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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↗

PubMed1996

Thermal necrosis after tibial reaming for intramedullary nail fixation. A report of three cases.

We present three young men who sustained closed diaphyseal fracture of the tibia and later developed severe osteocutaneous necrosis induced by heat during intramedullary reaming. They all had a narrow medullary cavity and in all a tourniquet had been used. Each developed a pretibial cutaneous blister soon after operation. In the following month severe osteomyelitis ensued, requiring segmental resection and osteocutaneous reconstruction.

Adolescent↗

PubMed1975

[Intramedullary fixation of fragments in soft-tissue injuries (author's transl)].

In cases of open fractures, careful reconstruction of the soft tissue and stable internal fixation are generally regarded as the best means of preventing infection. With this in mind, some of the author's own cases of open fractures of the upper and lower leg-stabilized either with conventional intramedullary nails or with interlocking nails-are demonstrated. The infection rate in the especially vulnerable open fracture of the tibia was 7.89 percent.

Adolescent↗

PubMed2001

Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur.

OBJECTIVES: To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures. DESIGN: A prospective, randomised controlled clinical trial with observer blinding. SETTING: A regional teaching hospital in the United Kingdom. PATIENTS: All patients admitted from the local population with intertrochanteric fractured femurs were included. There were 400 patients entered into the study and 399 followed-up to one year or death. INTERVENTION: The devices were assigned by randomization to either a short-type Gamma nail (203 patients) or a Richard's-type sliding hip screw and plate (197 patients). MAIN OUTCOME MEASUREMENTS: The main surgical outcome measurements were fixation failure and reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year. RESULTS: The requirement for revision in the Gamma nail group was twelve (6%); for Richard's group, eight (4%). This was not statistically different (p = 0.29; odds ratio, 1.48 [0.59-3.7]). A subcapital femoral fracture occurred in the Richard's group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richard's group (p = 0.13). Three required revision to another implant. Lag-screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richard's group (2%). This was not statistically significant (p = 0.37; odds ratio, 2.29 [0.6-9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year. CONCLUSIONS: The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate.

Adult↗

PubMed2006

Clinical inquiries. What is the most effective management of acute fractures of the base of the fifth metatarsal?

For acute Jones' fractures in recreationally active patients, early intramedullary screw fixation results in lower failure rates and shorter times to both clinical union and return to sports than non-weightbearing short leg casting (strength of recommendation [SOR]: A, based on 2 randomized controlled trials [RCT]). Non-weightbearing short leg casting achieves union in 56% to 100% of patients but can require prolonged casting (SOR: B, based on 2 prospective cohorts and multiple retrospective, follow-up studies). Stress fractures were not included in this review. For avulsion fractures of the fifth metatarsal tuberosity, a soft Jones' dressing allows earlier return to pre-injury levels of activity than rigid short leg casting (SOR: B, based on a lower-quality RCT).

Acute Disease↗

PubMed1991

Locked intramedullary nailing of open tibial fractures.

We report the use of Grosse-Kempf reamed intramedullary nailing in the treatment of 41 Gustilo type II and III open tibial fractures. The union times and infection rates were similar to those previously reported for similar fractures treated by external skeletal fixation, but the incidence of malunion was less and fewer required bone grafting. The role of exchange nailing is discussed and a treatment protocol is presented for the management of delayed union and nonunion.

Adolescent↗

PubMed1992

Ipsilateral fractures of the femur and tibia.

From October 1987 to September 1990, 32 patients with ipsilateral fractures of the femur and the tibia were treated. There were 20 men and 12 women with a mean age of 27 years (range 18-75 years). All were caused by road accidents. There were 7 femoral and 22 tibial open fractures. The management of the fractures was partially the same. The tibial fractures were reduced and stabilized by a unilateral external fixator, while in 29 out of 32 femoral fractures, a closed intramedullary nailing was performed. The remaining three patients with an open grade III fracture were initially treated by external fixation, with two of them converted into nailing. The time of hospitalization ranged from 12 to 105 days (mean 30 days). The femoral fractures healed in an average of 15.5 weeks, while the tibial fractures healed in 18.5 weeks. The evaluation of our results was made according to Karlstrom and Olerud's criteria. We achieved 81 per cent excellent or good results and 19 per cent acceptable or poor, in a follow-up time of 19.5 months.

Accidents, Traffic↗

PubMed2006

Recombinant human bone morphogenetic protein-2 in open tibial fractures. A subgroup analysis of data combined from two prospective randomized studies.

