No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Distal targeting device for long Gamma nail (R). Monocentric observational study
Abstract
Intramedullary nail distal locking screws make it possible to control length and rotation but include an increased risk of radiation exposure. A distal targeting device was recently developed for long Gamma(®) nails (Stryker(®)). The aim of this practical observational study was to evaluate the reliability of this system. Our hypothesis was that the targeting device would be systematically used without conversion or complications.
All of the long Gamma(®) nails implanted between November 2011 and October 2012 were recorded: 91 nails (59W/32M, mean age 73.5years old) for 68 traumatic fractures, 14 preventive nailings and nine pathological fractures. A junior surgeon performed the procedure in 45 cases and a senior in 46 cases. The number of times the device was used, the difficulties and complications encountered, the duration of fluoroscopy and the dose of radiation were noted. Risk factors were looked for.
The targeting device was used 79 times (the surgeon chose not to use it 11 times, and it was not available in one case). There was a measurement error in one case, therefore 78 nails could be evaluated. Three wrong positions of the distal locking screw occurred. No statistically significant risk factors were identified. Distal locking screw corresponded to 18% of the entire procedure at a radiation dose of 7.44% (this was higher with titanium nails and pathological fractures). Total fluoroscopy time was longer with junior than with senior surgeons but the dose and duration for distal locking were not different.
The hypothesis was not confirmed. The device was not systematically used and the risk of complications was not null. No risk factors were identified. The distal locking screw is a difficult step but the use of the targeting device can limit the dose of radiation. This device is effective and allows young surgeons to perform distal locking without increasing the dose of radiation compared to senior surgeons.
Level IV, cohort study, observational prospective follow-up.
... It has been shown to be an effective modality for long bone fracture fixation with good results (6)(7)(8). The interlocking screws were introduced to confer rotational stability on the construct which had hitherto been a constraint of the non-locked intramedullary nail (9)(10)(11). The interlocked nail is commonly locked with screws at the proximal and distal ends of the nail into each bone fragment of the fracture. ...
... The challenge with the interlocked nail has been in the accurate targeting of the screw holes to enable introduction of the locking screws. This problem is more prevalent with the distal screw hole (9,(12)(13)(14)(15). Various modalities for targeting the screw holes have been used with results improving with better techniques. ...
Background: Long bone fracture fixation has undergone a series of developments over the years, with the use of locked intramedullary nails now being widely accepted as the treatment of choice for most long bone fractures. The challenge in the use of these locked nails has been in the accurate targeting of the screw holes to enable passage of the locked screws. The use of intraoperative imaging such as the C arm is a tool used to assist accurate screw hole targeting. Incentres that do not have such imaging assistance, the use of external jig systems are employed for screw hole targeting. The surgical implant generation network (SIGN) is one of such systems. We present the result of screw targeting with the SIGN system. Methods:This was a retrospective study carried out at the Jos University teaching hospital on patients who had fracture fixation using the SIGN interlocking nail systemfrom January 2013 to October 2014 .Results: 36 fractures were fixed using the SIGN system in patients whose ages ranged from 19 to 64 yearswith a mean age of 37years +/-13.1 years. The male female ratio was 2.3:1.A total of 94 screws were inserted.53 distal screws were inserted while 41 proximal screws were inserted. 3 screws were not within the nail. All the missed screws were distal screws. Total accurate screw hole targeting was 96.8% and total missed screw percentage 3.2%. Accurate distal screw percentage 94.3% while distal missed screw percentage was 5.7%.Conclusion:The SIGN interlocking system has a good mechanism for accurate targeting of the screw holes in interlocking nail fixation in the absence of intraoperative imaging modalities.
... While distal targeting devices have been developed and have shown to reduce radiation exposure, even in long intramedullary nailing, their use is not widespread. [18][19][20] The three surgeries in which more radiation dosage was used were all femur fractures-proximal short and long nailing and DHS. One possible reason for this higher dosage needed may be related to the surface area of this anatomical region compared with others such as the wrist, forearm, phalanxes, and others. ...
Background:
While fluoroscopy is widely used in orthopedic trauma surgeries, it is associated with harmful effects and should, therefore, be minimized. However, reference values for these surgeries have not been defined, and it is not known how surgeon experience affects these factors. The aims of this study were to analyze the radiation emitted and exposure time for common orthopedic trauma surgeries and to assess whether they are affected by surgeon experience.
Methods:
Data from 1842 trauma orthopedic procedures were retrospectively analyzed. A total of 1421 procedures were included in the analysis. Radiation dose and time were collected to identify reference values for each surgery and compared for when the lead surgeon was a young resident, a senior resident, or a specialist.
