Locked intramedullary femoral nailing without fracture table or image intensifier

Closed reduction and locked intramedullary nailing of diaphyseal long bone fractures without intra-operative imaging and fracture table

PURPOSE

Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment.

METHODS

A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger.

RESULTS

Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients' ages were 41.33 and 13-81 years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p < 0.001). Closed reduction also had positive associations with: (i) humerus and tibia fractures (p < 0.001), (ii) middle, distal and segmental fractures (p = 0.025), (iii) retrograde approach to femur fracture nailing (p < 0.001), and (iv) wedge or multifragmentary type femur fractures (p = 0.005).

CONCLUSION

With constant practice, it is possible to achieve closed reduction of many fresh diaphyseal long bone fractures in spite of the limitations imposed on surgeons in LMICs by poor health systems and grossly inadequate fracture care facilities.

Is mini-open intramedullary nailing an effective intervention for adult femoral diaphyseal fractures in odd hours? A prospective case-control functional outcome and radiation safety study

BACKGROUND

Closed intramedullary (IM) nailing among various modalities is one of the commonest sought out procedure in current practice for management of femoral-diaphyseal fractures (FDF) following trauma. However, it has some limitations like prolonged procedural duration, high radiation exposure and a steep learning curve. Therefore, with limited resources in odd hours and at a high patient turnover center where closed reduction can be a challenge, we adopted a modified mini-open technique which can overcome the limitations of closed reduction technique.

PURPOSE

To compare the closed IM nailing and mini-open technique in FDF in terms of radiation exposure, surgical duration, radiological and functional outcome.

PATIENTS AND METHODS

A total of 100 patients (118 femurs) with FDF (AO 32A1-B2) operated in odd-hours (20:00-06:00 hrs. GMT +5.30) with closed (Group I, n=62) or mini-open (Group II, n=56) IM nailing technique between September 2018 to December 2019 with a minimum follow up of 12 months were included in this study. The functional outcomes were measured using Thoresen scoring system and statistical analysis were performed using paired t-test and χ2 -test.

RESULTS

The overall mean patient age was 33.5 years (18-74 years). The mean surgical duration, c-arm shoots for reduction and radiological union time were 71.5 minutes, 21 shoots and 16 weeks, respectively for group I and 47.5 minutes, 9.4 shoots and 18 weeks for group II. There was significant difference between the two groups in mean surgical duration (p<0.05) and c-arm shoots (p<0.05). However, there was no statistical significant difference between time for union, rate of union, functional results and incidence of superficial or deep infection between the two groups.

CONCLUSION

In conclusion, mini-open technique is a safer alternative in patients with FDF at high-volume centers and in odd-hours when the available resources are limited.

Intraoperative Distal Femoral Fine Wire Traction to Facilitate Intramedullary Nailing of the Femur

Many techniques have been employed to facilitate intramedullary nailing of femur fractures. Maintaining limb length during the operation can be difficult. The authors describe the use of distal femoral fine wire skeletal traction as a technique to maintain reduction while allowing intramedullary nailing of femur fractures. This technique is safe, is effective, and negates the need for a fracture table or an assistant.

Intra-operative augmented reality in distal locking

PURPOSE

To design an augmented reality solution that assists surgeons during the distal locking of intramedullary nailing procedures.

METHOD

Traditionally, the procedure is performed under X-ray guidance and requires a significant amount of time and radiation exposure. To absolve these complications, we propose video guidance that allows surgeons to achieve both the down-the-beam position of the intramedullary nail and its subsequent locking. For the down-the-beam position, the IM nail pose in X-ray is calculated using a 2D/3D registration scheme and later related to the patient leg pose which is calculated using video-tracked AR markers. For the distal locking, surgeons use an augmented radiolucent drill in which its tip position is detected and tracked in real-time under video guidance.

VALIDATION

To evaluate the feasibility of our solution, we performed a preclinical study on dry bone phantom with the participation of four clinicians.

RESULTS

Participants achieved 100 % success rate in the down-the beam positioning and 93 % success rate in distal locking using only two X-ray images in 100 s.

CONCLUSIONS

We confirmed that intra-operative navigation using augmented reality provides an alternative way to perform distal locking in a safe and timely manner.

Randomized controlled trials of proximal femoral nail antirotation in lateral decubitus and supine position on treatment of intertrochanteric fractures

The objective of this study was to compare the clinical results and complications of proximal femoral nail antirotation (PFNA) on treatment of intertrochanteric fractures in 120 elderly Chinese patients using Randomized Controlled Trials (RCTs). Totaly 120 cases enrolled were randomly assigned to a lateral decubitus position group and supine position group. The hospital stay, operating time, intraoperative blood loss, length of incision, X-ray fluoroscopy time, and out-of-bed activity time in the lateral decubitus position group were significantly lower than those in the supine position group. There was not statistical significance on union time and Harris values in the two position groups. Moreover, only complications of superficial wound infection were observed in the lateral decubitus position group, but two complications of deep venous thrombosis and wound deep infection were found in the supine position group. The present findings suggested that PFNA applied in elderly patients with intertrochanteric fracture can get satisfactory effects, and the treatment of intertrochanteric fractures using lateral decubitus position showed a satisfactory clinical outcome and a lower radiological complication rate.