Malalignment in intramedullary nailing. How to achieve and to maintain correct reduction?

Which of the three different intramedullary nail designs is superior in the treatment of femoral shaft fractures?

Aim: The aim of this study a retrospective comparison was the clinical and radiological results results of patients with femoral shaft fracture made oftreated with three different types of intramedullary nail (IMN). Material and Method: The study included 54 patients operated on in our clinic because of femoral shaft fracture. The records were retrospectively examined of 18 patients applied with locked IMN (LIMN), 17 with blade expandable IMN (BEIMN), and 19 with talon distalfix IMN (TDIMN). The groups were compared statistically in respect of age, gender, BMI, affected side, operating time (mins), radiation exposure (number of shots), time to union (weeks), visual analog scale (VAS) score, soft tissue problems associated with implant irritation, amount of shortening (mm), coronal, sagittal and torsional angulation (degrees). Results: The mean VAS score of the TDIMN group was determined to be statistically significantly higher than that of the LIMN and BEIMN groups (p=0.008, p=0.045). The operating times were similar in the BEIN and TDIMN groups (p=0.768) and significantly shorter than in the LIMN group (p

Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study

Objectives:

To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures.

Design:

Retrospective comparative study.

Setting:

Level I trauma center.

Patients:

Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017.

Intervention:

IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws.

Main outcome measures:

Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane).

Results:

Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05).

Conclusions:

The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone.

Level of evidence:

Therapeutic Level III.

Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm

Pertrochanteric hip fractures are among the most common and the use of short cephalomedullary nails as the treatment of choice is increasing.

A systematic review regarding distal locking options for short cephalomedullary nails was undertaken using Medline/PubMed®, Embase® and Cochrane Library® in order to evaluate current indications, associated complications and to provide treatment recommendations.

The results seem to support the use of distal static locking for unstable fractures, dynamic locking for length stable/rotational unstable fractures and no locking for stable fractures.

Complications associated with distal locking include iatrogenic fractures, thigh pain, delayed union and nonunion, implant failure, screw loosening and breaking, drill bit breaking, soft tissue irritation, femoral artery branch injury, intramuscular haematoma and compartment syndrome. It is also associated with longer operative time and radiation exposure.

In unlocked constructs, dorsomedial comminution and nail/medullary canal mismatch contribute to peri-implant fractures. Anterior cortical impingement is associated with cut-out and nonunion.

Most studies comparing distally locked and unlocked nails report a short follow-up.

Distal locking mode should be based on the fracture’s stability.

Cite this article: EFORT Open Rev 2020;5:421-429. DOI: 10.1302/2058-5241.5.190045

Development of a novel fracture fragment stabilization system for minimally invasive osteosynthesis and in vitro comparison to traditional Kern bone reduction forceps

OBJECTIVE

To develop and evaluate a novel fracture fragment stabilization system, the Sirius minimally invasive bone reduction handle system (SMH), in an artificial fracture model (FxM) simulating a canine femoral fracture repair with a minimally invasive orthopedic approach.

STUDY DESIGN

In vitro experimental study.

SAMPLE POPULATION

Synthetic fractured femurs with soft-tissue coverage analog (n = 8).

METHODS

The developed SMH consisted of modified Kern forceps connected with existing external skeletal fixation components. Intramedullary Steinman pin placement with the SMH or traditional Kern forceps only (KO) was performed by 16 participants in randomized order. Demographics and surgical experience of participants and outcome variables (fragment movement, early/final gap formation, time of procedure, assessed practicability by visual analog scale) were recorded and statistically evaluated.

RESULTS

The SMH was more difficult and took longer to assemble (P = .031 and P = .008); SMH resulted in a smaller final reduction gap (P = .008). More surgical experience resulted in faster surgery times (R² = 0.766) but was not correlated with final fracture gap formation.

CONCLUSION

The SMH was associated with reduced fragment gap formation in this simulated setting.

CLINICAL SIGNIFICANCE

The SMH may be helpful for maintaining reduction of femoral fractures in dogs. Additional studies of the SMH should be conducted to fully assess the effectiveness and practicality in clinical cases.