Results:
The most performed surgeries requiring fluoroscopy were proximal femur short intramedullary nailing (n = 401), ankle open reduction and internal fixation (ORIF) (n = 141), distal radius ORIF (n = 125), and proximal femur dynamic hip screw (DHS) (n = 114). Surgeries using higher radiation dose were proximal femur long intramedullary nailing (mean dose area [DAP]): 1361.35 mGycm2), proximal femur DHS (1094.81 mGycm2), and proximal femur short intramedullary nailing (891.41 mGycm2). Surgeries requiring longer radiation time were proximal humerus and/or humeral shaft intramedullary nailing (02 mm:20 ss), proximal femur long intramedullary nailing (02 mm:04 ss), and tibial shaft/distal tibia intramedullary nailing (01 mm:49 ss). Senior residents required shorter radiation time when performing short intramedullary nailing of the proximal femur than young residents. Specialists required more radiation dose than residents when performing tibial nailing and tibial plateau ORIF and required longer radiation time than young residents when performing tibial nailing.
Conclusions:
This study presents mean values of radiation dose and time for common orthopedic trauma surgeries. Orthopedic surgeon experience influences radiation dose and time values. Contrary to expected, less experience is associated with lower values in some of the cases analyzed.
... Measurement of radiation exposure were calculated using the methods described in the previous studies. [4,[17][18][19][20] Statistical Analysis SPSS 20.0 package program was used to analyze the data. The conformity of the data to the normal distribution was checked using the Kolmogorov-Smirnov test. ...
Background:
Intramedullary nailing (IMN) technique is the gold standard for the treatment of closed fractures of the lower extremity long bones. For orthopedic surgeons, one of the most important problems in IMN procedures is the fixation of distal locking screws (DLS). Accurate and rapid placement of DLSs with minimal radiation exposure is crucial. In this study, we aimed to compare the results of two different distal locking methods concerning surgery duration and radiation exposure in patients who underwent osteosynthesis of tibia fractures with IMN.
Methods:
In this prospective study, the results of 56 patients who met the inclusion and exclusion criteria from 72 patients were evaluated. Patients were divided into two groups according to the distal screwing method. Group 1 (n=29) comprised patients who used free-hand technique (FHT) for distal locking, while Group 2 (n=27) consisted of patients who used electromagnetic guidance system (EMGS) for distal locking. Demographic and medical data of the patients, duration of surgery time, amount of bleeding, total fluoroscopy counts, the time elapsed for distal locking, the measure of radiation exposure, number of attempts for distal screw locking, incorrect screw placements, complications and follow-up time were recorded. The groups were compared concerning demographic data and clinical results.
Results:
There was no statistically significant difference between the groups about gender and side (p=0.928 and p=0.432, respectively). The mean age in Group-1 was higher than that of Group-2, and the difference was statistically significant (p=0.012). However, there was no statistically significant difference in length of hospital stay in Group-1 (p=0.140). On the other hand, in Group-2, the number of distal shots, fluoroscopy duration, effective radiation dose and operation duration were lower compared to Group-1, although this difference was not statistically significant (p=0.057, 0.073, 0.058 and 0.056, respectively). Failure was encountered in distal locking during the first attempt in three cases in Group-1 and in two cases in Group-2. Aseptic nonunion was observed in one patient in both groups.
Conclusion:
Both the FHT distal screwing technique and the EMGS distal screwing technique are highly effective methods for distal locking. The duration of operation, the duration of the fluoroscopy and radiation exposure were similar. FHT can be preferred for distal locking in conventional intramedullary nail applications, as it is effective, easy and inexpensive.
... Diğer yandan; DAP (Dose-area Product : Birim alanda üretilen radyasyon dozu) = DOZ (Gy) ve Alan (m2) formülasyonuna göre hesaplanır [9]. Canlıya göre (hasta,personel,cerrah) hesaplamasında cm2 olarak hesaplanır [10]. Ayrıca alınan efektif radyasyon dozunun hesaplanmasında çeşitli formülasayonlar geliştirilmiştir [11]. ...
Aim: In this study, our
aim is to compare surgery time and radiation exposure for patients of treated with two different
intramedullar nail distal locking systems; free-hand technique and
electromagnetic navigation system.Method:
We evaluated 40 patients' femur fractures. we treated with Intramedullar Nail due to
femur fractures between the dates of February 2012 and February 2013 were
operated on by two different distal locking techniques; Distal Electromagnetic
guided technique(DML+) and Free-hand Technique(DML-). Radiation exposure was measured
by radiationmeter (NAB223) obtained from Civil Defense Directorate. Results:
In group
DML(-) 20 femur fractures were evaluated. Mean flouroscopy time was 33,7± 12,6,
operation time 68.5±7.1 minutes and whole radiation exposure was 461,7±172,7.
In group DML(-) 20 femur fractures were evaluated. Mean flouroscopy time was
29±17,6,operation time 66.25±10.1 minutes and whole radiation exposure was
397,3±241,1.Concllusion:
In
this study we compared distal locking time, radiation exposure and fluoroscopy
shoot by using two different distal locking techniques in long bone fractures
and found no significant differences in
both of techniques (p>0.05).
