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Abstract

A retrograde nail with posterior-to-anterior (PA) locking into os calcis, talus and tibia was used to correct deformity and achieve fusion after failed fusion. A variety of methods have been published to achieve union of the ankle and subtalar joint in a failed fusion situation. We have studied a retrograde locking nail technique through a 2.5-cm incision in the non-weightbearing part of the sole of the foot. Remaining cartilage in the ankle joint, where necessary, was percutaneously removed through an anterior approach and the locking nail was inserted after reaming of os calcis, talus and tibia. Locking screw insertion was in the sagittal plane (p.a. direction), in talus os calcis and tibial diaphysis using a nail mounted jig. Ten patients were entered in the study (age 27-60 years). The initial aetiology for attempted fusion was post-traumatic in nine cases and rheumatic in one case. There were 25 previous operations in the cohort not leading to fusion. An additional temporary external fixator was used in four cases to reach and maintain the optimum position for the procedure. The intervention time was 30-75 min. Dynamisation of the nail was performed after four months under local anaesthesia. The mean duration of follow-up was 4 years (3-5.5 years). Radiologically and clinically, fusion was achieved in 16 weeks (range, 12-20 weeks). There was no loosening of the implant or implant failure. A leg length discrepancy was avoided using this technique. There was one complication with varus malunion in a heavy smoker which united after corrective osteotomy, revision nailing and bone grafting. Patient satisfaction was measured on a scale (not visual analogue) of 0 (not satisfied) to 10 (completely satisfied); overall satisfaction averaged 9.5 points (range, 6-10 points). The postoperative ankle-hindfoot score of the American Orthopedic Foot and Ankle Society averaged 73.5 points (range, 61-81 points). Retrograde locked nailing with locking in the sagittal plane is a reliable minimally invasive procedure to achieve fusion of the ankle and the subtalar joint after failed fusion.

In this study we present a series of patients (n = 11) with resection of the entire distal fibula in the case of sarcoma or metastasis. Moreover, we describe a new method to restore ankle stability with a tibiotalocalcaneal arthrodesis using a retrograde hindfoot nail (n = 4) in contrast to tibiotalar arthrodesis with screws (n = 5). The screw fixation failed in two patients due to osteopoenic bone. The crucial benefits of an arthrodesis with a retrograde nail are a stable arthrodesis, intramedullary stabilisation of the tibia and avoidance of extrinsic material in the wound area. An arthrodesis with a retrograde nail is a good alternative for reconstruction after a wide distal fibula resection. The additional arthrodesis of the subtalar joint was not associated with worse functional results in the MSTS and TESS scores.

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.

Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.

Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.

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.

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.

Background and purpose

Arthrodesis after failed total ankle replacement is complicated and delayed union, nonunion, and shortening of the leg often occur—especially with large bone defects. We investigated the use of a trabecular metal implant and a retrograde intramedullary nail to obtain fusion.

Patients and methods

13 patients with a migrated or loose total ankle implant underwent arthrodesis with the use of a retrograde intramedullary nail through a trabecular metal Tibial Cone. The mean follow-up time was 1.4 (0.6–3.4) years.

Results

At the last examination, 7 patients were pain-free, while 5 had some residual pain but were satisfied with the procedure. 1 patient was dissatisfied and experienced pain and swelling when walking. The implant-bone interfaces showed no radiographic zones or gaps in any patient, indicating union.

Interpretation

The method is a new way of simplifying and overcoming some of the problems of performing arthrodesis after failed total ankle replacement.

We analyzed 51 patients with open tibial fractures treated with intramedullary nailing. In 29 patients the nailing was performed without reaming and in 22 after the “reamed-to-fit” technique. There was no statistically significant difference in the rate of union. The nonreamed group required a greater number of secondary procedures to achieve union and had a higher but not statistically significant incidence of infection. Analysis of the operative and anesthesia cost associated with the additional procedures revealed that on average, patients receiving nonreamed nailing incurred a cost of $4,900 more per fracture than patients of the reamed-to-fit technique. The healing rates of open tibia fractures using either minimally reamed or nonreamed techniques of intramedullary nailing are comparable. No increase in the rate of infection with the reamed-to-fit technique was found. A significant increase in the number of secondary procedures required to achieve union was found with the nonreamed nailing technique.

Background

The objective of this study is to analyze the proximal tibiofibular joint in patients with knee pain after treatment of tibial shaft fractures with locked intramedullary nail.

Findings

The proximal tibiofibular joint was analyzed in 30 patients, who reported knee pain after tibial nailing, and standard radiograph and computed tomography were performed to examine the proximal third of the tibia. Twenty patients (68.9%) presented the proximal screw crossing the proximal tibiofibular joint and 13 (44.8%) had already removed the nail and/or screw. Four patients (13.7%) reported complaint of knee pain. However, the screw did not reach the proximal tibiofibular joint. Five patients (17.2%) complained of knee pain although the screw toward the joint did not affect the proximal tibiofibular joint.

