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PubMed1994

The role of intramedullary nailing in modern treatment of open fractures of the tibia and femur.

The increasing incidence of open tibial and femoral fractures causes great suffering by patients and is an enormous economic burden, necessitating improved treatment. The current treatment of these fractures is reviewed, as well as the evolving role of intramedullary nailing in this treatment. Intramedullary nailing seems to give better results than external fixation in Gustilo type I and II fractures, and is at least as good in type III. The introduction of the non-reamed interlocking intramedullary nail may bring about even better outcomes. Any improvements in treatment should be based on thorough understanding of the biology and biomechanics of the injury.

Bone Nails↗
PubMed2001

Comparison of absorbable poly-L-lactide and metallic intramedullary rods in the fixation of femoral shaft osteotomies: an experimental study in rabbits.

An osteotomy of the distal femoral diaphysis was fixed with an intramedullary self-reinforced poly-L-lactide (SR-PLLA) rod in 22 and with a metallic rod in 38 skeletally mature rabbits. Histomorphometric and quantitative computed tomography (QCT) were performed to assess time-related changes in the consolidation process of the osteotomy of cortical bone and development of the external callus. The follow-up times were 8, 16, 24, and 48 weeks for radiologic and 16, 24, and 48 weeks for histologic studies; 19/22 of the SR-PLLA and 34/38 of the metallic fixed osteotomies healed during the observation periods. On microscopic evaluation, no difference was found in histologic parameters such as external callus area and fraction, and endosteal callus area and fraction between SR-PLLA and metallic fixed osteotomies. The total external callus area increased up to 16 weeks and subsequently decreased linearly over time in both experimental groups. However, the mean endosteal bone area and fraction decreased after 16 weeks in metallic fixated femora, while in the SR-PLLA fixated femora, both these values increased, being greater in the SR-PLLA group. The mean external callus QCT density decreased after 8 weeks in both experimental groups, the decrease being greater in the SR-PLLA group. Nevertheless, no significant difference was detected between SR-PLLA and metallic fixed femora in any of the follow-ups. These results suggest that both SR-PLLA and metallic rods are suitable in the fixation of femoral shaft osteotomies in rabbits. Furthermore, SR-PLLA rod fixation seems to have a minor stress-shielding effect.

Animals↗
PubMedDate not supplied

Ender nailing versus external fixation in the stabilization of type III open tibial shaft fractures.

UNLABELLED: Management of severe open tibial shaft fractures presents a difficult challenge to the orthopaedic surgeon. They are frequently associated with loss of limb, infection and high levels of morbidity. All the authors considered, now, that there are five keys to successful treatment: antibiotic therapy, radical debridement and pulsed lavage irrigation, stabilization of fracture with minimal further devascularization, early soft tissue coverage and early bone-grafting. It rests, also, a number of controversies in the management of open tibial fractures, not least of which is the method of fracture stabilization: the choice between intramedullary nailing and external skeletal fixation, the use of reamed or unreamed nails. MATERIAL AND METHODS: Fifty-seven patients with 62 open fractures of the tibial shaft type IIIA, B and C (Gustilo) were treated between 1.01.1994 and 31.12.1998 in the Department of Orthopaedic Surgery of the Emergency Hospital, Iasi, Romania. There were 29 cases type IIIA fractures, 26 cases type IIIB and 7 cases type IIIC (Mess score showed the viability of the limb). Our patients were 36 males and 21 females; their mean age was 36 years (range 17 to 70). Forty-six patients were injured in road traffic accidents and 11 in other traumatic incidents. In 33 cases the skeletal stabilization was achieved by Ender nailing under general or regional anesthesia. In 15 cases we used a bilateral uniplanar external fixator (Burghele) and 14 fractures were stabilized with an Ilizarov external fixator. We note a secondary amputation after the failure of the revascularization of the limb in a type IIIC fracture. RESULTS: All fractures united; the mean time to union was 30.2 weeks--in the external fixation group and 26.4 weeks--in the Ender nailing group. Malunions occurred slightly more frequently in the external fixation group that in the Ender nailing group (15.7% versus 5.8%). We noted--also--more secondary procedures required in the external fixation group. The infection rate was 3 of 33 (9.1%) in the Ender nailing group compared to 4 deep (13.8%) and 8 pin-tract infection (27.6%) in the external fixation group. CONCLUSIONS: Our study suggests that Ender nailing has several advantages over external fixation in the management of severe open tibial shafts fractures. Based on these results, over the last years, in our Department we use mainly the Ender nailing technique, as we consider it a better approach for these type of lesions.