... Diğer yandan; DAP (Dose-area Product : Birim alanda üretilen radyasyon dozu) = DOZ (Gy) ve Alan (m2) formülasyonuna göre hesaplanır [9]. Canlıya göre (hasta,personel,cerrah) hesaplamasında cm2 olarak hesaplanır [10]. Ayrıca alınan efektif radyasyon dozunun hesaplanmasında çeşitli formülasayonlar geliştirilmiştir [11]. ...
ZET Amaç: Bu çalışmada, serbest el tekniği ve elektromanyetik navigasyon sistemi ile distal kilitleme yapılan intramedüller çivi ameliyatı yapılan olguları, cerrahi süresi ve radyasyon maruziyeti açısından karşılaştırmayı amaçladık. Yöntem: Şubat 2012-Şubat 2013 arasında femur kırığı olan 40 hasta değerlendi-rildi. Distal manyetik kilitlemeli İntramedüller Çivileme (DMK+) ve distal serbest el kilitli intramedüller çivileme (DMK-) tekniği ile operasyon yapıldı. Distal kilitleme sırasında kullanılan floroskopi süresi, radyasyon maruziyeti ve cerrahi süresi karşılaştırıldı. Alınan radyasyon dozu; TC sivil savunma müdürlüğünden temin edilen NAB 223 marka radyasyon ölçer ile ölçüldü. Bulgular: DMK (-) grubunda 20 femur kırığı mevcuttu. Distal kilitleme sırasında ortalama skopi süresi33,7± 12,6 idi, ameliyat süresi 68.50±7.1dk idi. Radyasyon dozu femur kırığı için 461,7±172,7 idi. DMK (+) grubunda 20 hastada femur kırığı mevcuttu. Distal kilitleme sırasında ortalama skopi süresi 29±17,6 idi, ameliyat süresi 66.25±10.1 dk. İdi. Radyasyon dozu ise 397,3±241,1 idi. Sonuç: Uzun kemik kırıklarına uygulanan İntramedüller Çivileme tekniklerini karşılaştırdığımız bu çalışmada distal manyetik kilitlemeli İntramedüller civilerin alınan skopi sayısı, ameliyat süresi ve kanama miktarını kilitsiz intramedüller çivilere göre anlamlı şekilde azaltmadığı gözlenmiştir (p>0.05). Anahtar kelimeler: Femur kırığı, intramedüller çivileme, distal kilitleme, radyasyon ABSTRACT Aim: In this study, our aim is to compare surgery time and radiation exposure for patients of treated with two different intramedullar nail distal locking systems; free-hand technique and electromagnetic navigation system. Method: We evaluated 40 patients' femur fractures. we treated with Intramedullar Nail due to femur fractures between the dates of February 2012 and February 2013 were operated on by two different distal locking techniques; Distal Electromagnetic guided technique(DML+) and Free-hand Technique(DML-). Radiation exposure was measured by radiationmeter (NAB223) obtained from Civil Defense Directorate. Results: In group DML(-) 20 femur fractures were evaluated. Mean flouroscopy time was 33,7± 12,6, operation time 68.5±7.1 minutes and whole radiation exposure was 461,7±172,7. In group DML(-) 20 femur fractures were evaluated. Mean flouroscopy time was 29±17,6,operation time 66.25±10.1 minutes and whole radiation exposure was 397,3±241,1. Concllusion: In this study we compared distal locking time, radiation exposure and fluoroscopy shoot by using two different distal locking techniques in long bone fractures and found no significant differences in both of techniques (p>0.05).
... Third Gamma3 nail has a lag screw which is easier to insert in young people than PFNA and can be used for compression of the femoral neck fracture [15]. Fourth the long Gamma3 nail has a distal target device to limit the dose of radiation [16]. Hence, in our cases we performed open reduction to the sub-trochanteric fracture and then close reduction to the femoral neck fracture under fluoroscopy and fixation with Gamma3 nail, one implant for two fractures. ...
To our knowledge, the type of combination of ipsilateral femoral neck and sub-trochanteric fracture is rare. And the long term follow-up is seldom been reported. A 60 year old woman suffered from a traffic accident. We gave her the intramedullary nail treatment for the combination of ipsilateral femoral neck and sub-trochanteric fracture, and the fracture indeed cured after one year and there is no clue of necrosis of the femoral head, but after 5 years, there is an evidence of necrosis of the femoral head. Combination of ipsilateral femoral neck and sub-trochanteric fracture should be kept in mind. Patients with this unusual fracture should be kept under surveillance for longer than might be thought currently to be necessary for there is a possibility of necrosis of the femoral head, even a nondisplaced femoral neck fracture.
... 48 The increased radiation exposure intraoperatively, the prolonged operative time, and the creation of stress risers after mistargeting, or the eccentric insertion of locking screws predisposing to their fatigue failure constitute contemporary concerns relevant to distal interlocking of intertrochanteric fractures. [49][50][51] Currently, distal locking is dictated in intertrochanteric fractures with either severe comminution, or subtrochanteric distal extension, or in the presence of gross osteopenia and ballooning of the femoral diaphysis, to avoid painful toggling of the nail into the diaphyseal canal at the early stages, and malunion in the form of loss of femoral length, malalignment, and rotational deformity. ...
Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.
Copyright © 2015 Elsevier Ltd. All rights reserved.
... 48 The increased radiation exposure intraoperatively, the prolonged operative time, and the creation of stress risers after mistargeting, or the eccentric insertion of locking screws predisposing to their fatigue failure constitute contemporary concerns relevant to distal interlocking of intertrochanteric fractures. [49][50][51] Currently, distal locking is dictated in intertrochanteric fractures with either severe comminution, or subtrochanteric distal extension, or in the presence of gross osteopenia and ballooning of the femoral diaphysis, to avoid painful toggling of the nail into the diaphyseal canal at the early stages, and malunion in the form of loss of femoral length, malalignment, and rotational deformity. ...
A large number of implants have been developed for intramedullary fixation of intertrochanteric fractures. This article attempts to summarize the contemporary understanding of the existing biomechanical and clinical evidence on intramedullary nailing of intertrochanteric fractures, as to whether they should be short or long nails, and the use or not of distal locking screws. Difficulties on the translation of biomechanical findings to the clinical setting, as well as the pressing demand for standardization of the indications and the use of different modes of cephalomedullary nailing, should direct orthopaedic trauma research toward focused, well-designed clinical studies.
Level V-expert opinion.
Purpose
To determine if the DTS decreases radiation exposure (primary outcome measure), fluoroscopy time (secondary outcome measure), and time to distal screw placement (secondary outcome measure) compared to the freehand “perfect circles” method when used for locking of cephalomedullary nails in the treatment of femur fractures
Methods
Fifty-eight patients with hip or femoral shaft fractures that were treated with a long cephalomedullary nail were enrolled in this study. Cohorts were determined based on the method of distal interlocking screw placement into either the “Perfect Circles” or “Distal Targeting” cohort. Time from cephalad screw placement to placement of final distal interlocking screw (seconds), radiation exposure (mGy), and fluoroscopy time (seconds) were compared between groups. Hospital quality measures were compared between cohorts.
Results
Use of the DTS resulted in 77% (4.3x) lower radiation exposure (p<0.001), 64% (2.7x) lower fluoroscopy time (p<0.001), and 60% (1.7x) lower intraoperative time from end of cephalad screw placement to end of distal interlocking screw placement (p<0.001) compared to the freehand “perfect circles” method. There was no difference in 30-day or 90-day complication rates between cohorts.
Conclusion
The Stryker Gamma3® Distal Targeting System is a safe, effective and efficient alternative to the freehand “perfect circles” method.
Resumen
La fractura de la diáfisis femoral, propia del adulto joven por ser secundaria a un traumatismo de alta energía, ha visto recientemente cambiar su contexto epidemiológico, involucrando al paciente anciano o produciéndose sobre hueso ya sometido a artroplastia. La técnica de osteosíntesis de referencia es el enclavado intramedular anterógrado con fresado bloqueado estático. Las placas laterocorticales atornilladas convencionales por vía de acceso quirúrgica directa se van reemplazando por técnicas mínimamente invasivas que utilizan material con tornillos de bloqueo que responden a una filosofía de colocación específica. La fijación externa ha experimentado un progreso técnico significativo, ofreciendo montajes livianos y mecánicamente fiables. En este artículo se describirán detalladamente cada una de estas técnicas quirúrgicas: colocación del paciente, maniobras de reducción, vías de acceso quirúrgico, tipo de montaje, evolución postoperatoria. Se enumeran y detallan las indicaciones quirúrgicas preferentes de las tres técnicas según las lesiones asociadas, las complicaciones inmediatas y el contexto de presentación.
Riassunto
La frattura della diafisi femorale, caratteristica di giovani adulti perché secondaria a un trauma ad alta energia, ha visto recentemente mutare il suo contesto epidemiologico, coinvolgendo persone anziane o soggetti già portatori di artroplastica. La metodica di osteosintesi di elezione è l’inchiodamento endomidollare anterogrado con alesaggio statico bloccato. Le placche laterocorticali convenzionali poste mediante accesso chirurgico diretto sono sostituite da tecniche mininvasive che utilizzano una specifica filosofia di posa. Il fissaggio esterno ha compiuto notevoli progressi tecnici, offrendo assemblaggi leggeri e meccanicamente affidabili. Ciascuna di queste tecniche chirurgiche è descritta in dettaglio: installazione del paziente, manovre di riduzione, accesso operatorio, tipo di sintesi, decorso postoperatorio. Le indicazioni chirurgiche preferenziali per le tre tecniche sono elencate e dettagliate in base alle lesioni associate, alle complicanze immediate e alle condizioni in cui si sono verificate.