Conclusion

When using nails with oblique proximal lock, surgeons should be careful not to cause injury in the proximal tibiofibular joint, what may be one of the causes of knee pain. Thus, the authors suggest postoperative evaluation performing computed tomography when there is complaint of pain.

Nail impingement against the anterior femoral cortex during nail insertion, or anterior cortex penetration, has been described in the literature as a worrying complication. We describe a previously unreported surgical failure due to a compromised dynamic distal locking caused by distal jamming of the nail. An 80-year-old male suffered a closed right intertrochanteric femoral fracture. Due to the presence of a long medial fragment, a 240 mm long titanium trochanteric nail was chosen to stabilize the fracture. Dynamic distal locking was performed by placing the distal screw at the inferior rim of the elliptical locking hole to allow compression of the fracture site during weight-bearing. Six-month X-ray follow-up revealed a broken nail and nonunion of the fracture due to failed dynamization of the distal locking screw. The nail was removed and replaced by a total arthroplasty. Due to the femoral anterior bow of the shaft, anterior cortical impingement of the distal tip of a nail may result in the failure of the nail to slide within the diaphyseal canal when using a medium-length nail preventing compression of the fracture. Dynamic distal locking can be ineffective if the ability of the distal nail to slide within the diaphyseal canal is hindered. This type of scenario can represent an opportunity for anterior nail impingement. Distal jamming of the nail can thus compromise dynamic compression at the fracture site during loading, thus inducing nonunion of the fracture, and leading to breakage of the osteosynthesis device. For these reasons, caution is recommended when using medium-length trochanteric nails for unstable trochanteric fractures.

Background

Reamed interlocking intramedullary nailing is considered the gold standard treatment for complex fractures of the femoral and tibial shaft. There has been some controversies about dynamization of statically locked nails, and some authors recommended routine dynamization for promotion of healing. This study aims to evaluate treatment of complex fractures in tibia and femur with static interlocking intramedullary nail method.

Methods

In a retrospective study from January 2003 to April 2008, 173 patients with femoral and tibial shaft fracture that were treated with this method were enrolled. No rod was dynamized in our patients.

Results

All patients with tibial fractures achieved union without any need for dynamization during 12-18 weeks (mean; 13.4 weeks). Four patients developed delayed union but all achieved union without any intervention. In femoral fracture, all but one patient achieved complete union during 10-30 weeks (mean: 18.3 weeks). One patient developed non-union who was treated by an exchange nailing and iliac bone graft method. No significant complication was observed in our patients.

Conclusion

It is not necessary to routinely dynamize nails in tibial and femoral shaft fractures as all fractures united in acceptable alignment without any complication.

Septic and aseptic loosening with or without extensive bone loss after total knee replacement are the most common indications for knee fusion. Both external fixation and intramedullary nailing can be used for the treatment, though the latter appears to be the method of choice for most patients. Nine patients were treated after a total knee replacement failure using intramedullary nailing. A long intramedullary nail with a proximal interlocking screw was used in five cases, and a customised nail was used in four cases. Successful fusion occurred in eight of nine patients (89%). Average time for the joint union was 6.5 months, and average operative blood loss was 860 ml. In two patients, iliac crest and patellar bone graft were also used. In conclusion, intramedullary nailing can give excellent results in achieving knee fusion after a failed knee replacement as it allows early weight bearing and at the same time offers stability, pain relief, and a high rate of union, even though the surgical technique is demanding.

Distal third tibial fractures are prone to non-union following tibial nail insertion. The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws. Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed. Our results showed that 80% of non-unions in distal third fractures had only one distal locking screw compared to 20% who had two distal locking screws. This is statistically significant (p<0.01). We therefore conclude that two distal locking screws are essential for distal third fractures.

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.

Background:

Rotational malalignment after intramedullary tibial nailing is rarely addressed in clinical studies. Malrotation (especially >10°)of the lower extremity can lead to development and progression of degenerative changes in knee and ankle joints. The purpose of this study is to determine the incidence and severity of tibial malrotation after reamed intramedullary nailing for closed diaphyseal tibial fractures.

Materials and Methods:

Sixty patients (53 males and 7 females) with tibial diaphyseal fracture were included in this study. The mean age of the patients was 33.4±13.3 years. All fractures were manually reduced and fixed using reamed intramedullary nailing. A standard method using bilateral limited computerized tomography was used to measure the tibial torsion. A difference greater than 10° between two tibiae was defined as malrotation.

Results:

Eighteen (30%) patients had malrotation of more than 10°. Malrotation was greater than 15° in seven cases. Good or excellent rotational reduction was achieved in 70% of the patients. There was no statistically significant relation between AO tibial fracture classification and fibular fixation and malrotation of greater than 10°.

