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1.  Radiation-free Insertion of Distal Interlocking Screw in Tibial and Femur Nailing: A Simple Technique 
Background:
Distal interlocking screw insertion in intramedullary nailing of long-bone fracture is a challenging task for orthopedic surgeons. It is difficult particularly when the surgeon is in his learning stage or when image intensifier is not available. We describe a radiation-free technique of distal interlocking screw insertion which is easy and practicable.
Materials and Methods:
In this technique, a same length nail is placed over the skin (outer nail) and through its distal-most screw hole, a 3.2 mm drill bit is inserted to drill the distal locking screw hole of the intramedullary nail (inner nail). With a small skin incision over the distal screw holes, the distal-most screw hole is identified; the bone window overlying the screw hole is widened with an awl and a locking bolt is inserted with a washer under direct visualization. The other distal interlocking screw is simply drilled by matching the other three holes of the outer and inner nails. We have operated 86 patients (39 femoral shaft fracture and 47 tibial shaft fracture) in 1 year where this technique was used. There were 41 open fracture and 45 closed fracture.
Results:
Within 6 months of follow-up, bony union was achieved in 36 of 39 femur fractures and 45 of 47 tibial fractures. No unwanted complications were observed during the postoperative period and in follow-up.
Conclusion:
This method of radiation-free distal interlocking screw insertion is simple and can be used in third world country where image intensifier facility is not available. However, surgeons are encouraged to use image intensifier facility where the facility is available.
doi:10.4103/2006-8808.100346
PMCID: PMC3461770  PMID: 23066456
Intramedually nail; radiation; femur fracture; tibia frcature
2.  Surgical Technique: Static Intramedullary Nailing of the Femur and Tibia Without Intraoperative Fluoroscopy 
Background
On a recent mission directed at definitive care for victims of the Haitian earthquake, the orthopaedic team developed a technique for freehand distal locking of femoral and tibial nails without intraoperative fluoroscopy or proximally mounted targeting jigs.
Description of Technique
After performing open antegrade or retrograde nailing by standard techniques, the freehand lock must be obtained before doing standard outrigger locking. This allows the surgeon to control the nail and deliver the locking hole in the nail to a unicortical drill hole in the femur. Before nail insertion, the distance of the desired locking hole is measured from the outrigger in a standard way such that it can be reproduced after the nail is inserted. Through a unicortical drill hole, the nail is palpated with the tip of a Kirschner wire and systematic maneuvers allow the Kirschner wire to palpate and fall into the locking hole. The Kirschner wire is tapped across the second cortex before drilling. The screw is inserted, and the ball-tipped insertion guidewire is placed back into the nail to palpate the crossing screw confirming position.
Patients and Methods
We treated 16 patients with 18 long bone fractures using the described technique. We assessed patients clinically and radiographically immediately postoperatively.
Results
A total of 19 blind freehand interlocks were attempted, and 17 were successful as assessed by direct intraoperative observations and by postoperative radiographs.
Conclusions
We describe a simple technique for performing static locked intramedullary nailing of the femur and tibia without fluoroscopy. This technique was successful in most cases and is intended for use with any nailing system only when fluoroscopy or specialized systems for nailing without fluoroscopy are not available.
doi:10.1007/s11999-011-1829-7
PMCID: PMC3210293  PMID: 21369767
3.  Interlocking nailing without imaging: the challenges of locating distal slots and how to overcome them in SIGN intramedullary nailing 
International Orthopaedics  2009;34(6):891-895.
Placement of the distal interlocking screw is the most difficult part in all intramedullary nail interlocking screw systems and the Surgical Implant Generation Network (SIGN) interlocking system is not an exception. SIGN nails are interlocking implants designed with a precision instrumentation set for use in treatment of long bone fractures without an image intensifier. Locating the distal slots of SIGN nails could be challenging for young SIGN surgeons when treating very complex comminuted fractures and in obese patients. This study was stimulated by a patient who presented one year after surgery with knee pain due to a migrating nail because of missed distal screws. A total of 48 patients divided into two groups of 24 were studied retrospectively and prospectively. The retrospective studies revealed that failure to locate distal locking slots in ten antegrade nailing procedures was due to wrong entry point and comminution of the fracture. The challenges encountered led us to innovating methods to overcome the difficulties of placement of distal screws in a prospective study. Application of methods A and B made location of the distal slots easier in the prospective study even though there were more complex comminuted fractures. The methods also reduced the antegrade operation time by 1 hour 11 minutes. We concluded that SIGN nailing could be challenging and frustrating at the early learning stage. Application of the two innovative methods will make distal slot location easier. They will also make SIGN interlocking nailing less difficult for young SIGN surgeons as they journey through the learning curves.
doi:10.1007/s00264-009-0882-2
PMCID: PMC2989006  PMID: 19813011
4.  Achieving interlocking nails without using an image intensifier 
International Orthopaedics  2006;31(4):487-490.