Résumé
Introduction
Les clous centromédullaires sont particulièrement utilisés pour l’ostéosynthèse des fractures diaphysaires. Le verrouillage distal avec la technique dite « à main levée » peut nécessiter une exposition importante aux rayons ionisants. Notre méthode permet d’obtenir des trous ronds radiologiquement au premier essai pour les fractures des membres inférieurs sans instrumentation spécifique.
Technique chirurgicale
Le principe appliqué est un principe géométrique selon lequel deux droites perpendiculaires à une même droite sont parallèles entre elles. Le verrouillage proximal, qu’il soit réalisé ou non, nous guide en donnant la première droite perpendiculaire au clou. Il suffit alors d’orienter le fluoroscope comme la douille ou le tournevis laissé en place pour obtenir des trous ronds parfaits d’emblée.
Discussion
Cette technique simple est fiable et reproductible. Elle ne demande pas d’instrumentation spécifique, laisse libre choix concernant le fabricant du clou et limite l’exposition aux rayons ionisants.
Introduction: Intramedullary locked nails are mainly used for the fixation of mid-shaft fractures in the long bones. But inserting the distal locking screws by the free-hand technique may require high exposure to radiation. Our method achieves perfect circles on radiographs on the first attempt for lower limb fractures without any specific instrumentation.
Surgical technique: We applied a geometric principle in which two lines perpendicular to another line are parallel to each other. Proximal locking, whether it is done or not, serves as a guide for the first perpendicular line to the nail. The fluoroscopy unit is aligned along the drill sleeve or the screwdriver left in place to achieve perfect circles on the first attempt.
Discussion: This technique is simple, reliable, and reproducible. It does not require any specific instrumentation, allows the surgeon to choose any manufacturer’s nail and reduces the operating room staff’s exposure to radiation.
Las fracturas del macizo trocantéreo representan más de dos tercios de las fracturas de cadera y plantean problemas más que todo de estabilidad de la fractura y de osteosíntesis precaria en el hueso osteoporótico, y menos de consolidación ósea. En los países industrializados, la indicación de un tratamiento no quirúrgico o con fijador externo es infrecuente. La gran mayoría de estas fracturas se tratan mediante osteosíntesis extra o intramedular para permitir la movilización y el apoyo precoz, y favorecer así una reintegración social rápida. La osteosíntesis extramedular mediante placa atornillada estática o dinámica es el tratamiento de elección para las fracturas intertrocantéreas estables. En algunos casos, los implantes estáticos pueden facilitar la reducción y el mantenimiento de la fractura en posición anatómica, pero presentan un riesgo mayor de desmontaje secundario. Están indicados sobre todo en el hueso de buena calidad y cuando la fractura presenta una buena estabilidad intrínseca tras la reducción. Los tornillos-placas dinámicas permiten una impactación secundaria de la fractura, por lo que son más fiables en el hueso de mala calidad o cuando la fractura es más conminuta. Sin embargo, esta impactación de la fractura puede causar un acortamiento del miembro y comprometer la función de la cadera. Los implantes intramedulares tienen una ventaja mecánica y pueden limitar la impactación de la fractura. Sin embargo, el riesgo de complicación per y postoperatoria (fracturas secundarias, lesiones de los músculos glúteos) es mayor, sobre todo para los implantes de primera generación. Están indicados sobre todo para las fracturas intertrocantéreas conminutas y/o inestables. Las fracturas aisladas del trocánter mayor y del trocánter menor son raras y deben evaluarse de forma minuciosa, en ocasiones mediante tomografía computarizada ósea o por resonancia magnética, en busca de un trazo de fractura intertrocantérea oculto o de un proceso tumoral asociado. Si se descarta una patología asociada, un tratamiento funcional mediante descarga es suficiente en la mayoría de los casos.
Seit kurzem stehen röntgendurchleuchtungsunabhängige, mechanische Zielsysteme für die distale Verriegelung von ungeschlitzten Tibiamarknägeln zur Verfügung, die die insertionsbedingte Nageldeformation kompensieren. Vergleichende Untersuchungen über Vor- und Nachteile dieser Systeme sind bisher noch nicht durchgeführt worden. Die vorliegende Studie untersuchte Operationsdauer, Länge der Durchleuchtungszeit und Präzision der Schraubenplazierung mit einem strahlenunabhängigen, mechanischen Zielsystem und einer Freihandtechnik (strahlentransparentes Winkelgetriebe). Von einem mit beiden Techniken unerfahrenen Chirurgen wurden am Frakturmodell der Tibia (Schrägosteotomie) an humanen Ganzkörperpräparaten im Rechts-Links-Vergleich Unterschenkelmarknagelungen mit statischer Verriegelung durchgeführt. Für das distale Zielgerät bzw. für die Freihandtechnik betrug die Gesamtoperationszeit 25,4 ± 11,3 vs. 30,9 ± 14,3 min (p = 0,029), die distale Verriegelungszeit 16,7 ± 8,6 vs. 21,9 ± 10,5 min (p = 0,004), die gesamte Durchleuchtungszeit 9 ± 5 vs. 93 ± 34 s (p p p = 0,001). Die Versagerquote betrug in beiden Gruppen je 1,6 % (1 von 60 Schrauben). Beide Techniken können von einem unerfahrenen Chirurgen gleich schnell erlernt werden. Der Hauptvorteil des röntgenstrahlenfreien, mechanischen distalen Zielgerätes ist die Vermeidung von Röntgenstrahlen während der distalen Verriegelung und die präzisere Schraubenplazierung mit einer geringeren insertionsbedingten Implantatbeschädigung.