Conclusions:

Considering the high incidence rate of tibial malrotation following intramedullary nailing, we need a precise method to evaluate the torsion intraoperatively to prevent the problem.

We followed 12 patients with nailed femoral shaft fractures in which breakage of the static locked nail occurred during fracture treatment. Only two fractures united. The remaining ten fractures had to be treated with exchange nailing after a median of 10 (4–14) months. Nine fractures healed after a median of 5 (4–7) months and one was lost to follow-up. Although breakage of a proximal static reamed femoral locked nail may imitate the effect of dynamisation, the success rate is low. Early exchange nailing is a more successful option to achieve fracture union.

Background:

Charcot's neuroarthropathy of ankle leads to instability, destruction of the joint with significant morbidity that may require an amputation. Aim of surgical treatment is to achieve painless stable plantigrade foot through arthrodesis. Achieving surgical arthrodesis in Charcot's neuroarthropathy has a high failure rate. This is a retrospective nonrandomized comparative study assessing the outcomes of tibio-talar arthrodesis for Charcot's neuroarthropathy treated by uniplanar external fixation assisted by external immobilization or retrograde intramedullary interlocked nailing.

Materials and Methods:

Records of the authors′ institution were reviewed to identify those patients who had undergone ankle fusion for diabetic neuroarthropathy from January 1998 to December 2008. A total of11 patients (six males and five females) with a mean age of 56 year and diabetes of a mean duration of 15.4 years with ankle tibio-talar arthrodesis using retrograde nailing or external fixator for Charcot's neuroarthropathy were enrolled for the analysis. Neuropathy was clinically diagnosed, documented and substantiated using the monofilament test. All procedures were performed in Eichenholz stage II/III.Six patients were treated with uniplanar external fixator, while the remaining five underwent retrograde intramedullary interlocking nail. The outcomes were measured for union radiologically, development of complications and clinical follow-up, according to digital archiving systems and old case notes.

Results:

All five (100%) patients treated by intramedullary nailing achieved radiological union on an average follow-up of 16 weeks. The external fixation group had significantly higher rate of complications with one amputation, four non unions (66.7%) and a delayed union which went on to full osseous union.

Conclusion:

The retrograde intramedullary nailing for tibio-talar arthrodesis in Charcot's neuroarthropathy yielded significantly better outcomes as compared to the use of uniplanar external fixator.

Background

In the last years intramedullary nailing has become the treatment of choice for most displaced diaphyseal tibia fractures. In contrast intramedullary nailing of distal tibia fractures is accompanied by problems like decreased biomechanical stability. Nevertheless the indications for intramedullary nailing have been extended to include even more distal fractures. The purpose of this study was to compare long-term mechanical characteristics of angle-stable versus conventional locked intramedullary nails in the treatment of unstable distal tibia fractures. Therefore, the effect of time on the mechanical properties of biodegradable sleeves was assessed.

Methods

8 pairs of fresh, frozen porcine tibiae were used. The expert tibial nail (Synthes) was equipped with either three conventional locking screws (CL) or the angle-stable locking system (AS), consisting of a special ASLS screw and a biodegradable sleeve. Biomechanical testing included torsional and axial loading at different time-points over 12 weeks.

Results

The AS group showed a significantly higher torsional stiffness at all time-points (at least 60%) compared to the CL group (p < 0.001). The neutral zone was at least 5 times higher in the CL group (p < 0.001). The mean axial stiffness was maximum 10% higher (week 6) in the angle-stable locked group compared to the conventional group. There was no significant change of the torsional mechanical characteristics over the 12 weeks in both groups (p > 0.05). For axial stiffness and range of motion significant differences were found in the AS group.

Conclusions

The angle-stable locking system (ASLS) with the biodegradable sleeve provides significantly higher long-term stability. Especially the differences determined under torsional loading in this study may have clinical relevance. The ASLS permits the potential to decrease complications like secondary loss of reduction and mal-/non-union.

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.

This is a retrospective study of 18 patients who had ipsilateral femoral and tibial fractures. They were treated by the retrograde femoral and antegrade tibial intramedullary nail from a single incision in the knee. The average time for union of femoral shaft fractures was 27.6 (18–40) weeks. One patient required antegrade nailing with a bone graft due to metal failure after using the short nail. Two tibial fractures required bone grafting due to bone loss, with an initial open fracture. The average time for union of tibial fractures was 24.5 (18–30) weeks. Functional results using the Karlstrom–Olerud criteria were excellent in 14, good in three, and acceptable in one. The only acceptable result was in a supra- and inter-condylar femoral fracture, with protrusion of the nail tip into the knee joint, which created moderate limitation of knee motion. Simultaneous retrograde femoral and antegrade tibial nailing with a single incision in the knee can achieve satisfactory results in the management of these types of fracture.