BACKGROUND: The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to improve the healing of open tibial shaft fractures has been the focus of two prospective clinical studies. The objective of the current study was to perform a subgroup analysis of the combined data from these studies. METHODS: Two prospective, randomized clinical studies were conducted. A total of 510 patients with open tibial fractures were randomized to receive the control treatment (intramedullary nail fixation and routine soft-tissue management) or the control treatment and an absorbable collagen sponge impregnated with one of two concentrations of rhBMP-2. The rhBMP-2 implant was placed over the fracture at the time of definitive wound closure. For the purpose of this analysis, only the control treatment and the Food and Drug Administration-approved concentration of rhBMP-2 (1.50 mg/mL) were compared. Patients who anticipated receiving planned bone-grafting as part of a staged treatment were excluded from enrollment. RESULTS: Fifty-nine trauma centers in twelve countries participated, and patients were followed for twelve months postoperatively. Two subgroups were analyzed: (1) the 131 patients with a Gustilo-Anderson type-IIIA or IIIB open tibial fracture and (2) the 113 patients treated with reamed intramedullary nailing. The first subgroup demonstrated significant improvements in the rhBMP-2 group, with fewer bone-grafting procedures (p = 0.0005), fewer patients requiring invasive secondary interventions (p = 0.0065), and a lower rate of infection (p = 0.0234), compared with the control group. The second subgroup analysis of fractures treated with reamed intramedullary nailing demonstrated no significant difference between the control and the rhBMP-2 groups. CONCLUSIONS: The addition of rhBMP-2 to the treatment of type-III open tibial fractures can significantly reduce the frequency of bone-grafting procedures and other secondary interventions. This analysis establishes the clinical efficacy of rhBMP-2 combined with an absorbable collagen sponge implant for the treatment of these severe fractures.

Absorbable Implants↗

PubMed2003

Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices.

The choice between dynamic screw-intramedullary nail (DSIN) devices and dynamic screw-plate (DSP) devices for the fixation of unstable trochanteric fractures remains controversial. This study presents a meta-analysis of fixation failures in unstable trochanteric femoral fractures using DSP devices or DSIN devices. Two independent assessors selected randomised controlled trials using a range of electronic databases, as well as reference lists of selected articles. A study quality checklist was used. The occurrence of fixation failure, in particular cut-out, was the primary subject of analysis using descriptive statistics and random-effect meta-analyses. Seventeen trials were identified. Meta-analyses showed no significant difference in the frequency of implant-related complications between the two types of devices. Iatrogenic femoral fractures associated with the use of DSIN devices represent a rare, but persistent, risk. There was a tendency for less frequent cut-out with intramedullary devices compared with DSP devices.

Bone Nails↗

PubMed2001

Intramedullary fixation of pediatric forearm diaphyseal fractures.

Surgical treatment of pediatric forearm fractures is controversial. In this retrospective study, we reviewed 24 skeletally immature radial and ulnar fractures in 24 patients treated with intramedullary Rush pins and/or Kirschner wires between 1994 and 1999. The indication for surgical intervention was unacceptable closed reduction, unstable fracture pattern, open fracture, or recurrence after nonsurgical treatment. For each patient, a sugar tong splint was used for 4 weeks, and pins were removed 8 weeks after surgery. Average length of follow-up was 32 months (range, 6-58 months). All fractures in this series healed. Average time to union was 8 weeks. There were no complications of delayed union, nonunion, infection, or neurovascular injury. All patients regained full range of motion of the injured extremity.

Adolescent↗

PubMed1995

[Closed tibial fracture--reamed or unreamed intramedullary nailing. A clinical study].

When comparing the unreamed tibial nail (UTN) with the external fixator in the treatment of open tibial fractures the UTN has shown advantages. Whether we can find these advantages also in the treatment of closed tibial fractures using the UTN instead of a reamed system should be clarified in the following study. We compared 35 UTN treated patients with 35 patients that were treated with a reamed A0-universal tibial nail. Both groups showed no differences in age, sex, etiology and severity of trauma. The fractures were classified by the A0-classification of fractures and the soft tissue damage by the classification of Tscherne and Oestern. The length of mean hospital stay, the time of partial weight bearing and the duration of fracture healing, were shorter using the UTN. 5 of 9 complications using the UTN were immanent to the system (deformation of the locking screws). The other complications were 2 axis shifts, 1 compartment syndrome and 1 pseudarthrosis. The other group showed 1 hematoma, 1 axis shift, 1 compartment syndrome, 2 thromboembolic complications, 2 infections and 3 cases of pseudarthrosis. We think that there is an advantage to use an UTN instead of a reamed nailing system in treatment of closed tibial fractures.

Adult↗

PubMed2006

Expandable intramedullary nailing for tibial and femoral fractures: a preliminary analysis of perioperative complications.

