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Alcaraz JG, Fernandez EA, Martín IA, Recuenco DB, González CO, Agundez AC. Ipsilateral proximal and shaft femoral fractures: Results of two treatment strategies. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:354-364. [PMID: 36924841 DOI: 10.1016/j.recot.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/17/2023] Open
Abstract
INTRODUCTION Ipsilateral proximal and shaft femoral fractures typically occur in young adults after high-energy trauma. No consensus exists regarding the optimal internal fixation device or surgical strategy for these complex fractures. Our main objective is to identify differences on outcomes and complications between patients treated with one or combined implants. MATERIAL AND METHOD This is a single-center retrospective cohort study in patients with associated fractures of the proximal (31 AO) and shaft femur (32 AO). We divided the patients into two groups according to the use of single (Group I) or combined implants (Group II). Demographic, clinical, radiological, surgical data and development of complications were collected. RESULTS We identified 28 patients (19 men and 9 women) with an average age of 43 years. We used an anterograde femoral nail in group I (17 patients) and a retrograde femoral nail or a plate associated with hip lag screws or sliding hip screw in Group II (11 patients). Patients were followed up for 26.28 (9.12-62.88) months. Osteonecrosis of the femoral head, osteoarthritis, infection or nonunion was found in 9 patients (32%). No significant differences (p 0.70) were found in complications between two groups or between definitive surgical fixation before or after the first 24h. CONCLUSIONS No differences in the development of complications or timing of definitive fixation were found between the use of one or combined implants in ipsilateral proximal femur and shaft fractures. Regardless of the implant chosen, an appropriate osteosynthesis technique is crucial, even so high complication rates are expected. LEVEL OF EVIDENCE IV. Grade of Recommendation: C.
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Affiliation(s)
- J G Alcaraz
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain.
| | - E A Fernandez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
| | - I A Martín
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
| | - D B Recuenco
- Department of Orthopaedic Surgery and Traumatology, Hospital General de Nuestra Señora del Prado, Talavera, Spain
| | - C O González
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
| | - A C Agundez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 Octubre, Madrid, Spain
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Gómez Alcaraz J, Ajuria Fernández E, Auñón Martín I, Bustamante Recuenco D, Olaya González C, Capel Agúndez A. Ipsilateral proximal and shaft femoral fractures: Results of two treatment strategies. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T354-T364. [PMID: 37311476 DOI: 10.1016/j.recot.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/06/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Ipsilateral proximal and shaft femoral fractures typically occur in young adults after high-energy trauma. No consensus exists regarding the optimal internal fixation device or surgical strategy for these complex fractures. Our main objective is to identify differences on outcomes and complications between patients treated with one or combined implants. MATERIAL AND METHOD This is a single-center retrospective cohort study in patients with associated fractures of the proximal (31 AO) and shaft femur (32 AO). We divided the patients into two groups according to the use of single (GroupI) or combined implants (GroupII). Demographic, clinical, radiological, surgical data and development of complications were collected. RESULTS We identified 28 patients (19 men and 9 women) with an average age of 43years. We used an anterograde femoral nail in GroupI (17 patients) and a retrograde femoral nail or a plate associated with hip lag screws or sliding hip screw in GroupII (11 patients). Patients were followed up for 26.28 (9.12-62.88) months. Osteonecrosis of the femoral head, osteoarthritis, infection or nonunion was found in 9 patients (32%). No significant differences (P=.70) were found in complications between two groups or between definitive surgical fixation before or after the first 24h. CONCLUSIONS No differences in the development of complications or timing of definitive fixation were found between the use of one or combined implants in ipsilateral proximal femur and shaft fractures. Regardless of the implant chosen, an appropriate osteosynthesis technique is crucial, even so high complication rates are expected.
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Affiliation(s)
- J Gómez Alcaraz
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - E Ajuria Fernández
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - I Auñón Martín
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - D Bustamante Recuenco
- Departamento de Cirugía Ortopédica y Traumatología, Hospital General de Nuestra Señora del Prado, Talavera de la Reina, Toledo, España
| | - C Olaya González
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - A Capel Agúndez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
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Huang X, Chen Y, Chen B, Zheng K, Lin C, Lin F, Luo X. Reamed versus unreamed intramedullary nailing for the treatment of femoral shaft fractures among adults: A meta-analysis of randomized controlled trials. J Orthop Sci 2022; 27:850-858. [PMID: 34303590 DOI: 10.1016/j.jos.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/03/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this meta-analysis is to compare the merits and drawbacks between reamed intramedullary nailing (RIN) and unreamed intramedullary nailing (URIN) among adults. METHODS We comprehensively searched PubMed, MEDLINE database through the PubMed search engine, Google Scholar, Cochrane Library, Embase, VIPI (Database for Chinese Technical Periodicals), and CNKI (China National Knowledge Infrastructure) from inception to March 2020. Outcomes of interest included nonunion rates, implant failure rates, secondary procedure rates, blood loss, acute respiratory distress syndrome (ARDS) rates, and pulmonary complications rates. RESULTS Eight randomized controlled trials were included. The result of nonunion rates shows that the nonunion rate is significantly lower in the RIN group (RR = 0.20, 95% CI = 0.09-0.48, Z = 3.63, P = 0.0003). There were no significant differences for the risk of implant failure rates (RR = 0.55, 95% CI = 0.18-1.69, Z = 1.04, P = 0.30). The secondary procedure rates were significantly lower in the RIN group (RR = 0.28, 95% CI = 0.12-0.66, Z = 2.91, P = 0.004). The result shows that the blood loss of URIN group is significantly lower (RR = 145.52, 95% CI = 39.68-251.36, Z = 2.69, P = 0.007). The result shows that there was no significant difference in the ARDS rates (RR = 1.53, 95% CI = 0.37-6.29, Z = 0.59, P = 0.55) and the pulmonary complications rates between RIN group and URIN group (RR = 1.59, 95% CI = 0.61-4.17, Z = 0.94, P = 0.35). CONCLUSIONS Reamed intramedullary nailing would lead to lower nonunion rate, secondary procedure rate and more blood loss. Unreamed intramedullary nailing is related to a higher nonunion rate, secondary procedure rate and less blood loss. No significant difference is found in implant failure rate, ARDS rate and pulmonary complication rate between the two groups.
