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Chinese Journal of Traumatology =... Sep 2023Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including... (Review)
Review
Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.
Topics: Humans; Femoral Fractures; Bone Nails; Femur; Fracture Fixation, Intramedullary; Lower Extremity
PubMed: 37031048
DOI: 10.1016/j.cjtee.2023.03.006 -
Veterinary Surgery : VS Jul 2023To compare pin placement accuracy, intraoperative technique deviations, and duration of pin placement for pins placed by free-hand probing (FHP) or 3D-printed drill...
OBJECTIVE
To compare pin placement accuracy, intraoperative technique deviations, and duration of pin placement for pins placed by free-hand probing (FHP) or 3D-printed drill guide (3DPG) technique.
SAMPLE POPULATION
Four greyhound cadavers.
METHODS
Computed tomography (CT) examinations from T6-sacrum were obtained for determination of optimal pin placement and 3DPG creation. Two 3.2/2.4-mm positive profile pins were inserted per vertebra, one left and one right from T7-L7 (FHP [n = 56]; 3DPG [n = 56]) by one surgeon and removed for repeat CT. Duration of pin placement and intraoperative deviations (unanticipated deviations from planned technique) were recorded. Pin tracts were graded by two blinded observers using modified Zdichavsky classification. Descriptive statistics were used.
RESULTS
A total of 54/56 pins placed with 3DPGs were assigned grade I (optimal placement) compared with 49/56 pins using the FHP technique. A total of 2/56 pins placed with 3DPGs and 3/56 pins using the FHP technique were assigned grade IIa (partial medial violation). A total of 4/56 pins placed using the FHP technique were assigned grade IIIa (partial lateral violation). No pins were assigned grade IIb (full medial violation). Intraoperative technique deviations occurred with 6/56 pins placed using the FHP technique and no pins with 3DPGs. Overall, pins were placed faster (mean ± SD 2.6 [1.3] vs. 4.5 [1.8] min) with 3DPGs.
CONCLUSIONS
Both techniques were accurate for placement of spinal fixation pins. The 3DPG technique may decrease intraoperative deviations and duration of pin placement.
CLINICAL RELEVANCE
Both techniques allow accurate pin placement in the canine thoracolumbar spine. The FHP technique requires specific training and has learning curve, whereas 3DPG technique requires specific software and 3D printers.
Topics: Dogs; Animals; Bone Nails; Fracture Fixation; Tomography, X-Ray Computed; Printing, Three-Dimensional
PubMed: 37071824
DOI: 10.1111/vsu.13958 -
Journal of Orthopaedic Surgery (Hong... Dec 2015
Topics: Bone Nails; Bone Plates; Female; Femoral Fractures; Fracture Fixation, Intramedullary; Fractures, Ununited; Humans; Male
PubMed: 27101638
DOI: 10.1177/230949901502300335 -
Clinical Orthopaedics and Related... May 2017The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixator. Although in widespread use, little comparative data exist to... (Comparative Study)
Comparative Study
BACKGROUND
The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixator. Although in widespread use, little comparative data exist to quantify the biomechanical effect of substituting the tried-and-tested Ilizarov construct for the TSF hexapod system.
QUESTIONS/PURPOSES
This study was designed to investigate the mechanical properties of the TSF system under physiologic loads, with and without the addition of a simulated bone model, with comparison to the standard Ilizarov frame.
METHODS
The mechanical behaviors of three identical four-ring TSF and Ilizarov constructs were tested under levels of axial compression, bending, and rotational torque to simulate loading during normal gait. An acrylic-pipe fracture model subsequently was mounted, using fine wires and 5 mm half pins, and the testing was repeated. Load-deformation curves, and so rigidity, for each construct were calculated, with statistical comparisons performed using paired t-tests.