We present a salvage technique for distal femoral interlocking under direct vision through a window in the anterior femoral cortex in a subgroup of six patients, among those presented to our institution during the last 10 years with a femoral shaft fracture treated with reamed, locked intramedullary nailing. The common characteristic of these patients was the performance of distal locking under direct vision through a small window in the anterior femoral cortex because of intraoperative dysfunction of the image intensifier. Screw insertion was successful in all cases. All fractures and all cortical windows healed uneventfully. No postoperative fractures occurred through the cortical defect. This technique, despite being a salvage one, has proven a safe alternative to the common distal targeting techniques. It can be used when an image intensifier is unavailable without jeopardizing the excellent clinical and radiographic outcome of reamed locked nailing of femoral shaft fractures.
The indications for intramedullary nailing have expanded to include most tibial shaft fractures. Nail design has improved since their first introduction, but distal locking remains a difficult part of the procedure, resulting in radiation exposure to the patient and the surgeon and increased operation time. To address these issues, we describe an alternative surgical technique using a newly designed distal targeting device that consists of a proximally mounted aiming arm, and we report the preliminary data from its use in all tibial shaft fractures amenable to surgery for a 2–year period. Sixty-three tibial shaft fractures were treated with this method. The mean duration of the distal locking was 6.5 minutes, and in all successful cases, radiation exposure for distal locking was two shots (one shot before targeting and another for the confirmation of proper screw insertion). Radiation exposure was on average 0.85 seconds (range, 0.4–1.2 seconds) and 1.4 mGy (range, 0.8–1.9 mGy). There were no major intraoperative complications related to the technique. The method has certain advantages and can reduce radiation exposure and operation time. Nonetheless, familiarity with the instrumentation is a prerequisite for accurate distal locking.
Level of Evidence: Level IV Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
The free hand technique remains the most popular method for distal locking; however, radiation exposure is a major concern. In an endeavour to overcome this concern, distal locking with the nail over nail technique is evaluated. Seventy patients with femoral diaphyseal fractures treated by intramedullary nailing were divided in two groups for distal locking: either using the free hand technique (group I) or with the nail over nail technique (group II). The average number of images taken to achieve nail insertion without locking, for distal locking, and for the complete procedure in group I was 25.8, 24.2, and 50.08, respectively, compared with 24.8, 4.1, and 28.9, respectively, in group II (statistically extremely significant decrease in radiation). The nail over nail technique appears to be a reliable solution for decreasing radiation exposure during closed femoral intramedullary nailing. However, over-reaming of 1.5 mm is the key to the success of the technique.
For many fractures of the femoral shaft, closed intramedullary nailing will not control rotation or telescoping of the fragments. Locked intramedullary nailing combines closed nailing with the percutaneous insertion of screws that interlock the bone and nail. This method permits static locking that controls rotation and telescoping and subsequently conversion to dynamic locking when weight-bearing is started after approximately twelve weeks. By providing greater stability, this method extends the indications for intramedullary nailing to severely comminuted, oblique, and spiral fractures as well as to fractures complicated by loss of bone and fractures in the proximal and distal ends of the femoral shaft. Of fifty-two patients with forty-nine severely comminuted fractures of the femoral shaft and three fractures that were complicated by loss of bone, forty-seven patients had uneventful consolidation of the fracture, with a mean time of 4.5 months for the severely comminuted fractures and seven months for the fractures that had a loss of bone. At follow-up, all forty-seven patients had normal motion of the hip, and forty-five had normal motion of the knee. Of the remaining five patients, four had a non-union that eventually healed (three after a second locked nailing and one after a third) and one had a septic non-union that eventually healed after removal of the nail and screws, debridement, and immobilization with an external fixator. Based on this experience, we concluded that this form of treatment has many advantages. The risk of infection and non-union is low, the incidence and severity of malunion are reduced, the hospital stay is short, and early mobilization of the patient is possible.
Introduction:
In locking intramedullary nails, the most important problem is to put the distal interlocking screw accurately and quickly with minimum radiation exposure. The purpose of this clinical study was to compare the fluoroscopic time and surgical time required for distal locking with either free-hand fluoroscopic guidance or with an electromagnetic navigation system.
Materials and methods:
The study comprised 54 patients with 58 fractures of the lower extremity. The patients were divided in two groups: distal locking with freehand fluoroscopic guidance (group I) and distal locking with electromagnetic navigation (group II). The primary outcome in this study was fluoroscopy time. The secondary outcome was the operative time in distal interlocking.