Background

Management of tibial fractures associated with soft tissue injury remains controversial. Previous studies have assessed perfusion of the fractured tibia and surrounding soft tissues in the setting of a normal soft tissue envelope. The purpose of this study was to determine the effects of muscle contusion on blood flow to the tibial cortex and muscle during reamed, intramedullary nailing of a tibial fracture.

Methods

Eleven adult canines were distributed into two groups, Contusion or No-Contusion. The left tibia of each canine underwent segmental osteotomy followed by limited reaming and locked intramedullary nailing. Six of the 11 canines had the anterior muscle compartment contused in a standardized fashion. Laser doppler flowmetry was used to measure cortical bone and muscle perfusion during the index procedure and at 11 weeks post-operatively.

Results

Following a standardized contusion, muscle perfusion in the Contusion group was higher compared to the No-Contusion group at post-osteotomy and post-reaming (p < 0.05). Bone perfusion decreased to a larger extent in the Contusion group compared to the No-Contusion group following osteotomy (p < 0.05), and the difference in bone perfusion between the two groups remained significant throughout the entire procedure (p < 0.05). At 11 weeks, muscle perfusion was similar in both groups (p > 0.05). There was a sustained decrease in overall bone perfusion in the Contusion group at 11 weeks, compared to the No-Contusion group (p < 0.05).

Conclusions

Injury to the soft tissue envelope may have some deleterious effects on intraosseous circulation. This could have some influence on the fixation method for tibia fractures linked with significant soft tissue injury.

Infection is a devastating complication following total knee replacement (TKR). In the majority of cases, single- or two-stage revision has excellent results in eradicating infection and restoring function. Rarely, recurrent infection requires alternative treatments such as resection, amputation, or arthrodesis. A review of infections following TKR treated at two joint replacement centers identified 29 cases of resistant knee sepsis treated with a long intramedullary fusion nail. Clinical outcome and radiographs were reviewed at an average follow-up of 48 months (13–114). After the initial intramedullary arthrodesis union occurred in 24 of 29 patients (83%). The average time to fusion was 6 months (3–18 months). Failures included two cases of nail breakage, one of which subsequently achieved fusion following revision nailing, and three cases of recurrent infection requiring nail removal and permanent resection. At a minimum 2-year follow-up, 28% of the patients that achieved fusion complained of pain in the fused knee, 28% complained of ipsilateral hip pain, and two patients complained of contralateral knee pain. Four of the 25 fused patients (16%) remained nonambulatory after fusion, 17 required walking aids (68%) and only four ambulated unassisted. There was no association between age, number of previous procedures, the use of two-stage versus single stage technique, or infecting organism and failure of arthrodesis. Intramedullary arthrodesis is a viable treatment for refractory infection after TKR. Patients undergoing fusion should be informed of the potential for nonunion, recurrence of infection, pain in the ipsilateral extremity, and the long-term need for walking aids.

Background:

The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis.

Materials and Methods:

We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (≤6 h or >6 h), method of soft-tissue management, skin closure time (≤1 week or >1 week), existence of polytrauma (ISS< 18 or ISS≥18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection.

Results:

Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r2 = 0.263, P = 0.0001).

Conclusion:

Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.

Background

The use of artificial endoprostheses has become a routine procedure for knee and hip joints while ankle arthritis has traditionally been treated by means of arthrodesis. Due to its advantages, the implantation of endoprostheses is constantly increasing. While finite element analyses (FEA) of strain-adaptive bone remodelling have been carried out for the hip joint in previous studies, to our knowledge there are no investigations that have considered remodelling processes of the ankle joint. In order to evaluate and optimise new generation implants of the ankle joint, as well as to gain additional knowledge regarding the biomechanics, strain-adaptive bone remodelling has been calculated separately for the tibia and the talus after providing them with an implant.

Methods

FE models of the bone-implant assembly for both the tibia and the talus have been developed. Bone characteristics such as the density distribution have been applied corresponding to CT scans. A force of 5,200 N, which corresponds to the compression force during normal walking of a person with a weight of 100 kg according to Stauffer et al., has been used in the simulation. The bone adaptation law, previously developed by our research team, has been used for the calculation of the remodelling processes.

Results

A total bone mass loss of 2% in the tibia and 13% in the talus was calculated. The greater decline of density in the talus is due to its smaller size compared to the relatively large implant dimensions causing remodelling processes in the whole bone tissue. In the tibia, bone remodelling processes are only calculated in areas adjacent to the implant. Thus, a smaller bone mass loss than in the talus can be expected. There is a high agreement between the simulation results in the distal tibia and the literature regarding.

Conclusions

In this study, strain-adaptive bone remodelling processes are simulated using the FE method. The results contribute to a better understanding of the biomechanical behaviour of the ankle joint and hence are useful for the optimisation of the implant geometry in the future.