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Affiliation(s)
- Xu'an Huang
- School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Yifan Chen
- Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Bin Chen
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Ke Zheng
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Chaohui Lin
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Fengfei Lin
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China.
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Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures. OTA Int 2021; 4:e154. [PMID: 34765904 PMCID: PMC8575427 DOI: 10.1097/oi9.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Abstract
Objective To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures. Design Retrospective 1:1 matched cohort study. Setting Single-level 1 trauma center. Participants One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups. Intervention Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture. Main Outcome Measurement Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores. Results Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group. Conclusions Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.
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Albareda J, Ibarz E, Mateo J, Suñer S, Lozano C, Gómez J, Redondo B, Torres A, Herrera A, Gracia L. Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study. Injury 2021; 52 Suppl 4:S61-S70. [PMID: 33707035 DOI: 10.1016/j.injury.2021.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful. MATERIAL AND METHODS This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation. RESULTS The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%. CONCLUSIONS The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.
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Affiliation(s)
- J Albareda
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - E Ibarz
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - J Mateo
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital. Zaragoza, Spain
| | - S Suñer
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - C Lozano
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - J Gómez
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital.
| | - B Redondo
- Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Torres
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Herrera
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - L Gracia
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
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Bekos A, Sioutis S, Kostroglou A, Saranteas T, Mavrogenis AF. The history of intramedullary nailing. INTERNATIONAL ORTHOPAEDICS 2021; 45:1355-1361. [PMID: 33575858 DOI: 10.1007/s00264-021-04973-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To summarize the evolution of intramedullary nailing, highlight important milestones, introduce the atmosphere of the era concerning the first uses and development of intramedullary nailing, and present the status of nailing in modern international orthopaedics and traumatology. METHOD A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of intramedullary nailing. RESULTS The first use of an intramedullary device was attested in ancient Egypt; however, the first use of intramedullary nailing was reported in 1524 in Mexico, and the first medical journals reported on intramedullary nailing around the mid-1800s. The evolutions of intramedullary nailing including approach, material, cross-section and shape, and reaming technique occurred in the twentieth century. During the 1960s, intramedullary nailing was abandoned in favour of plate and screws osteosynthesis; however, in the 1970s, 1980s, and 1990s, a surge of novelties including flexible reaming, interlocking, and use of image intensification and titanium nails led to the advent of the second-generation intramedullary nailing. Today, intramedullary nailing has become the standard treatment of long bone fractures with low infection rates, small scars, excellent stabilization of the fractures, and immediate mobilization of the patients. CONCLUSION Intramedullary nailing has revolutionized the treatment of long bone fractures. However, with numerous nail designs, a lot of information on their efficacy is lacking. Considerably more work will need to be done to determine the optimal nail specifications.
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Affiliation(s)
- Achilles Bekos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Spyridon Sioutis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas Kostroglou
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Theodosios Saranteas
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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Chokotho L, Wu HH, Shearer D, Lau BC, Mkandawire N, Gjertsen JE, Hallan G, Young S. Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi. Acta Orthop 2020; 91:724-731. [PMID: 32698707 PMCID: PMC8023961 DOI: 10.1080/17453674.2020.1794430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.
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Affiliation(s)
- Linda Chokotho
- Department of Surgery, College of Medicine, University of Malawi
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hao-Hua Wu
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
| | - David Shearer
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
| | - Brian C Lau
- Department of Orthopedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - Nyengo Mkandawire
- Department of Surgery, College of Medicine, University of Malawi
- School of Medicine, Flinders University, Adelaide, Australia
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Geir Hallan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Sven Young
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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Trikha V, Albert V, Kumar VS, Das S, Subramanian A, Chowdhury B. Effect of Time Lag from Injury to Surgery on the Temporal Expression of Growth Factors After Intramedullary Nailing of Isolated Fracture of Femur Shaft. Indian J Orthop 2020; 54:109-115. [PMID: 32952917 PMCID: PMC7474011 DOI: 10.1007/s43465-020-00173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/07/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Growth factors are considered to play an important role in the process of bone healing. This study assessed serum levels of transforming growth factor-β1 (TGF-β1) and vascular endothelial growth factor (VEGF) in patients undergoing intramedullary nailing for isolated fracture of femur shaft operated at various time lag from injury. PATIENTS AND METHODS All patients between 18 and 60 years of age group operated for isolated femoral shaft fractures (AO/OTA32 A, B, C) were included. The serum levels of VEGF and TGF-β1 were compared at various intervals amongst the study group divided into two groups based on the time lag between injury and surgery along with a health control cohort. RESULTS 31 patients were operated within the first 48 h while 28 patients were operated within 2-12 days after injury. Highest VEGF levels were observed on postop day 3, followed by a subsequent decline thereafter. TGF-β1 level also showed increasing trend after surgery, but the levels reached dual peaks after 2 weeks and 12 weeks after surgery. Both groups revealed similar trends of temporal expression of serum VEGF and TGF-β1. There was no statistical difference between the two groups at any point of time during the observation period. There was also no statistical difference in clinico-radiological healing of fractures among the groups. CONCLUSION There is a definite and specific trend of serum levels of growth factors in the fracture healing process. There is no effect of time lag from injury to surgery on the healing outcome of isolated femoral shaft fractures both at the molecular level and also at the clinical level.