Interlocking nails are commonly performed using an image intensifier. These are expensive and are not readily available in most resource-poor countries of the world. The aim of this study was to achieve interlocking nailing without the use of an image intensifier. This is a prospective descriptive analysis of 40 consecutive cases seen with shaft fractures of the humerus, femur, and tibia. Fracture fixation was done using Surgical Implant Generation Network (SIGN) nails. Forty limbs in 34 patients were studied. There were 12 females and 22 males, giving a ratio of 1:2. The mean age (years) was 35.75±13.16 and the range was 17–70 years. The studied bones were: humerus 10%, femur 65%, and tibia 25%. The fracture lines were: transverse 40%, oblique 15%, and communited 45%. Fracture grades were: closed 90%, grade I, 5%, grade II, 2.5%, and grade IIIA, 2.5%. Surgical approaches were: antegrade 62.5% and retrograde 37.5%. Indications for fixation were: recent fracture 92.5%, non-union 5%, and malunion 3%. Methods of reductions were: open 85% and closed 15%. The mean follow-up period (years) was 1.50±0.78. The union time averaged 3 months. Complication was mainly screw loosening due to severe osteoporoses in one case. It is, therefore, concluded that, with the aid of external jigs and slot finders, interlocking can be achieved without an image intensifier.
doi:10.1007/s00264-006-0219-3
PMCID: PMC2267632  PMID: 17039384
5.  Case Report: A Technique to Remove a Jammed Locking Screw from a Locking Plate 
Background
Locking titanium plates revolutionized the treatment of osteoporotic and metaphyseal fractures of long bones. However as with any innovation, with time new complications are identified. One of the problems with titanium locking plates is removal of screws, often attributable to cold welding of screw heads into the locking screw holes. Several techniques have been described to overcome this problem. We describe a new easy technique to remove a jammed locking screw in a locking plate that is easily reproducible and suggest an algorithm to determine the method to remove screws from locking plates.
Case Description
A 57-year-old man underwent removal of a locking titanium plate from the distal femur. Because the screws could not be readily removed, we used a new technique to remove the jammed locking screws. A radial cut was made in the plate into the locking screw hole and wedged with an osteotome. This released the screw head from the locking screw hole. The screw holes were connected with radial cuts and jammed locking screws were removed in a similar fashion.
Literature Review
Instruments used for removal of locking screws, including conical extraction screws, hollow reamers, extraction bolts, modular devices, and carbide drill bits, have been described. However, these do not always work.
Purposes and Clinical Relevance
Removing screws from locking titanium plates can be difficult. There is no method of implant removal that can be universally applied. Therefore, this new technique and our algorithm may be used when removing screws from locking titanium plates.
doi:10.1007/s11999-010-1508-0
PMCID: PMC3018209  PMID: 20700670
6.  Symptoms Indicating Imminent Breakage of a Femoral Interlocking Nail: A Case Report 
Malaysian Orthopaedic Journal  2013;7(3):21-23.
Abstract
Fractures of the femoral shaft treated with interlocking nails will ultimately result in breakage of the nail if the bone does not unite. Further management requires removal of the broken nail which may be a difficult process for the distal segment. If we can identify the symptoms just before the nail breaks, an exchange nailing becomes much easier. We present a patient with fibromatosis who underwent repeated surgery as well as radiotherapy at the age of 16. Six years later, she had a pathological fracture of the upper third of the femur for which an interlocking nail was inserted. The femur did not unite and the nail subsequently broke. Over a period of 12 years, three nails broke and had to be replaced. Two to 3 months before each breakage, the patient experienced the same set of symptoms for each episode. Knowing that her fracture was not going to heal will now alert us to do an exchange nailing before the nail broke again. It is well known that where there is evidence of non-union, pre-emptive treatment is necessary before implant failure.
