should not always be categorized as preventable surgical error. Surgeons should be familiar with technical and design factors that contribute to chamfering of implants to reduce failures.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature

Objective:

To describe the surgical aspects potentially contributing to hardware failure of cephalomedullary nails.

Data Sources:

A search of the Embase, PubMed (MEDLINE), Web of Science, and the Cochrane library for reports of hardware failures after intramedullary fixation of proximal femur fractures. Issues of cut out and cut through phenomena related to technique were excluded. Expert opinion of 3 surgeons, each trained on several fixation systems at Level | trauma centers is reported.

Data Extraction:

Three authors extracted data using a predesigned form. Implant type, reported failure mechanism, and associated factors with implant failure were recorded as well as potential bias.

Results:

Of 2182 search results screened, 64 articles were deemed relevant for our research question and were included. The authors identified factors associated with implant failure: preoperative patient and fracture characteristics, intraoperative reduction, implant handling, and postoperative nonunion. Issues were identified as independent modifiable intraoperative risk factors: inadequate fracture reduction, varus position of femoral neck, direct damage of the cephalomedullary nail aperture by eccentric drilling related to guide sleeve handling, and implant design mechanism failures.

Conclusions:

Multiple factors associated with intraoperative handling can influence the healing of proximal femur fractures. Although many of these have been well described and are taught in fracture courses, surgeons should be aware of subtle intraoperative complications reported in the literature that can weaken implants and add to the likelihood of early failure.

Level of Evidence: IV

Power-Tool Use in Orthopaedic Surgery: Iatrogenic Injury, Its Detection, and Technological Advances: A Systematic Review

Power tools are an integral part of orthopaedic surgery but have the capacity to cause iatrogenic injury. With this systematic review, we aimed to investigate the prevalence of iatrogenic injury due to the use of power tools in orthopaedic surgery and to discuss the current methods that can be used to reduce injury.