OBJECTIVE: To report the results of using the expandable nailing system in the treatment of femoral and tibial shaft fractures. DESIGN: Prospective, cohort series. SETTING: Two level-1 university trauma centers. PARTICIPANTS: Forty-eight patients with acute, traumatic diaphyseal fractures of the tibia or femur. INTERVENTION: Internal fixation of lower extremity long bone fractures using expandable intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Perioperative complications and time to healing. RESULTS: Forty-nine long bone fractures were treated: 22 femoral fractures (OTA classification: 4 type A1, 6 A2, 7 A3, 1 B1, and 4 B2) and 27 tibial fractures (OTA classification: 4 type A1, 11 A2, 9 A3, 0 B1, and 3 B2). There were 13 open fractures and 37 closed fractures. Healing occurred in 37 (75%) fractures without additional interventions. There were 2 tibial delayed unions and 1 femoral and 1 tibial nonunion. Five tibial shaft fractures and 6 femoral fractures shortened by 1.0 cm or more postoperatively. In 3 tibias and 4 femurs, shortening occurred after fractures judged to be length-stable became unstable because of fracture propagation during nail expansion. Five tibias and 3 femurs were converted to standard locked nails because of shortening. The average time to healing, excluding nonunion, was 15 weeks in the tibia and 16 weeks in the femur. The expandable nail resulted in an unplanned reoperation in 12 cases (25%). CONCLUSION: We found a high complication rate because of shortening, which was independent of fracture classification. Consequently, we cannot recommend the use of an unlocked, expandable nail in diaphyseal fractures of the femur or tibia.

Female↗

PubMed2006

[Treatment of the ununited lower limb fracture with reamed intramedullary interlocking nail].

OBJECTIVE: To investigate the clinical effect of the treatment of the ununited lower limb fracture with reamed intramedullary interlocking nail. METHODS: Fifty-two patients with ununited lower limb fracture were treated with intramedullary interlocking nail (femur 36, tibia 16). The main cause of nonunion was interternal fixation loosening or fracture (41 cases, 78.8%), other reasons included bone defection, bone infection or too much traction of fracture (11 cases, 21.2%). According to X-ray classification: 41 cases in type hypertrophy, 11 cases in type atrophy. All these patients need operation to remove the primary implant, clean the hard bone, ischemia bone and scar, manual ream and fix by intramedullary interlocking nail, then bone graft were done around the fracture site. With the knee joint stiffness, relax it by manipulate or operation. RESULTS: Beside 3 superficial infection (2 delayed healing and 1 healing after debridement), other 49 wounds healed on time. All cases were followed up for an average of 25.2 months, ranging from 12 months to 39 months. All the ununion healed from 5 to 11 months, mean union time were 6.1 months. Deep tissue infection, fat embolism, implant loosening, nail broken or nonunion were not found in this series. According to judet standard on the movement of knee, the excellent-good rate was 82.7%. CONCLUSIONS: Intramedullary interlocking nail is effective to treat nonunion of lower limb fracture.

Adolescent↗

PubMed2003

Evaluation and treatment of metastases to the humerus.

The humerus is the second most common long bone site of metastatic disease, and the proximal third and diaphysis are frequent sites. Purely lytic disease and cortical bone destruction increase the risk of fracture more than 50%. For most patients, external beam irradiation is effective as a means of pain control and halting bone destruction. Fractures of the head or surgical neck can be treated with standard endoprostheses, whereas extensive proximal bone destruction is treated with custom proximal humeral replacements. Impending and complete diaphyseal fractures can be treated effectively with either intramedullary nail fixation or plate fixation. Rigid fixation, which can be achieved with dual plate fixation, is optimal because patients can begin immediate unrestricted activities using the upper extremity. Methylmethacrylate is an effective adjuvant for filling defects and for augmenting the fixation of intramedullary nails and screws. Postoperative external beam irradiation is necessary to prevent progressive bone destruction and subsequent loss of fixation.

Bone Neoplasms↗

PubMed1997

[Healing modalities in unstable tibial fractures treated by locked flexible intramedullary fixation].