Key Words
Femur nonunion, interlocking nail, symptoms before breakage of nail
doi:10.5704/MOJ.1311.003
PMCID: PMC4322138
7.  Closed retrograde retrieval of the distal broken segment of femoral cannulated intramedullary nail using a ball-tipped guide wire 
Indian Journal of Orthopaedics  2011;45(4):347-350.
Background:
Extracting broken segments of intramedullay nails from long bones can be an operative challenge, particularly from the distal end. We report a case series where a simple and reproducible technique of extracting broken femoral cannulated nails using a ball-tipped guide wire is described. This closed technique involves no additional equipment or instruments.
Materials and Methods:
Eight patients who underwent the described method were included in the study. The technique involves using a standard plain guide wire passed through the cannulated distal broken nail segment after extraction of the proximal nail fragment. The plain guide wire is then advanced distally into the knee joint carefully under fluoroscopy imaging. Over this wire, a 5-millimeter (mm) cannulated large drill bit is used to create a track up to the distal broken nail segment. Through the small knee wound, a ball-tipped guide wire is passed, smooth end first, till the ball engages the end of the nail. The guide wire is then extracted along with the broken nail through the proximal wound.
Results:
The method was successfully used in all eight patients for removal of broken cannulated intramedullary nail from the femoral canal without any complications. All patients underwent exchange nailing with successful bone union in six months. None of the patients had any problems at the knee joint at the final follow-up.
Conclusion:
We report a technique for successful extraction of the distal fragment of broken femoral intramedullary nails without additional surgical approaches.
doi:10.4103/0019-5413.82342
PMCID: PMC3134021  PMID: 21772629
Ball-tipped guide wire; broken intramedullary nail; extraction; femur
8.  Removal of a broken intramedullary femoral nail with an unusual pattern of breakage: a case report 
To the best of our knowledge, only 3 cases, including the present case, have been reported with a three part broken pattern. However, this is the first case associated with a distal locking screw broken. We report the case of a 31-year-old patient who sustained an open femoral shaft fracture . The fracture was stabilized with a Kuntcher femoral nail. After 7 months of the initial surgery he presented with a three part broken intramedullary nail and the distal locking screw broken. We used a combined technique for the removal of the nail through the nonunion fracture site; we used a pull out technique for the middle fragment and a curved thin hook for the distal fragment. Then we applied bone allograft and stabilized with a cannulated intramedullary femoral nail (Synthes, Oberdorf, Switzerland). After 2 years of follow up the nonunion was consolidated and the patient presented a good clinical outcome. This is of particular interest because it is a unique case and the association with a broken distal locking screw is reported for the first time in this study. A combination of methods through the nonunion site approach and an alternative instrumental is a good method for the removal of a hollow femoral intramedullary nail with this unusual pattern of breakage.
doi:10.1007/s11751-009-0066-z
PMCID: PMC2787202  PMID: 19777163
Broken nail; Intramedullary nailing; Removal; Narrow hollow; Guide wire
9.  Removal of a broken intramedullary femoral nail with an unusual pattern of breakage: a case report 
To the best of our knowledge, only 3 cases, including the present case, have been reported with a three part broken pattern. However, this is the first case associated with a distal locking screw broken. We report the case of a 31-year-old patient who sustained an open femoral shaft fracture . The fracture was stabilized with a Kuntcher femoral nail. After 7 months of the initial surgery he presented with a three part broken intramedullary nail and the distal locking screw broken. We used a combined technique for the removal of the nail through the nonunion fracture site; we used a pull out technique for the middle fragment and a curved thin hook for the distal fragment. Then we applied bone allograft and stabilized with a cannulated intramedullary femoral nail (Synthes, Oberdorf, Switzerland). After 2 years of follow up the nonunion was consolidated and the patient presented a good clinical outcome. This is of particular interest because it is a unique case and the association with a broken distal locking screw is reported for the first time in this study. A combination of methods through the nonunion site approach and an alternative instrumental is a good method for the removal of a hollow femoral intramedullary nail with this unusual pattern of breakage.
doi:10.1007/s11751-009-0066-z
PMCID: PMC2787202  PMID: 19777163
Broken nail; Intramedullary nailing; Removal; Narrow hollow; Guide wire
10.  Fatigue performance of angle-stable tibial nail interlocking screws 
International Orthopaedics  2012;37(1):113-118.
Purpose
Tibial nail interlocking screw failure often occurs during delayed fracture consolidation or at early weight bearing of nailed unstable fractures, in general when high implant stress could not be reduced by other means. Is there a biomechanical improvement in long-term performance of angle stable locking screws compared to conventional locking screws for distal locking of intramedullary tibial nails?