RESULTS
Under axial loading, the TSF was found to be less rigid than the Ilizarov frame (645 ± 57 N/mm versus 1269 ± 256 N/mm; mean difference, 623 N/mm; 95% CI, 438.3-808.5 N/mm; p < 0.001), but more rigid under bending and torsional loads (bending: 42 ± 9 Nm/degree versus 78 ± 13 Nm/degree; mean difference, 37 Nm/degree; 95% CI, 25.0-47.9 Nm/degree; p < 0.001; torsion: 16 ± 2 Nm/degree versus 5 ± 0.35 Nm/degree; mean difference, 11 Nm/degree; 95% CI, 9.5-12.2 Nm/degree; p < 0.001). On mounting the bone models, these relationships broadly remained in the half-pin and fine-wire groups, however the half-pin constructs were universally more rigid than those using fine wires. This effect resulted in the TSF, using half pins, showing no difference in axial rigidity to the fine-wire Ilizarov (107 ± 3 N/mm versus 107 ± 4 N/mm; mean difference, 0.05 N/mm; 95% CI, -6.99 to 7.1 N/mm; p > 0.999), while retaining greater bending and torsional rigidity. Throughout testing, a small amount of laxity was observed in the TSF construct on either side of neutral loading, amounting to 0.72 mm (±0.37 mm) for a change in loading between -10 N and 10 N axial load, and which persisted with the addition of the synthetic fracture model.
CONCLUSIONS
This study broadly shows the TSF construct to generate lower axial rigidity, but greater bending and torsional rigidity, when compared with the Ilizarov frame, under physiologic loads. The anecdotally described laxity in the TSF hexapod strut system was shown in vitro, but only at low levels of loading around neutral. It also was shown that the increased stiffness generated by use of half pins produced a TSF construct replicating the axial rigidity of a fine-wire Ilizarov frame, for which much evidence of good clinical and radiologic outcomes exist, while providing greater rigidity and so improved resistance to potentially detrimental bending and rotational shear loads.
CLINICAL RELEVANCE
If replicated in the clinical setting, these findings suggest that when using the TSF, care should be taken to minimize the observed laxity around neutral with appropriate preloading of the construct, but that its use may produce constructs better able to resist bending and torsional loading, although with lower axial rigidity. Use of half pins in a TSF construct however may replicate the axial mechanical behavior of an Ilizarov construct, which is thought to be conducive to bone healing.
Topics: Biomechanical Phenomena; Bone Nails; Compressive Strength; Equipment Design; Equipment Failure; External Fixators; Ilizarov Technique; Materials Testing; Rotation; Stress, Mechanical; Torque
PubMed: 27896679
DOI: 10.1007/s11999-016-5182-8 -
International Journal of Surgery... Oct 2015Intramedullary nails (IM nails) now include dedicated fibular nails for lateral malleolus fractures. This study reviewed nail versus plate for fixation of unstable ankle... (Comparative Study)
Comparative Study Review
INTRODUCTION
Intramedullary nails (IM nails) now include dedicated fibular nails for lateral malleolus fractures. This study reviewed nail versus plate for fixation of unstable ankle fractures.
DESIGN
Systematic review and meta-analysis of published reports.
RESULTS
Four studies met the inclusion criteria, including 375 patients. Two included studies were randomised-control studies and two were non-randomised case series. The implants investigated included: Knowles Pins, Fibular Nails, Rush Rods and Inyo Nails. The overall risk of bias was high. Pooled data showed a statistically significant lower risk of wound infection (RR 0.10; 95% CI 0.02 to 0.44), symptomatic hardware (RR 0.14; 95% CI 0.05 to 0.35) and removal of hardware (RR 0.57; 95% CI 0.39 to 0.81) with intramedullary nail fixation.
CONCLUSIONS
There is a paucity of literature upon which to draw reliable conclusions. There was a high risk of bias towards favourable outcomes for the nail group. It would appear that intramedullary nail fixation of distal fibular fractures can outperform conventional fixation with plate and screws. There is a need for adequately powered, scientific trials.
Topics: Ankle Fractures; Bone Nails; Bone Plates; Fracture Fixation, Internal; Humans
PubMed: 26255000
DOI: 10.1016/j.ijsu.2015.07.697 -
Tidsskrift For Den Norske Laegeforening... Oct 2017The purpose of the study was to conduct a systematic analysis based on data from the Norwegian Patient Registry and describe the incidence and treatment of wrist...
BACKGROUND
The purpose of the study was to conduct a systematic analysis based on data from the Norwegian Patient Registry and describe the incidence and treatment of wrist fractures among adults, at national level and in the catchment areas of the various regional health authorities.