Adolescent↗
PubMed1999

The classic nail in the therapy of trochanteric fractures.A prospective, controlled study.

In a prospective controlled study we analysed the classic nail, a new intramedullary implant for the fixation of peritrochanteric fractures. By means of lateral bending of 4 degrees, unreamed implantation is generally possible. Our collective of 85 patients was characterized by elderly mean age (82.3 years), a predominance of female patients (4.3 : 1), a minor trauma aetiology without relevant additional injuries, and a high rate of concomitant disease (92%). Only 31A-type femur fractures were treated, with a low specific complication rate of 13%, whereby operative revision was necessary in only two patients (3%). A good anatomic reconstruction and full weight-bearing with the osteosynthesis was achieved in the majority of patients. No secondary shaft fractures and only one case of cutting out was observed. The mortality (30 days: 18%, 6 months: 25%) as well as the high rate of unspecific complications (20%) were caused by the patients' multiple morbidity. Deficits in the Merle d'Aubigne score at follow-up after 6 months can be interpreted within the same context. Nevertheless, 85% could return to their former social environment and only 15% became dependent on a nursing institution in connection with the fracture treatment.

Aged↗
PubMed2003

[Effect of absorbable poly-DL-lactide rods on experimental fracture healing].

This study was designed to assess the effect of a home-bred poly-DL-lactide (PDLLA) rods on experimental fracture healing. An operation was performed to create bilateral ulnar and radial fractures of forearm in 15 rabbits. The right sides were fixed with 2 PDLLA (Mv = 34 x 10(4), 1.6 mm x 1.6 mm x 30 mm) rods, and the contralateral sides were fixed with 2 Kirschner wires to be used as controls. After operation, casts were used for external fixation, and the joint above and the joint below the fracture were immobilized. The casts were removed at the 6th week after operation. The specimens were removed at specific intervals between 2 and 12 weeks. Histologically, the light microscopy and scanning electron microscopy evaluation of the rabbit ulnar and radial fractures fixation revealed that, the fractured bone gradually healed and the PDLLA rods properly fixed on the fracture area during the implanted period. However, results suggest that internal fixation by absorbable material made the course of fracture healing slower than that in the control group, but the osteogenesis appeared to be normal. In the absorbable group, the collagenous fiber was characterized by order and orientation, and calcified normally. In conclusion, this kind of PDLLA rods have an effect on delaying the process of the normal union of fracture and should be applicable to fractures where the tissues are rich in blood supply.

Absorbable Implants↗
PubMed1993

Closed intramedullary biopsy for metastatic disease.

The surgical stabilization of metastatic fractures or impending fractures of long bones is recommended with the use of intramedullary nails. While the primary tumour has often been diagnosed previously, there are occasions when the fracture may be the presenting feature of malignancy. In both circumstances surgical oncologists require a histological diagnosis from around the fracture site so that any adjuvant therapy can be planned. Open biopsy is often employed although a closed method has been used by percutaneous puncture. Although intramedullary specimens have been obtained before with long bronchial type biopsy forceps, we report a simple and reliable technique for closed biopsy taken from intramedullary reamings at the time of fracture fixation. Lesions from both the femur and the humerus are amenable to this technique.

Aged↗
PubMed1996

Foreign-body reaction and the course of osteolysis after polyglycolide implants for fracture fixation: experimental study in sheep.

Foreign-body reaction to polyglycolide (PGA) implants has been described in man. Many animal experiments have verified the mechanical properties of fixation devices made from PGA, but a significant foreign-body reaction has not been described. We studied the effect of PGA rods in 12 sheep with standardised osteochondral fractures of the medial femoral condyle fixed with uncoloured, self-reinforced PGA rods (Biofix). Radiographs were taken at intervals ranging from two weeks to two years, and the sheep were killed at intervals ranging from six to 24 months. All knees were examined histologically. Eleven of the 12 fractures healed radiologically and histologically. Moderate to severe osteolysis was seen at four to six weeks with maximum changes at 12 weeks in ten animals. Six knees showed fistula-like connections between the implant site and the joint space. Three developed synovitis, one with inflammatory changes involving the whole cartilage and one with destruction of the medial condyle. Although in our study osteochondral fractures fixed with PGA rods healed reliably, there were frequent, significant foreign-body reactions. Caution is needed when considering the use of PGA fixation devices in vulnerable regions such as the knee.

Animals↗