Results:
In group I, the mean operation time was 108 (81-135) min, the mean time for distal interlocking was 18.35 (9-27) min, the total fluoroscopy time was 47.77 (19-74) s, the mean fluoroscopy time during distal interlocking was 18.29 (2-29) s and the mean attempt at number of distal locking for two screws was 9.96 (2-18) times. In group II, the mean operation time was 80.96 (63-100) min, the mean time for distal interlocking was 7.85 (6.5-10) min, the total fluoroscopy time was 22.59 (15-32) s, the mean fluoroscopy time during distal interlocking was 1.62 (0-2) s and the mean attempt number of distal interlocking was 2 (2-2).
Conclusion:
Fluoroscopy time to achieve equivalent precision is significantly reduced with electromagnetism-based surgical navigation compared with free hand fluoroscopic guidance. Also the operative time is significantly reduced with electromagnetic based navigation.
Current methods of distal interlocking of intramedullary femoral nails are dependent on image intensification. However, radiation exposure to the patient, the operating room staff, and the surgeon remains a concern. Proximally mounted, radiation-free aiming systems for distal interlocking of femoral nails have reportedly failed because of nail deformation with insertion. To better understand this deformation, a threedimensional magnetic motion tracking system was used to determine the position of the distal interlocking hole following nail insertion. The amount and direction of deformation of commercially available smalldiameter implants (unslotted 9-mm nails inserted without reaming) and large-diameter implants (slotted 13-mm nails inserted with reaming) from a single manufacturer were analyzed. Measurements of deformation (three translations and three angles), based on the center of the distal transverse locking hole, were performed on 10 paired intact human cadaveric femora before and after insertion. The technique produced the following results for the small and large-diameter nails, respectively: lateral translations of 18.1 ± 10.0 mm (mean ± SD, range: 47.8 mm) and 21.5 ± 7.9 mm (range: 26.4 mm), dorsal translations of -3.1 ± 4.3 mm (range: 15.2 mm) and 0.4 ± 9.8 mm (range: 30.1 mm), and rotation about the longitudinal axes of −0.1 ± 0.2° (range: 0.7°) and 10.0 ±3.1° (range: 7.8°). This technique is useful for measuring insertion-related femoral nail deformation. The data for the nails tested suggest that a simple aiming arm, mounted on the proximal end of the femoral nail alone, will not sufficiently provide accurate distal aiming.
: The purpose of this study was to assess the effectiveness of a novel radiation-independent aiming device for distal locking of intramedullary nails in a human cadaver model.
: A new targeting system was used in 25 intact human cadaver femora for the distal locking procedure after insertion of an intramedullary nail. The number of successful screw placements and the time needed for this locking procedure were recorded. The accuracy of the aiming process was evaluated by computed tomography.
: The duration of the distal locking process was 8.0 ± 1.8 minutes (mean ± SD; range, 4-11 minutes). None of the screw placements required fluoroscopic guidance. Computed tomography revealed high accuracy of the locking process. The incidence angle (α) of the locking screws through the distal locking holes of the nail was 86.8° ± 5.0° (mean ± SD; range, 80°-96°). Targeting failed in 1 static locking screw because of a material defect in the drilling sleeve.
: This cadaver study indicated that an aiming arm-based targeting device is highly reliable and accurate. The promising results suggest that it will help to decrease radiation exposure compared with the traditional "free-hand technique."
During the last decades, intramedullary nailing has become the standard treatment for diaphyseal fractures of long bones. Numerous innovative techniques and devices have been proposed to simplify distal locking. Each has its own limitations and, as a result, the fluoroscopy-dependent "free-hand technique" remains the most popular method. However, radiation exposure to the patient and operating room staff remains a concern.
Before the development of a new radiation-independent, nail-mounted targeting system, we mathematically analyzed the aiming accuracy that such a system has to achieve. The correctness of this mathematical model was evaluated using a mechanical testing apparatus.
We found a quite large targeting range for the unimpeded passage of the drill bit through the locking hole of a given nail. Important degrees of nail bending can thereby be compensated. As predicted by the mathematical formula, a 4-mm drill bit passed the distal locking hole of a 320/11mm femoral nail up to a deflection of ±13mm in the coronal plane.
This mathematical model can be considered to be an additional tool for the development of new targeting devices. Combining our mathematical model with data previously published, not only torsional deformation along the longitudinal axis of the nail but also bending in the coronal plane can approximately be neglected. Hence, the three-dimensional aiming process can be simplified to the determination of the interlocking hole of the nail in the sagittal plane provided that the insertion-induced nail deformation in vivo stays in the range of that observed in vitro.
Level III. Basic sciences control study.
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.
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.
We treated 16 patients with 18 long bone fractures using the described technique. We assessed patients clinically and radiographically immediately postoperatively.
A total of 19 blind freehand interlocks were attempted, and 17 were successful as assessed by direct intraoperative observations and by postoperative radiographs.
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.