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Affiliation(s)
- Vivek Trikha
- grid.413618.90000 0004 1767 6103Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), Room No. 406, 4th Floor, Ring Road, New Delhi, 110029 India
| | - Venencia Albert
- grid.19096.370000 0004 1767 225XIndian Council of Medical Research, New Delhi, India
| | | | - Saubhik Das
- Department of Orthopaedics, Rajindra Institute of Medical Sciences, Ranchi, Jharkhand India
| | - Arulselvi Subramanian
- grid.413618.90000 0004 1767 6103Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Buddhadev Chowdhury
- grid.413618.90000 0004 1767 6103Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), Room No. 406, 4th Floor, Ring Road, New Delhi, 110029 India
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Doll J, Moghaddam A, Daniel V, Biglari B, Heller R, Schmidmaier G, Raven TF. LIPUS vs. reaming in non-union treatment: Cytokine expression course as a tool for evaluation and differentiation of non-union therapy. J Orthop 2020; 17:208-214. [PMID: 31889743 DOI: 10.1016/j.jor.2019.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 08/11/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Julian Doll
- HTRG - Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, D-69118, Heidelberg, Germany
| | - Arash Moghaddam
- HTRG - Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, D-69118, Heidelberg, Germany.,ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center of Trauma & Orthopaedic Surgery, Sports Medicine, Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany
| | - Volker Daniel
- Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, D-69120, Heidelberg, Germany
| | - Bahram Biglari
- BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Straße 13, D-67071, Ludwigshafen, Germany
| | - Raban Heller
- HTRG - Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, D-69118, Heidelberg, Germany
| | - Gerhard Schmidmaier
- HTRG - Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, D-69118, Heidelberg, Germany
| | - Tim Friedrich Raven
- HTRG - Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, D-69118, Heidelberg, Germany.,ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center of Trauma & Orthopaedic Surgery, Sports Medicine, Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany
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Durigan JR, Silva ACD, Takata P, Zamboni C, Santili C, Mercadante MT. ANTEGRADE X RETROGRADE NAILING IN FEMORAL FRACTURES: A STUDY ON CONSOLIDATION AND INFECTION. ACTA ORTOPEDICA BRASILEIRA 2019; 27:313-316. [PMID: 31798322 PMCID: PMC6870539 DOI: 10.1590/1413-785220192706218655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective: Osteosynthesis with intramedullary nailing is considered the method of choice to treat diaphyseal femur fractures in adults. The objective of this retrospective study was to evaluate the bone healing time and incidence of infection in patients with diaphyseal femur fractures treated surgically with retrograde and antegrade intramedullary nailing. Methods: The medical records of 123 patients from two university hospitals dated 2011-2013 were evaluated, with 126 diaphyseal femur fractures having been found. The most frequent treatment was antegrade intramedullary nailing (51%), of which 38% involved reaming (n=25). Results: We found evidence of 92% healed fractures at 12 months postoperatively. Complications included chronic osteomyelitis in one patient and femoral neck fracture in another patient, both after reamed antegrade nailing. Pyoarthritis of the knee associated with osteomyelitis affected two patients after reamed retrograde nailing and one patient after unreamed retrograde nailing. Conclusion: We did not observe a significant difference in bone healing rates with the use of reamed or unreamed antegrade or retrograde nailing. Complications included the presence of infection with an incidence similar to that reported in the literature, and of particular significance, unrelated to the type of approach. Level of evidence III, Retrospective comparative study.