MATERIAL AND METHOD
A search was conducted in the Norwegian Patient Registry for all patients aged ≥ 18 years with diagnosis codes for wrist fractures in the period 2009–2014. Age, sex and type of treatment were recorded. The results are presented as rates adjusted for age and sex for the catchment areas of Norway’s 21 regional health authorities.
RESULTS
In the period 2009–2014, a total of 75 132 patients aged ≥ 18 years were registered as having a wrist fracture. Almost 1/3 of these patients received operative treatment. During this period, the age- and sex-adjusted rate of wrist fractures in Norway averaged 244 per 100 000 inhabitants per year. Operation rates varied across catchment areas by a factor of three, and the use of plates by a factor of nine.
INTERPRETATION
We found great variation in clinical practice, which is reflected in differences in operation rates and choice of surgical method across the catchment areas to which the patients belong.
Topics: Adult; Age Factors; Aged; Bone Nails; Bone Plates; Conservative Treatment; Female; Fracture Fixation; Fracture Fixation, Internal; Fractures, Bone; Humans; Male; Middle Aged; Norway; Registries; Sex Factors; Wrist Injuries; Young Adult
PubMed: 29043745
DOI: 10.4045/tidsskr.17.0065 -
European Spine Journal : Official... Jul 2009The objective of our study is to report a rare complication of halo pin insertion associated with an epileptic seizure and brain abscess, and to discuss the diagnostic... (Review)
Review
The objective of our study is to report a rare complication of halo pin insertion associated with an epileptic seizure and brain abscess, and to discuss the diagnostic and therapeutic approach to its management. The treatment of unstable cervical spine injuries with a halo vest is an established procedure. Complications of pin penetration such as brain abscess and seizure are rare, and need to be urgently treated. Intracranial abscess and seizure associated with the use of the halo device is an unusual complication, and only a few cases have been reported in the literature. A 21-year-old male had a halo vest placed for the management of an odontoid type II fracture, which he sustained from a motor vehicle accident. Ten weeks after halo ring placement he complained of headaches which relieved by analgesics. After 2 weeks he was admitted at the emergency unit in an unconscious condition after a generalized tonic-clonic seizure. The halo pins were displaced during the seizure and were removed at his admission. No drainage was noted from the pin sites, and a Philadelphia cervical collar was applied. A brain CT and MRI revealed intracranial penetration of both posterior pins and a brain abscess in the right parietal lobe. Computed tomography of the cervical spine revealed stable fusion of the odontoid fracture. Cultures from the pin sites were negative; however, intravenous wide spectrum antibiotic treatment was administered to the patient immediately for 4 weeks followed by oral antibiotics for additional 2 weeks. Anti-epileptic medication was also started at his admission. The patient was discharged from the hospital in 6 weeks without symptoms, continuing anti-epileptic medication. On the follow-up visits he had fully recovered without any neurologic sequelae. In conclusion, complications of halo pin penetration are rare which need immediate intervention. Any neurologic or infectious, local or generalized, symptom need to be investigated urgently with available imaging techniques and treated promptly. Pin over-tightening may cause bone penetration and possible deep cranial infection with serious complications.
Topics: Anti-Bacterial Agents; Anticonvulsants; Bone Nails; Brain Abscess; Device Removal; Epilepsy; Fractures, Bone; Humans; Magnetic Resonance Imaging; Male; Odontoid Process; Tomography, X-Ray Computed; Traction; Treatment Outcome; Young Adult
PubMed: 18751739
DOI: 10.1007/s00586-008-0759-x -
Joint Diseases and Related Surgery 2021This study aims to mechanically compare five different extra-focal bi-cortical pin configurations (using two and three pins) employed for fixation of a simulated...
OBJECTIVES
This study aims to mechanically compare five different extra-focal bi-cortical pin configurations (using two and three pins) employed for fixation of a simulated unstable extra-articular distal radius fracture with dorsal comminution using a sawbone model.