PURPOSE OF THE STUDY: This clinical study aimed specifically to evaluate the role of flexibility in aseptic consolidation of unstable tibial fractures on compact bones. The device employed was made of intramedular nails placed separately and locked together using an original proximal system. MATERIAL: 125 unstable compact bone fractures of the tibial shaft were treated by this method for almost 6 years. 110 cases were included in this study. 30 per cent of the fractures were open. The topographical breakdown of fracture sites on the diaphysis was 6 times, in the upper third (Sector I), 23 times in Sector II and 66 times in the lower third (Sector III). In 13 cases, there were sequential fractures of which the upper site was in Sector I. 57 cases were simple sites (A), 27 were sites with edges greater than 50 per 100 of the diaphyseal circumference (B), and 26 per 100 of comminuted sites (C). The distance measured in the fracture sites after osteosynthesis were 66 times within 3 mm, 24 cases from 4 to 10 mm, 12 cases from 11 to 15 mm, and 8 cases over 16 mm. METHODS: 110 cases were followed for more than 6 months. Consolidation was established on standard clinical and radiological criteria. The value of parameters affecting consolidation and the time period recorded were validated by a precise statistical evaluation using Stat. View II software, and Fisher and Yates tables. RESULTS: Complications due to implants were rare and minor. There were only 4 cases of nonunion resulting from secondary desaxation of two pins apparatus. 16 cases of nonunion (14.5 per 100) were recorded but 3 were forseeable nonunions, because of a traumatic bone loss. 8 cases were Sector I fractures of which 7 were Sector I unsequental fractures. 7 cases had a gap of 10 to 15 mm, and 5 of 16 to 20 mm. Thus 42.1 per 100 of cases in Sector I were not consolidated compared to only 6.1 per 100 of cases in Sector III. Primary consolidation of the 94 cases was achieved in an average of 11.08 +/- 3.19 weeks (minimum 6 weeks, maximum 20 weeks). Time for consolidation did not appear to be affected by anatomical type, opened fracture (degree 1 or 2) nor number of nails used. But, there were significant differences according to topography and postoperative gap at the fracture site. Sector II fractures took 15 days less than Sector I fracture: average 10.5 as compared to 12.6 weeks. The cases with a gap of 0 to 3 mm consolidated at an average of 10.6 weeks, those with 4 to 10 mm: 11.39 weeks, with a gap of 11 to 15 mm: 14.4 weeks, and the cases superior to 16 mm: 14.8 weeks. DISCUSSION: Compared to the interlocking nail, this procedure gave an average shortening of consolidation delay of 1 month for closed and degree 1 and 2 open fractures. This rapidity of consolidation can only be explained by the flexibility parameter. Thus it is only the flexibility of the device which can explain that even with a gap of 11 to 15 mm left within the fracture site, consolidation occurred 1 time out of 2 and 9 times out of 10 when the gap was 4 to 10 mm. Finally, this mechanical parameter can explain that consolidation is by far the shortest for low fractures although these are reputed to be the least osteogenic.

Adult↗

PubMedDate not supplied

Treatment of proximal humeral fractures with Polarus nail fixation.

A chart review of 20 patients who sustained acute proximal humeral fractures and who were treated by surgical stabilization with locked antegrade humeral intramedullary nails (Polarus nails) was undertaken. The clinical outcome measurements were fracture healing, infection, and neurologic injury. Radiologic outcome measurements included fracture alignment, loosening, fixation and hardware failure, and malunion and nonunion. Of 20 fractures, 11 healed without complications. The mean immediate postoperative and final radiographic valgus neck/shaft angulation measured 131 degrees. Of the 20 implants, 3 had proximal fixation screw loosening. Of the 20 implants, 2 underwent revision surgery for proximal fixation failure. With certain fracture types, the Polarus intramedullary humeral nail can be an effective implant. In fracture cases involving an unstable or comminuted lateral metaphyseal fracture, if the starting point extends into the greater tuberosity, fixation failure or fracture displacement may result.

Adolescent↗

PubMed1982

Treatment of pathologic fractures or impending fractures of the humerus with Rush rods and methylmethacrylate. Experience with 55 cases in 54 patients, 1968-1977.

A retrospective study of 54 patients with established or impending pathologic humeral fractures was done to evaluate the technique of intramedullary fixation with a Rush rod, during the period from 1968 to 1977. Breast carcinoma, multiple myeloma, and hypernephroma were the most common metastatic tumors. Primary tumors included Ewing's sarcoma and a low-grade chondrosarcoma, in which case the patient refused any other form of treatment. An anterolateral incision was used to expose the fracture site and a deltoid-splitting incision to introduce the Rush rod. Thirty-eight of the 55 procedures utilized methylmethacrylate to help stabilize the fracture. All patients had relief of their preoperative pain after the procedure. Seven patients subsequently experienced pain: four had proximal migration of the Rush rod with impingement, three of which required removal of the Rush rod; three other patients had discomfort two years postoperatively. All patients except one had good functional motion. Six patients had complications: three with proximal migration of the Rush rod, two with transient subluxation of the humeral head, and one with limited glenohumeral motion secondary to a technical error. This procedure provides significant pain relief and maintains function.

Adolescent↗