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Affiliation(s)
| | | | - Pedro Takata
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil
| | - Caio Zamboni
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil
| | - Claudio Santili
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil
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Abstract
OBJECTIVES To identify the risk factors for osteomyelitis development in US military personnel with combat-related, open femur fractures? DESIGN Retrospective observational case-control study. SETTING US military regional hospital in Germany and tertiary care hospitals in United States (2003-2009). PATIENTS/PARTICIPANTS One hundred three patients with open femur fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Sixty-four patients with open femur fractures who did not meet osteomyelitis diagnostic criteria were included as controls. MAIN OUTCOME MEASUREMENTS The main outcome measurements were multivariable odds ratios (ORs) and 95% confidence interval (CI). RESULTS Among patients with surgical implants, osteomyelitis cases had significantly longer time to definitive orthopaedic surgery compared with controls (median: 21 vs. 13 days). Independent predictors for osteomyelitis risk were Gustilo-Anderson classification (transfemoral amputation OR: 19.3; CI: 3.0-123.0) and Orthopaedic Trauma Association Open Fracture Classification for muscle loss (OR: 5.7; CI: 1.3-25.1) and dead muscle (OR: 32.9; CI: 5.4-199.1). Being injured between 2003 and 2006, antibiotic bead use, and foreign body plus implant(s) at fracture site were also risk factors. CONCLUSIONS Patients with open femur fractures resulting in significant muscle damage have the highest osteomyelitis risk. Foreign body contamination was only significant when an implant was present. Increased risk with antibiotic bead use is likely a surrogate for clinical suspicion of contamination with complex wounds. The timeframe association is likely due to changing trauma system patterns around 2006-2007 (eg, increased negative pressure wound therapy, reduced high-pressure irrigation, decreased crystalloid use, and delayed definitive internal fixations). LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Hamahashi K, Uchiyama Y, Kobayashi Y, Ebihara G, Ukai T, Watanabe M. Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments: a retrospective analysis of risk factors for delayed union. Trauma Surg Acute Care Open 2019; 4:e000203. [PMID: 31058233 PMCID: PMC6461209 DOI: 10.1136/tsaco-2018-000203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/13/2018] [Accepted: 02/25/2019] [Indexed: 01/26/2023] Open
Abstract
Background This study retrospectively evaluated the clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments and analyzed the risk factors for delayed union. Methods Retrospective analyses involving 51 patients who underwent intramedullary nailing of femoral shaft fractures with third fragments (AO classification type B, 35 cases; type C, 16 cases) were conducted. Delayed union was defined as either more than 10 months required for callus formation in more than three of the four cortical bone surfaces observed in the frontal and lateral radiographic views or the requirement for additional surgery such as nail conversion or bone transplantation. Seventeen patients developed delayed union (D group). Thirty-four patients achieved bony union within 9 months (U group). The following background variables were compared between groups: age at the time of the injury; AO classification; ratio of open fracture; waiting period before surgery; rate of the infraisthmal fracture; diameter of the intramedullary nail; ratio of the intramedullary nail to the femur; length and displacement of the third fragment; and use of open reduction, poller screws, or dynamization. Results Significant differences were found between the D and U groups for age (32.2±14.1 vs. 25.3±9.6 years), open fracture ratio (35.3% vs. 11.8%), and displacement of the third fragment (13.7±6.4 vs. 9±6.3 mm). Multiple logistic regression analysis only identified displacement of the third fragment as a risk factor for delayed union (p=0.03; OR 1.13; 95% CI 1.01 to 1.26). Discussion Delayed union was observed in 17 cases (33.3%) after intramedullary nailing of femoral shaft fractures with third fragments. Displacement of the third fragment influenced delayed union. Level of evidence Level III.
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Affiliation(s)
- Kosuke Hamahashi
- Department of Orthopaedic Surgery, SurgicalScience, Tokai University School of Medicine, Isehara, Japan
| | - Yoshiyasu Uchiyama
- Department of Orthopaedic Surgery, SurgicalScience, Tokai University School of Medicine, Isehara, Japan
| | - Yuka Kobayashi
- Department of Orthopaedic Surgery, SurgicalScience, Tokai University School of Medicine, Isehara, Japan
| | - Goro Ebihara
- Department of Orthopaedic Surgery, SurgicalScience, Tokai University School of Medicine, Isehara, Japan
| | - Taku Ukai
- Department of Orthopaedic Surgery, SurgicalScience, Tokai University School of Medicine, Isehara, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, SurgicalScience, Tokai University School of Medicine, Isehara, Japan
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Wang H, Hao Z, Wen S. Finite element analysis of the effect of medullary contact on fracture healing and remodeling in the intramedullary interlocking nail-fixed tibia fracture. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2017; 33:e2816. [PMID: 27327490 DOI: 10.1002/cnm.2816] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 06/13/2016] [Accepted: 06/14/2016] [Indexed: 06/06/2023]
Abstract
Intramedullary interlocking nail is an effective treatment for tibial diaphyseal fracture. The contact between medullary rod and diaphyseal cortex is able to enhance fracture stability. However, how and to what degree the contact affects fracture healing and subsequent bone remodeling is still unclear. To investigate this, fracture healing and remodeling algorithms were combined, improved, and used to simulate the healing and remodeling processes in a transverse tibial diaphyseal fracture fixed with an intramedullary interlocking nail device. Two different diaphyseal fracture statuses, three different initial loading levels, and two nail materials were considered. The results showed that the medullary contact could significantly enhance the fixation stability; the strain reduction was up to 80% in the initial granulation callus. However, low initial loading level was found to be a more potential risk factor for the insufficient loading-induced nonunion other than medullary contact and stiffer nail material. Furthermore, the stabilizing effect of medullary contact diminished when stiff bone tissue formed in the callus; thus, the remodeling in the long-term was not affected by medullary contact. Copyright © 2016 John Wiley & Sons, Ltd.
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Influence of implant properties and local delivery systems on the outcome in operative fracture care. Injury 2016; 47:595-604. [PMID: 26847958 DOI: 10.1016/j.injury.2016.01.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 01/15/2016] [Indexed: 02/02/2023]
Abstract
Fracture fixation devices are implanted into a growing number of patients each year. This may be attributed to an increase in the popularity of operative fracture care and the development of ever more sophisticated implants, which may be used in even the most difficult clinical cases. Furthermore, as the general population ages, fragility fractures become more frequent. With the increase in number of surgical interventions, the absolute number of complications of these surgical treatments will inevitably rise. Implant-related infection and compromised fracture healing remain the most challenging and prevalent complications in operative fracture care. Any strategy that can help to reduce these complications will not only lead to a faster and more complete resumption of activities, but will also help to reduce the socio-economic impact. In this review we describe the influence of implant design and material choice on complication rates in trauma patients. Furthermore, we discuss the importance of local delivery systems, such as implant coatings and bone cement, and how these systems may have an impact on the prevalence, prevention and treatment outcome of these complications.