MATERIALS AND METHODS
This in vitro mechanical study was conducted between June 2019 and July 2019. A standard fracture model (Arbeitsgemeinschaft für Osteosynthesefragen [AO] type 23-A3.3) was created using a fourth generation composite artificial radius bone. Five groups with two- and three-pin configurations were tested under axial, volar, and dorsal loading with a universal test device. Mean stiffness values were compared statistically.
RESULTS
Comparison of stiffness values from axial and volar loading tests between groups in paired comparison showed no statistically significant difference (p=0.194 and p=0.086, respectively). Dorsal loading tests showed statistically significant difference between the groups in pairwise comparison (p=0.002). Three-pin groups (Groups 3, 4, and 5) had higher stiffness values compared to two-pin groups (Groups 1 and 2) in dorsal loading tests (p=0.001). Three-pin configuration test groups with two divergent or convergent pins from the radial styloid performed better compared to both two-pin groups (p=0.01, p=0.002) in dorsal loading tests.
CONCLUSION
Our data demonstrated that the three-pin configuration with two divergent or convergent Kirschner wires from the styloid and a third wire from the dorsal/ulnar cortex had higher stiffness values compared to two-pin configurations in dorsal loading tests. When indicated, we suggest the use of a three-pin construct. Particularly in cases with a risk of volar angulation, we recommend a three-pin configuration with two divergent or convergent bi-cortical Kirschner wires.
Topics: Bone Nails; Comparative Effectiveness Research; Fracture Fixation, Intramedullary; Humans; Materials Testing; Mechanical Phenomena; Radius Fractures
PubMed: 33463418
DOI: 10.5606/ehc.2021.75817 -
European Journal of Medical Research Jan 2022Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers...
INTRODUCTION
Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure.
MATERIALS AND METHODS
We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal-pertrochanteric, subtrochanteric-or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected.
RESULTS
A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 ± 13.5 years and in the PO group was 65.6 ± 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure.
CONCLUSION
Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site.
Topics: Aged; Bone Nails; Bone Plates; Female; Femoral Fractures; Follow-Up Studies; Fracture Fixation, Intramedullary; Fracture Healing; Humans; Male; Postoperative Complications; Retrospective Studies
PubMed: 35027077
DOI: 10.1186/s40001-021-00630-7 -
Medicina (Kaunas, Lithuania) Jun 2022Freehand distal interlocking of intramedullary nails is technically demanding and prone to handling issues. It requires precise placement of a screw through the nail...
Freehand distal interlocking of intramedullary nails is technically demanding and prone to handling issues. It requires precise placement of a screw through the nail under fluoroscopy guidance and can result in a time consuming and radiation expensive procedure. Dedicated training could help overcome these problems. The aim of this study was to assess construct and face validity of new Digitally Enhanced Hands-On Surgical Training (DEHST) concept and device for training of distal interlocking of intramedullary nails. Twenty-nine novices and twenty-four expert surgeons performed interlocking on a DEHST device. Construct validity was evaluated by comparing captured performance metrics-number of X-rays, nail hole roundness, drill tip position and drill hole accuracy-between experts and novices. Face validity was evaluated with a questionnaire concerning training potential and quality of simulated reality using a 7-point Likert scale. Face validity: mean realism of the training device was rated 6.3 (range 4-7). Training potential and need for distal interlocking training were both rated with a mean of 6.5 (range 5-7), with no significant differences between experts and novices, ≥ 0.234. All participants (100%) stated that the device is useful for procedural training of distal nail interlocking, 96% wanted to have it at their institution and 98% would recommend it to colleagues. Construct validity: total number of X-rays was significantly higher for novices (20.9 ± 6.4 versus 15.5 ± 5.3, = 0.003). Success rate (ratio of hit and miss attempts) was significantly higher for experts (novices hit: = 15; 55.6%; experts hit: = 19; 83%, = 0.040). The evaluated training device for distal interlocking of intramedullary nails yielded high scores in terms of training capability and realism. Furthermore, construct validity was proven by reliably discriminating between experts and novices. Participants indicate high further training potential as the device may be easily adapted to other surgical tasks.
Topics: Bone Nails; Bone Screws; Fluoroscopy; Fracture Fixation, Intramedullary; Humans; Radiography
PubMed: 35744036
DOI: 10.3390/medicina58060773