Methods
Surrogate bones of human tibiae were cut in the distal third and distal locking of the 10 mm intramedullary tibial nail was performed with either two angle stable locking screws or two conventional locking screws in the mediolateral plane. Six specimens per group were mechanically tested under quasi-static and cyclic axial loading with constantly increasing force.
Results
Angle stable locking screw constructs exhibited significantly higher stiffness values (7,809 N/mm ± 647, mean ± SD) than conventional locking screw constructs (6,614 N/mm ± 859, p = 0.025). Angle stable locking screw constructs provided a longer fatigue life, expressed in a significantly higher number of cycles to failure (187,200 ± 18,100) compared to conventional locking screw constructs (128,700 ± 7,000, p = 0.004).
Conclusion
Fatigue performance of locking screws can be ameliorated by the use of angle stable locking screws, being especially important if the nail acts as load carrier and an improved stability during fracture healing is needed.
doi:10.1007/s00264-012-1633-3
PMCID: PMC3532652  PMID: 22875484
11.  Intramedullary fixation of forearm fractures with new locked nail 
Indian Journal of Orthopaedics  2011;45(5):410-416.
Background:
Lack of availability of interlocked nails made plate osteosynthesis the first choice of treatment of forearm fractures inspite of more surgical exposure, periosteal stripping and big skin incision subsequent scar along with higher risk of refracture on implant removal. We hereby report the first 12 cases with 19 forearm bone fractures internally fixed by indegenous interlocked nail.
Materials and Methods:
Existing square nails were modified to have a broad proximal end of 5.5 mm with a hole for locking screw of 2.5 mm. The nail has a distal hole of 1/1.2/1.5 mm in 2.5/3/3.5 mm diameter nail, respectively. A new method of distal locking with a clip made of k wire is designed. The clip after insertion into the bone and hole in nail and opposite cortex snuggly fits the bone providing a secure locking system. Twelve skeletally mature patients, mean age 32 years (range 24-45 years) with 19 diaphyseal fractures of the forearm were treated with this indigenously made new nail. The patient were evaluated for fracture union, functional recovery and complications. The functional outcome was assessed by disabilities of arm, shoulder and hand questionnaire (DASH score).
Results:
Time to radiographic union ranged between 12 and 28 weeks, with a 100% union rate. Complications were minimal, with mild infection in open fracture (n=1) and delayed union (n=1) in patient with comminuted fracture of the ulna only. The clinical results were excellent. The DASH score ranged between 0 and 36 points.
Conclusion:
This new interlocking nail may be considered as an alternative to plate osteosynthesis for fractures of the forearm in adults. The advantages are benefit of closed reduction, smaller residual scar, reduced cost and early union with allowance of immediate movements.
doi:10.4103/0019-5413.83760
PMCID: PMC3162676  PMID: 21886921
Forearm fractures; intramedullary fixation; locked nail; osteosynthesis
12.  Expandable self-locking nail in the management of closed diaphyseal fractures of femur and tibia 
Indian Journal of Orthopaedics  2009;43(3):264-270.
Background:
Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail.
Materials and Methods:
Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Patients were followed for at least one year.
Results:
The average operative time was 90 min (range, 55-125 min) for femoral fractures and 53 min (range, 25-115 min) for tibial fractures. Radiation exposure was minimum, average being 84 seconds (range, 54-132) for femoral fractures and 54 seconds (range, 36-78) for tibial fractures. All fractures healed, but few had complications, such as infection (one case with tibial fracture) bent femoral nail with malunion (n = 1), and delayed union (n = 3; 2 cases in femur and 1 case in tibia). Mean time of union was 5.1 months (range, 4-10½ months) for femoral fractures and 4.8 months (range, 3-9 months) for tibial fractures.
Conclusion:
We found the nail very easy to use with effective fixation in AO type A and B fractures in our setting. Less surgical time is required with minimum complications. The main advantage of the expandable nail is that if affords. satisfactory axial, rotatory, and bending stability with decreased radiation exposure to operating staff and the patient.
doi:10.4103/0019-5413.53457
PMCID: PMC2762176  PMID: 19838349
Diaphyseal fracture femur; diaphysial fracture tibia; expandable nail; self-locking nail; radiation risk
13.  Reinforcing the role of the conventional C-arm - a novel method for simplified distal interlocking 
Background
The common practice for insertion of distal locking screws of intramedullary nails is a freehand technique under fluoroscopic control. The process is technically demanding, time-consuming and afflicted to considerable radiation exposure of the patient and the surgical personnel. A new concept is introduced utilizing information from within conventional radiographic images to help accurately guide the surgeon to place the interlocking bolt into the interlocking hole. The newly developed technique was compared to conventional freehand in an operating room (OR) like setting on human cadaveric lower legs in terms of operating time and radiation exposure.