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Halawi MJ, Morwood MP. Acute Management of Open Fractures: An Evidence-Based Review. Orthopedics 2015; 38:e1025-33. [PMID: 26558667 DOI: 10.3928/01477447-20151020-12] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 04/08/2015] [Indexed: 02/03/2023]
Abstract
Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma.
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Westhauser F, Zimmermann G, Moghaddam S, Bruckner T, Schmidmaier G, Biglari B, Moghaddam A. Reaming in treatment of non-unions in long bones: cytokine expression course as a tool for evaluation of non-union therapy. Arch Orthop Trauma Surg 2015; 135:1107-16. [PMID: 26085339 DOI: 10.1007/s00402-015-2253-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Indexed: 11/29/2022]
Abstract
UNLABELLED The analysis of peripheral serum cytokine expression patterns has been shown to be a possible method for demonstrating changes in bone metabolism. The aim of this study is to evaluate the effectiveness of this method within the treatment of long bone non-union with intramedullary reaming, a well-established non-union treatment concept. MATERIALS AND METHODS Three groups were added to this study: group one (G1) suffered from long bone non-unions, treated successfully with intramedullary reaming; group two (G2) consisted of long bone fractures with proper fracture healing; and group three (G3) included long bone fractures resulting in non-unions. We took blood samples on day 2, and after week 1, 4, 6, month 3 and 6 after initial treatment. Clinical and radiological follow-up were provided for 6 months. We measured transforming growth factor ß-1 (TGFß-1), platelet-derived growth factor (PDGF-AB), and insulin like growth factor-1 (IGF-1) at all-time points. RESULTS TGF-ß1 levels in G1 and G2 increased from day 2 to 6 weeks after surgery. In general, G1 and G2 showed parallel TGF-ß1 expression patterns, and G3 had a significant peak during first week compared to G1 (p = 0.023). PDGF peaked in G3 during first week after treatment, whereas G1 had its maximum after 4 weeks and G2 after 6 weeks. We were able to detect a significantly lower PDGF concentration at 3 months in G1 compared to G3 (p = 0.029). IGF-1 showed a peak concentration in G1 during the first 4 weeks. Afterwards, concentration levels in both G1 and G2 were higher. CONCLUSIONS Our study was able to show that the cytokine expression pattern in physiological bone healing is similar to that in successful non-union treatment with intramedullary reaming. Our results show that the effect of non-union therapy could be observed objectively by measuring cytokine expression patterns in peripheral blood even in a small group of patients.
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Affiliation(s)
- Fabian Westhauser
- Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, HTRG-Heidelberg Trauma Research Group, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
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17
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Metsemakers WJ, Roels N, Belmans A, Reynders P, Nijs S. Risk factors for nonunion after intramedullary nailing of femoral shaft fractures: Remaining controversies. Injury 2015; 46:1601-7. [PMID: 26026201 DOI: 10.1016/j.injury.2015.05.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 05/01/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing (IMN) is the preferred treatment for femoral shaft fractures in adults. Although previous studies published good outcomes, some controversies remain. The purpose of this retrospective study was to identify factors that influence outcome after IMN for femoral shaft fractures. MATERIALS AND METHODS Between July 1998 and July 2013, we treated 230 patients with 248 femoral shaft fractures. Statistical analyses were performed to determine predictors of nonunion. The following set of variables was selected based on the speculation that they would contribute to the outcome: sex (male or female), smoking, obesity, polytrauma, fracture type, open fractures, Gustilo type, primary external fixation (EF) and reaming. RESULTS Initial fracture stabilization was performed by IMN in 161 (64.9%) and by EF in 87 (35.1%) fractures. There were no documented cases of deep infection. Nonunion was diagnosed in 27 patients with 28 fractures (11.3%). Factors affecting nonunion in the univariate analysis were Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture type (odds ratio [OR] 25.0; p<0.0001), Gustilo type (OR 0.64; p=0.0358), and EF (OR 0.42; p=0.0401). Multiple logistic regression analysis only identified AO/OTA fracture type (OR 22.0; p<0.0001) as a risk factor for nonunion. Fracture reaming did not change the outcome (OR 0.80; p=0.6073). A separate analysis showed that damage control EF was not a risk factor in polytrauma patients (OR 0.76; p=0.5825). CONCLUSIONS Fracture stabilisation with IMN is a good treatment option for femoral shaft fractures in adults. The purpose of this study was to evaluate risk factors of poor outcome after IMN of femoral shaft fractures. The present analysis revealed that there was no difference in the outcome whether the fracture was reamed or not. Univariate and multivariate analysis could only correlate AO/OTA fracture type with the occurrence of nonunion. Therefore, in this study, unreamed nailing and damage control EF were not associated with a negative outcome.
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Affiliation(s)
- W-J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium.
| | - N Roels
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - A Belmans
- KU Leuven - University of Leuven, L-BioStat, B-3000 Leuven, Belgium
| | - P Reynders
- Department of Orthopaedic and Trauma Surgery, Brugmann University Hospital, B-1000 Brussels, Belgium
| | - S Nijs
- Department Development and Regeneration, KU Leuven - University of Leuven, B-3000 Leuven, Belgium; Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
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18
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Fantry AJ, Elia G, Vopat BG, Daniels AH. Distal femoral complications following antegrade intramedullary nail placement. Orthop Rev (Pavia) 2015; 7:5820. [PMID: 25874066 PMCID: PMC4387367 DOI: 10.4081/or.2015.5820] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/27/2015] [Indexed: 11/23/2022] Open
Abstract
While antegrade nailing for proximal and diaphyseal femur fractures is a commonly utilized fixation method with benefits including early mobilization and high rates of fracture union, both intraoperative and postoperative complications may occur. Intraoperative errors include leg length discrepancy, anterior cortical perforation, malreduction of the fracture, and neurovascular injury, and postoperative complications include nonunion, malunion, infection, and hardware failure. This case series reviews complications affecting the distal femur after intramedullary nailing including fracture surrounding a distal femoral interlocking screw (Case #1), nonunion after dynamization with nail penetration into the knee joint (Case #2), and anterior cortical perforation (Case #3). Prevention of intraoperative and postoperative complications surrounding intramedullary nailing requires careful study of the femoral anatomy and nail design specifications (radius of curvature), consideration of the necessity of distal interlocking screws, the need for close radiographic follow-up after nail placement with X-rays of the entire length of the nail, and awareness of possible nail penetration into the knee joint after dynamization.
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Affiliation(s)
- Amanda J Fantry
- Department of Orthopedic Surgery, Alpert Medical School at Brown University , Providence, RI, USA
| | - Gregory Elia
- Department of Orthopedic Surgery, Alpert Medical School at Brown University , Providence, RI, USA
| | - Bryan G Vopat
- Department of Orthopedic Surgery, Alpert Medical School at Brown University , Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Alpert Medical School at Brown University , Providence, RI, USA
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Alt V, Thormann U, Ray S, Zahner D, Dürselen L, Lips K, El Khassawna T, Heiss C, Riedrich A, Schlewitz G, Ignatius A, Kampschulte M, von Dewitz H, Heinemann S, Schnettler R, Langheinrich A. A new metaphyseal bone defect model in osteoporotic rats to study biomaterials for the enhancement of bone healing in osteoporotic fractures. Acta Biomater 2013; 9:7035-42. [PMID: 23434894 DOI: 10.1016/j.actbio.2013.02.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 01/01/2013] [Accepted: 02/01/2013] [Indexed: 11/18/2022]
Abstract
The intention of this study was to establish a new critical size animal model that represents clinically relevant situations with osteoporotic bone status and internally fixated metaphyseal defect fractures in which biomaterials for the enhancement of fracture healing in osteoporotic fracture defects can be studied. Twenty-eight rats were ovariectomized (OVX) and treated with a calcium-, phosphorus-, vitamin D3-, soy- and phytoestrogen-free diet. After 3months Dual-energy X-ray absorptiometry measurements showed statistically significant reductions in bone mineral density of the spine of -25.9% and of the femur of -21.3% of the OVX rats compared with controls, confirming osteoporosis in the OVX rats. The OVX rats then underwent either 3 or 5mm wedge-shaped osteotomy of the distal metaphyseal area of the femur that was internally stabilized with a T-shaped mini-plate. After 42days biomechanical testing yielded completely unstable conditions in the 5mm defect femora (bending stiffness 0Nmm(-2)) and a bending stiffness of 12,500Nmm(-2) in the 3mm defects, which showed the beginning of fracture consolidation. Micro-computed tomography showed statistically significant more new bone formation in the 3mm defects (4.83±0.37mm(2)), with bridging of the initial fracture defect area, compared with the 5mm defects (2.68±0.34mm(2)), in which no bridging of the initial defect was found. These results were confirmed by histology. In conclusion, the 5mm defect can be considered as a critical size defect model in which biomaterials can be tested.
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Affiliation(s)
- Volker Alt
- Department of Trauma Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, Giessen, Germany.
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Bagheri F, Sharifi SR, Mirzadeh NR, Hootkani A, Ebrahimzadeh MH, Ashraf H. Clinical outcome of ream versus unream intramedullary nailing for femoral shaft fractures. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:432-5. [PMID: 24349734 PMCID: PMC3838656 DOI: 10.5812/ircmj.4631] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 06/13/2012] [Accepted: 01/08/2013] [Indexed: 11/16/2022]
Abstract
Background Stabilization of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults; however, to ream or not to ream is still being debated. Objectives The primary objective of this study was to determine clinical results following unreamed versus ream intramedullary nailing of femoral fractures. Patients and Methods Between January 2008 and August 2009, 50 patients with femoral shaft fractures were treated with unreamed or reamed femoral nails in our clinic. From this prospective single centre study, 16 patients were excluded due to insufficient follow-up data. According to the AO classification, fractures in this study were either type A or B. Dynamic proximal locking was performed in all cases. The remaining 34 patients were divided into two groups of 17 with ream or unream nailing. During and after the operation, we evaluated some variables in whole series. Results After statistical analyzes, we found that there were no differences in radiologic union time (P = 1) or full weight bearing time (P = 0.73) between ream and unream nailing. Nail breakage or iatrogenic fractures during nail insertion did not occur and we did not have any fat emboli in both groups but one secondary loss of reduction occurred in the unream group. Superficial infection after the operation was seen in one case which was treated successfully with antibiotics. In the ream group surgical time was about thirty minutes longer and differences were significant (P = 0.000). Patients had to pay more for ream nailing but the difference was not significant. We found no statistical difference between union time with or without reaming; on the other hand, there was significant increased operation length, blood loss and systemic changes in BP or So2 in the ream group versus the unream group. Conclusions We advocate that unream nailing in traumatic femoral shaft fractures is a simple, safe and effective procedure with significant advantages, especially in multitrauma patients.