Methods
The proposed concept (guided freehand), generally based on the freehand gold standard, additionally guides the surgeon by means of visible landmarks projected into the C-arm image. A computer program plans the correct drilling trajectory by processing the lens-shaped hole projections of the interlocking holes from a single image. Holes can be drilled by visually aligning the drill to the planned trajectory. Besides a conventional C-arm, no additional tracking or navigation equipment is required.
Ten fresh frozen human below-knee specimens were instrumented with an Expert Tibial Nail (Synthes GmbH, Switzerland). The implants were distally locked by performing the newly proposed technique as well as the conventional freehand technique on each specimen. An orthopedic resident surgeon inserted four distal screws per procedure. Operating time, number of images and radiation time were recorded and statistically compared between interlocking techniques using non-parametric tests.
Results
A 58% reduction in number of taken images per screw was found for the guided freehand technique (7.4 ± 3.4) (mean ± SD) compared to the freehand technique (17.6 ± 10.3) (p < 0.001). Total radiation time (all 4 screws) was 55% lower for the guided freehand technique compared to conventional freehand (p = 0.001). Operating time per screw (from first shot to screw tightened) was on average 22% reduced by guided freehand (p = 0.018).
Conclusions
In an experimental setting, the newly developed guided freehand technique for distal interlocking has proven to markedly reduce radiation exposure when compared to the conventional freehand technique. The method utilizes established clinical workflows and does not require cost intensive add-on devices or extensive training. The underlying principle carries potential to assist implant positioning in numerous other applications within orthopedics and trauma from screw insertions to placement of plates, nails or prostheses.
doi:10.1186/1471-2474-13-8
PMCID: PMC3305668  PMID: 22276698
Distal interlocking; Distal targeting; Nailing; Free-hand locking; Computer aided surgery
14.  Surgical Technique: Simple Technique for Removing a Locking Recon Plate With Damaged Screw Heads 
Background
The introduction of locking plates in the treatment of periarticular fractures was a major breakthrough in orthopaedic evolution. Removal of these implants is extremely difficult as a result of cold welding and stripping of screw heads.
Description of Technique
A 31-year-old man had a schwannoma of the left C5-C6 nerve roots and upper trunk of the brachial plexus. One year before presentation he had undergone excision of the lesion through an approach using a clavicular osteotomy. The osteotomy had been fixed with a titanium locking recon plate. While surgically removing the implant, only one screw could be removed. The remaining five screws could not be turned owing to cold welding; repeated attempts at removing the screws damaged the screw heads. A large bolt cutter was used to cut the plate between the holes, and the resulting rectangular sections with the screws then were unscrewed from the bone.
Review of Literature
Limited literature is available regarding techniques for locking screw removal. These include using a carbide drill bit or diamond-tipped burr, high-speed disc, or conical extraction screw.
Conclusions
Not all centers have specialized instruments such as carbide drill bits to remove screw heads, but a large bolt cutter usually is available when screws cannot be unscrewed owing to cold welding. The technique of cutting is easily reproducible and does not require additional soft tissue stripping.
doi:10.1007/s11999-012-2733-5
PMCID: PMC3613543  PMID: 23229429
15.  New Technique: A Novel Femoral Derotation Osteotomy for Malrotation following Intramedullary Nailing 
Case Reports in Orthopedics  2012;2012:837325.
A 19-year-old female patient sustained a closed spiral midshaft femoral fracture and subsequently underwent femoral intramedullary nail insertion. At followup she complained of difficulty in walking and was found to have a unilateral in-toeing gait. CT imaging revealed 30 degrees of internal rotation at the fracture site, which had healed. A circumferential osteotomy was performed distal to the united fracture site using a Gigli saw with the intramedullary femoral nail in situ. The static distal interlocking screws were removed and the malrotation was corrected. Two further static distal interlocking screws were inserted to secure the intramedullary nail in position. The osteotomy went on to union and her symptoms of pain, walking difficulty, and in-toeing resolved. Our paper is the first to describe a technique for derotation osteotomy following intramedullary malreduction that leaves the intramedullary nail in situ.
doi:10.1155/2012/837325
PMCID: PMC3508528  PMID: 23198226
16.  Broken guidewire protruding into the hip joint: A bone endoscopic-assisted retrieval method 
Indian Journal of Orthopaedics  2012;46(1):109-112.