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Affiliation(s)
- Farshid Bagheri
- Orthopedic and Trauma Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Seyed Reza Sharifi
- Orthopedic and Trauma Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding author: Seyed Reza Sharifi, Orthopedic and Trauma Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel/Fax: +98-5118417453, E-mail:
| | - Navid Reza Mirzadeh
- Orthopedic and Trauma Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Alireza Hootkani
- Orthopedic and Trauma Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Mohamad Hosein Ebrahimzadeh
- Orthopedic and Trauma Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Hami Ashraf
- Orthopedic and Trauma Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, IR Iran
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Risk factors for nonunion in 337 displaced midshaft clavicular fractures treated with Knowles pin fixation. Arch Orthop Trauma Surg 2013; 133:15-22. [PMID: 23080421 DOI: 10.1007/s00402-012-1631-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures. METHODS The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion. RESULTS A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion (p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion. CONCLUSIONS Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion.
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Fang X, Jiang L, Wang Y, Zhao L. Treatment of Gustilo grade III tibial fractures with unreamed intramedullary nailing versus external fixator: a meta-analysis. Med Sci Monit 2012; 18:RA49-56. [PMID: 22460106 PMCID: PMC3560815 DOI: 10.12659/msm.882610] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Unreamed Intramedullary nailing and external fixation are 2 major treatments widely used in Gustilo grade III open tibial fractures, but the difference in effectiveness and complication remains controversial. We retrieved original publications of comparative studies from medical literature databases and selected 9 of them for a meta-analysis. Observation items include malunion and deep infection rate, non-union and comparison of time to union. The analysis showed a lower malunion rate using unreamed intramedullary nailing than external fixation. No significant differences were revealed in deep infection/nonunion rate and time to union. More studies of larger scale and better design are needed to reach an ultimate and definite conclusion.
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Affiliation(s)
- Xiao Fang
- Changzheng Hospital, 2nd Military Medical University, Shanghai, China
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23
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Gelalis ID, Politis AN, Arnaoutoglou CM, Korompilias AV, Pakos EE, Vekris MD, Karageorgos A, Xenakis TA. Diagnostic and treatment modalities in nonunions of the femoral shaft: a review. Injury 2012; 43:980-8. [PMID: 21741650 DOI: 10.1016/j.injury.2011.06.030] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 05/28/2011] [Accepted: 06/15/2011] [Indexed: 02/02/2023]
Abstract
Nonunions of the femoral shaft represent a treatment challenge for the orthopaedic surgeon and a serious socioeconomic problem for the patient. Inadequate fracture stability, insufficient blood supply, bone loss or presence of infection are the main reasons for the development of a nonunion. Careful classification and exclusion of infection are crucial for the choice of the proper treatment alternative. Nail dynamization, primary intramedullary nailing or nail exchange, plate osteosynthesis and external fixation along with bone grafting, usage of bone substitutes and electrical stimulation can stimulate osseous union. A review of the aetiology, classification and treatment should prove helpful managing this serious complication.
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Affiliation(s)
- Ioannis D Gelalis
- Department of Orthopaedic Surgery and Traumatology, University of Ioannina, School of Medicine, Ioannina, Greece.
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Tang P, Hu L, Du H, Gong M, Zhang L. Novel 3D hexapod computer-assisted orthopaedic surgery system for closed diaphyseal fracture reduction. Int J Med Robot 2011; 8:17-24. [PMID: 22081502 DOI: 10.1002/rcs.417] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 06/16/2011] [Accepted: 06/17/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Long-bone fractures are very common in trauma centers. The conventional Arbeitsgemeindschaft fur Osteosynthesefragen (AO) technique contributes to most fracture healing problems, and external fixation technology also has several disadvantages, so new techniques are being explored. METHOD A novel hexapod computer-assisted fracture reduction system based on a 3D-CT image reconstruction process is presented for closed reduction of long-bone diaphyseal fractures. A new reduction technique and upgraded reduction device are described and the whole system has been validated. RESULTS Ten bovine femoral fracture models were used with random fracture patterns. Tests results were as follows: residual deviation 1.24 + 0.65 mm for the axial deflection, 1.19 + 0.37 mm for the translation, 2.34 + 1.79° for the angulation, and 2.83 + 0.9° for the rotation. CONCLUSION The reduction mechanism has the advantages of high positioning, reduction and computer accuracy, and intra-operative stability for both patients and surgical team. With further investigation, it could be applied in many kinds of long-bone diaphyseal fractures.
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Affiliation(s)
- Peifu Tang
- Chinese PLA General Hospital, Department of Orthopaedics, Beijing, China
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25
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Abstract
Despite the continuous advances of surgical solutions, still 1-7% of fractures develop non-unions. The delays in fracture healing increase the period of incapacity of the patient with major consequences, on the psychological and functional recovery, but also on the direct and indirect health-related costs. In particular, femoral diaphyseal non-unions are often characterised by a challenging and long-lasting period of healing. The clinician treating these complex cases has to consider amongst other parameters, the condition of the soft tissue envelope, the adequacy of any pre-existing fixation, the alignment and length of the affected limb, the potential presence of an infection, as well as the general condition of the patient. Open reduction and plate fixation of femoral diaphyseal non-unions offers a valid alternative of stabilisation and if applied to carefully selected cases, can give optimal results.
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Affiliation(s)
- Francesco Benazzo
- Clinic of Orthopaedics and Traumatology, Foundation IRCCS Policlinico S. Matteo, Viale Golgi 19, 27100 Pavia, Italy.
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Affiliation(s)
- Peter V Giannoudis
- Academic Department Orthopaedic Trauma Surgery, Leeds University, Leeds, UK
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Wild M, Gehrmann S, Jungbluth P, Hakimi M, Thelen S, Betsch M, Windolf J, Wenda K. Treatment strategies for intramedullary nailing of femoral shaft fractures. Orthopedics 2010; 33:726. [PMID: 20954660 DOI: 10.3928/01477447-20100826-15] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).
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Affiliation(s)
- Michael Wild
- Department of Trauma and Hand Surgery, Heinrich Heine University Hospital Düsseldorf, Germany
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Blum ALL, BongioVanni JC, Morgan SJ, Flierl MA, dos Reis FB. Complications associated with distraction osteogenesis for infected nonunion of the femoral shaft in the presence of a bone defect: a retrospective series. ACTA ACUST UNITED AC 2010; 92:565-70. [PMID: 20357336 DOI: 10.1302/0301-620x.92b4.23475] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistent pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.
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Affiliation(s)
- A L L Blum
- Department of Orthopaedics and Traumatology, Federal University, Rua Borges Lagoa, São Paulo, Brazil
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Gross T, Huettl T, Audigé L, Frey C, Monesi M, Seibert FJ, Messmer P. How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe. Injury 2010; 41:388-95. [PMID: 19900673 DOI: 10.1016/j.injury.2009.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 07/01/2009] [Accepted: 10/12/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA). METHODS Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05). RESULTS Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values. CONCLUSIONS Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.
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Affiliation(s)
- Thomas Gross
- Computer Assisted Radiology & Surgery, University Hospital Basel, Realpstrasse 54, CH-4057 Basel, Switzerland.
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Kanakaris NK, Lasanianos N, Calori GM, Verdonk R, Blokhuis TJ, Cherubino P, De Biase P, Giannoudis PV. Application of bone morphogenetic proteins to femoral non-unions: a 4-year multicentre experience. Injury 2009; 40 Suppl 3:S54-61. [PMID: 20082793 DOI: 10.1016/s0020-1383(09)70013-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fracture non-unions often complicate orthopaedic trauma. BMPs (bone morphogenetic proteins) are currently considered the most appealing osteoinductive agents. Applications of BMP-7 since January 2004 were prospectively recorded in a multicentre registry of aseptic femoral non-unions. The study included 30 patients who had undergone a median of 1 revision operation before BMP-7 application and who were followed up for a median 24 months. In 23/30 cases the application of BMP-7 was combined with revision of the fixation, and in 12 it was combined also with autograft. Non-union healing was verified in 26/30 cases in a median period of 6 months. No adverse events were associated with BMP-7 application. Our case series supports the safety and efficacy of BMP-7 in femoral non-unions. Multicentre networks and systematic, long-term follow-up of patients may improve understanding of this promising osteoinductive bone substitute.
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Affiliation(s)
- N K Kanakaris
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds LS1 3EX, UK
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Surgical techniques: how I do it? The Reamer/Irrigator/Aspirator (RIA) system. Injury 2009; 40:1231-6. [PMID: 19783249 DOI: 10.1016/j.injury.2009.07.070] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 07/20/2009] [Indexed: 02/02/2023]
Abstract
Although reamed intramedullary nailing has long been considered a safe procedure, pulmonary complications have been reported in some groups of patients. Concerns over fat embolisation, adult respiratory distress syndrome (ARDS), and sudden intraoperative death have prompted some authors to question whether the benefits of reaming are outweighed by its potential adverse effects to the patient. In response to these complications, recent evaluations have focused on alternative systems that reduce intramedullary pressure during reaming. The Reamer/Irrigator/Aspirator (RIA) system (Synthes, Inc., West Chester, PA) was developed as a simultaneous reaming and aspiration system to reduce the intramedullary pressure, heat generation, operating time, and systemic effects of reaming. It was designed with an aggressive one-pass reamer head which is connected to a hand-held reamer via a drive shaft, simultaneously irrigating and aspirating femoral canal contents during reaming, thus preventing thermal necrosis and fat embolisation. After its early use, investigators examined the "aspirate" captured by the RIA which appeared to be loaded with osteogenic substrates. This discovery revealed a second potential use for the RIA-a bone graft harvester. The different design characteristics and technicalities of the RIA system necessitate a deep and clear understanding of its technique, a meticulous preoperative planning and a strict adherence to its principles intraoperatively. We present our current approach to the use of the RIA system, including the preoperative planning, the details of the operative procedure, the pitfalls and the potential complications that could be encountered.
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