Broken implants, especially broken wires at difficult sites, may pose a challenge for the treating orthopedic surgeon. We describe a method for extraction of a broken guidewire that was, protruding into the hip joint following the insertion of a proximal femoral nail. A 35-year-old man with displaced femoral neck fracture with ipsilateral fracture shaft of femur was operated and fixed with long proximal femoral nail. The guidewire of proximal screw broke during the process of drilling. The tip of the 2-cm-long broken guidewire was touching the articular surface. The guidewire was misdirected posteroinferiorly from its path for the insertion of the proximal screw (6.8 mm), this screw was removed and bone endoscopy was performed with a 30° arthroscope. The broken end of the guidewire was located under direct vision. The grasper was introduced with its jaws at the 8 O’clock position and its position was confirmed under a C-arm image intensifier in both anteroposterior and lateral views. The broken end of the guidewire was grasped and it was retrieved. The screw was replaced in its original track to complete the procedure. The fractures united and patient was asymptomatic when last followed-up at 12 months.
doi:10.4103/0019-5413.91646
PMCID: PMC3270595  PMID: 22345818
Bone endoscopy; broken guidewire; proximal femoral nail; femoral neck fracture
17.  Fatigue strength of common tibial intramedullary nail distal locking screws 
Background
Premature failure of either the nail and/or locking screws with unstable fracture patterns may lead to angulation, shortening, malunion, and IM nail migration. Up to thirty percent of all unreamed nail locking screws can break after initial weight bearing is allowed at 8–10 weeks if union has not occurred. The primary problem this presents is hardware removal during revision surgery. The purposes of our study was to evaluate the relative fatigue resistance of distal locking screws and bolts from representative manufacturers of tibial IM nail systems, and develop a relative risk assessment of screws and materials used. Evaluations included quantitative and qualitative measures of the relative performance of these screws.
Methods
Fatigue tests were conducted to simulate a comminuted fracture that was treated by IM nailing assuming that all load was carried by the screws. Each screw type was tested ten times in a single screw configuration. One screw type was tested an additional ten times in a two-screw parallel configuration. Fatigue tests were performed using a servohydraulic materials testing system and custom fixturing that simulated screws placed in the distal region of an appropriately sized tibial IM nail. Fatigue loads were estimated based on a seventy-five kilogram individual at full weight bearing. The test duration was one million cycles (roughly one year), or screw fracture, whichever occurred first. Failure analysis of a representative sample of titanium alloy and stainless steel screws included scanning electron microscopy (SEM) and quantitative metallography.
Results
The average fatigue life of a single screw with a diameter of 4.0 mm was 1200 cycles, which would correspond roughly to half a day of full weight bearing. Single screws with a diameter of 4.5 mm or larger have approximately a 50 percent probability of withstanding a week of weight bearing, whereas a single 5.0 mm diameter screw has greater than 90 percent probability of withstanding more than a week of weight bearing. If two small diameter screws are used, our tests showed that the probability of withstanding a week of weight bearing increases from zero to about 20 percent, which is similar to having a single 4.5 mm diameter screw providing fixation.
Conclusion
Our results show that selecting the system that uses the largest distal locking screws would offer the best fatigue resistance for an unstable fracture pattern subjected to full weight bearing. Furthermore, using multiple screws will substantially reduce the risk of premature hardware failure.
doi:10.1186/1749-799X-4-11
PMCID: PMC2672078  PMID: 19371438
18.  Treatment of Open Pediatric Tibial Fractures by External Fixation Versus Flexible Intramedullary Nailing: A Comparative Study 
Archives of Trauma Research  2013;2(3):108-112.
Background
Tibial fractures are the third most common pediatric long-bone fracture after forearm and femoral fractures. Approximately 50% of pediatric tibial fractures occur in the distal third of the tibia. This is followed by midshaft tibial fractures (39%), and least commonly, the proximal third of the tibia is involved. Tibial fractures in the skeletally immature patient can usually be treated without surgery but tibial fractures resulting from high energy traumas are of special importance considering type of the selected treatment method affecting the children future. Manipulation and casting are regarded as definite treatments for children tibial fractures. They are used following compartment syndrome in poly-trauma, neurovascular damages, open fractures, and fasciotomy cases.
Objectives
In children, most open fractures occur due to high energy traumas and inappropriate treatment of the fractures may result in several complications. Flexible intramedullary nailing is one of the popular options as an effective method of treating long-bone fractures in children. The external fixator is used in cases with severe injuries and open fractures. The present study aims at comparing results of these two treatment methods in the open pediatric tibial fractures.
Materials and Methods
In this descriptive analytical study, 32 patients with open tibial fractures were treated with either fixator (n = 18) or TEN nails (n=14) during 2006-2011. Some patients were treated with a combination method of TEN and pin. The results were evaluated considering infection, union, mal-union, and re-fracture and the patients were followed up for two years.
Results
Mean time required for fracture union was 12.5 (11-14) and 11.8 (10-12) weeks for the external fixator and TEN groups, respectively. There was no statistical difference in time of union between the two methods. The main complications in external fixation were infection around the pin 4 (22.2%), leg-length discrepancy 2 (11.1%) and re-fracture 4 (22.2%). In the TEN group, 2 cases (14.2%) of painful bursitis were observed at the entry point of TEN and the pin was removed earlier. There was not any report of mal-union requiring correction in the groups. No complication was seen in 6 patients treated with a combined method of pin and flexible intramedullary nails.
Conclusions
Although external fixation in open pediatric fractures and severe injuries is recommended, intramedullary nailing is also an effective method with low complications. Combining pins and flexible intramedullary nails is effective in developing more stability and is not associated with more complications.
doi:10.5812/atr.13826
PMCID: PMC3950912  PMID: 24693519
Fractures, Open; External Fixator; Fracture Fixation; Child
19.  Minimally invasive plate osteosynthesis (MIPO) in the treatment of the femoral shaft fracture where intramedullary nailing is not indicated 
International Orthopaedics  2008;33(4):1119-1126.
The aim of this study was to examine the results of minimally invasive plate osteosynthesis (MIPO) of the femoral shaft fracture in patients where intramedullary nailing is contraindicated and evaluate the proper number of the screws for stable fixation. This was a retrospective study of 36 closed femoral shaft fractures which underwent MIPO using a conventional 4.5 broad dynamic compression plate (DCP) with 14–18 holes fixed with three or four screws in the proximal and distal fragments. Thirty-three fractures had bony union in 21.0 weeks (range, 12–28 weeks), two had delayed union that required bone graft and union at 28 and 32 weeks. Malalignment occurred in five cases. Sixty-two fragments were fixed with three screws—40 in cluster and 22 in separated positions. Ten fragments were fixed with four screws—eight in cluster and two separated. Broken screws were found in three cases; all were in the group with three screws fixed in cluster group. MIPO of the femoral shaft fracture is an alternative treatment in the patient where intramedullary nailing is contraindicated. Malalignment is the common complication that must be carefully evaluated intraoperatively. We recommend using at least three separated screws in each fragment to reduce the risk of screw breakage.
doi:10.1007/s00264-008-0603-2
PMCID: PMC2898967  PMID: 18597087
20.  Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result? 
The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.
doi:10.1007/s11751-009-0065-0
PMCID: PMC2746276  PMID: 19705253
Tibia; Fracture; Open fracture; Intramedullary nail; Nonunion; Dynamization; Exchange nailing
21.  Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result? 
The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.
doi:10.1007/s11751-009-0065-0
PMCID: PMC2746276  PMID: 19705253
Tibia; Fracture; Open fracture; Intramedullary nail; Nonunion; Dynamization; Exchange nailing
22.  A sonography assisted technique for the removal of a femoral interlocking nail – a technical note 
Background
Open methods for removal of femoral interlocking nails involve an incision (up to 10 cm) over the trochanter to find the tip of the nail. The distal locking screws are some times difficult to palpate and an incision (up to about 5 cm) is often needed for exposure. Intra-operative fluoroscopy is often used as an adjunct technique to minimize the surgical wound. However, patients and surgeons are exposed to a radiation hazard. Sonography can provide a real-time and efficient alternative to fluoroscopy.
Methods
Sonography of soft tissue has been established to identify a foreign body. A metallic implant has a hyperechoic image; therefore, we can identify the correct position of the screws preoperatively and intraoperatively.
Results
We have developed a technique using sonography and minimal incisions for the removal of a femoral interlocking nail. The proximal wound is 2.5 cm in length and the wound is 0.5 cm in length for each distal locking screw.
Conclusion
The sonography can be used to minimize the length of incision and prevent radiation exposure in the removal of intramedullary femoral nails.
doi:10.1186/1471-2474-6-51
PMCID: PMC1274328  PMID: 16229748
23.  Intramedullary nailing of humeral diaphyseal fractures. Is distal locking really necessary? 
Purpose:
Distal interlocking is regarded as an inherent part of the antegrade humeral nailing technique, but it exposes both the patient and surgeon to radiation, is time consuming, and has a potential risk of damaging neurovascular structures. We have presented our technique of diaphyseal humeral nailing without any distal interlocking in this paper.
Materials and Methods:
We have presented a series of 64 consecutive patients (33 male and 31 female, mean age: 41.5 years) with humeral shaft fractures treated with antegrade rigid intramedullary nailing without distal interlocking following a strict intra and postoperative protocol. According to the AO classification, there were 36 type A fractures, 22 type B, and 6 type C. Nails were inserted unreamed or by using limited proximal reaming and they were fitted as snuggly as possible into the medullary canal. After impaction of the nail into the fossa, we carefully tested rotational stability of fixation by checking any potential external rotation when the arm was slightly turned externally and left to the gravity forces. We were ready to add distal screws, but that was not required in these cases. Follow-up assessment included fracture union, complications and failures, and the final clinical outcome at minimum 2-year follow-up using the parameters of the constant score.
Results:
All fractures, except two, united between the 4th and 5th postoperative month. In one case, nail was exchanged with plate, and, in another, a larger nail was used at a second surgery. Shoulder function according to constant score, at a minimum of 2-year follow-up, was excellent or very good in 93.7% of the patients.
Conclusions:
Provided that some technical issues are followed, the method reduces intraoperative time and radiation exposure and avoids potential damage to neurovascular structures.
doi:10.4103/0973-6042.114233
PMCID: PMC3743033  PMID: 23960365
Distal interlocking; humeral fractures; humeral nailing
24.  Technique and Early Results of Percutaneous Reduction of Sagittally Unstable Intertrochateric Fractures 
Clinics in Orthopedic Surgery  2011;3(3):217-224.
Background
This paper introduces a percutaneous reduction technique using one or two Steinman pin(s) to reduce sagittally unstable intertrochanteric fractures.
Methods
A fracture was defined as a sagittally unstable intertrochanteric fracture when posterior sagging of a distal fragment and flexion of the proximal fragment worsens after usual maneuvers for a closed reduction. Of 119 intertrochanteric fractures treated from June 2007 to December 2008, twenty-one hips showed sagittal instability. The sagittal displacement was reduced using a Steinmann pin as a joystick, and stabilized with a nail device. Nineteen hips were followed up for more than one year. The clinical and radiological results were reviewed in 19 hips and compared with those of the remaining cases.
Results
The demographics were similar in both groups. The mean anesthetic time did not differ. Although the pre-injury and final activity levels were significantly lower in the study group, the degree of recovery was the same. No clinical complications related to this technique were encountered. Radiologically, the reduction was good in all hips in both groups. Union was obtained in all cases without any time differences.
Conclusions
This less invasive reduction technique is simple and safe to use for this type of difficult fracture.
doi:10.4055/cios.2011.3.3.217
PMCID: PMC3162202  PMID: 21909469
Intertrochanteric fracture; Sagittal; Unstable; Percutaneous reduction
25.  Use of Huckstep nail in the periimplant femoral shaft fracture 
Indian Journal of Orthopaedics  2012;46(6):718-720.
87-year-old female underwent open reduction of distal femoral fracture and internal fixation with locking compression plate and bone graft. She was operated for ipsilateral proximal femoral fractures and stabilized by intramedullary interlocked nail 5 years ago. She developed stress fracture proximal to locked plate. We inserted Huckstep nail after removal of the previous operated proximal femoral nail without removing the remaining plate and screws. At 15 month followup the fractures have united. The Huckstep nail has multiple holes available for screw fixation at any level in such difficult situations.
doi:10.4103/0019-5413.104240
PMCID: PMC3543895  PMID: 23325980
Femur; Huckstep nail; periimplant fracture; stress riser

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