Distal locking is one of the most difficult steps in intramedullary nailing. Numerous methods can help the surgeon, but all are time-consuming and involve much irradiation. We have developed and tested a new method based on only two fluoroscopic shots that do not need to be taken in the axes of the holes. This avoids requiring the presence of an experienced fluoroscopy operator to accurately adjust the imaging device in front of the locking holes, and decreases the exposure to radiation of the patient and medical team. A 3-D model of the distal nail and of its locking holes was constructed from a pair of calibrated fluoroscopic views. Prior to this, the contours of the nail and locking holes projections had to be determined. A 3-D optical localizer allowed the tracking of reference frames fixed to the nail, imaging device, and drilling motor. A navigation system based on the model guided the surgeon during distal targeting. The robustness, accuracy, and duration of the technique were evaluated in laboratory. The range of acceptable orientations of the X-ray beam has also been determined. Twenty drilling tests were carried out on sawbones. The accuracy and the duration required by our system to perform the distal targeting shows potential suitability for clinical use. The drill passed through the nail locking holes for all of them. The accuracy was about 1.5 mm in translation and 1 degree in rotation. The total time spent on drilling did not exceed 15 min. The system was also assessed in vivo on three patients.
Distal locking is one challenging step during intramedullary nailing of femoral shaft fractures that can lead to an increase of radiation exposure. In the present study, the authors describe a technique for the distal locking of femoral nails, implementing a new targeting device in an attempt to reduce radiation exposure and operational time. Over a 2-year period, 127 consecutive cases of femoral shaft fractures were included in the study. All cases were treated with nailing of femoral shaft fractures with an unslotted reamed antegrade femoral nail and distal locking was performed with the use of a proximally mounted aiming device. Mean duration of the procedure was 63.5 18.1 min while the duration for distal locking was 6.6 +/- 2.6 min. In all successful cases, exposure from intraoperative fluoroscopy was 17.2 +/- 7.4 s for the whole operative procedure, and for distal locking was 2 shots, 1.35 s (range, 0.9-2.2 s) and 1.9 mGy (range, 1.1-2.9 mGy). Five cases (3.9%) were unsuccessful, but overall no intraoperative complications were encountered from the application of this technique. The ability of the device to correspond to the level of nail deformation and to properly identify the distal holes, reduced exposure to radiation compared to other published reports, and should be considered as a valuable tool for distal locking of femoral fractures.
Owing to the continuous turnover of registrars and radiographers, most of the trauma-related orthopaedic surgery in this academic hospital is done by inexperienced surgeons-in-training and the fluoroscopy by junior radiographers. This could result in excessive radiation doses. Calibrated lithium fluoride thermoluminescent chips were secured to various parts of the primary surgeon's body to quantify the radiation dose received during the insertion of an intramedullary nail. Closed intramedullary fixation of 15 fractures of the femur was done with interlocking as necessary. The total average exposure time was 14 minutes 45 seconds per procedure. Distal locking took up 31% of this time. The mean radiation dose to the surgeon's eyes and thyroid was 0.13 mGy and to the dominant hand 2.10 mGy. This would allow the performance of about 350 such procedures per year before the maximum permissible dose level was reached. Recommendations to decrease irradiation dosage are made.
Interlocking nailing is an alternative method of internal fixation following corrective osteotomies for malunions or after correction of leg length inequality. Of 13 osteotomies (six femoral, seven tibial) for angular or rotational malunion, all healed following dynamic locked nailing. Eleven were considered anatomic and two had mild residual deformity. One-stage femoral lengthening was performed in 17 patients. The preferred operative technique includes a long Z-shaped osteotomy, static interlocking nailing, primary cancellous bone grafts, and one or two supplemental screws at the osteotomy site to prevent shortening following dynamization. Thirteen complications developed following one-stage lengthening of the femur, which included significant loss of length in five patients, femoral nerve palsies in four patients, three deep infections, and one nonunion. Lengthening should not exceed 4.0 cm in the femur. The recommended technique of shortening osteotomy consists of resection of a cylindric segment of bone from the distal diaphyseal metaphyseal area. Shortening should not exceed 4.5 cm in the femur or 3.0 cm in the tibia. In ten patients who were shortened, all healed, but radiologic signs of union appeared very slowly in most cases.
For many fractures of the femoral shaft, closed intramedullary nailing will not control rotation or telescoping of the fragments. Locked intramedullary nailing combines closed nailing with the percutaneous insertion of screws that interlock the bone and nail. This method permits static locking that controls rotation and telescoping and subsequently conversion to dynamic locking when weight-bearing is started after approximately twelve weeks. By providing greater stability, this method extends the indications for intramedullary nailing to severely comminuted, oblique, and spiral fractures as well as to fractures complicated by loss of bone and fractures in the proximal and distal ends of the femoral shaft. Of fifty-two patients with forty-nine severely comminuted fractures of the femoral shaft and three fractures that were complicated by loss of bone, forty-seven patients had uneventful consolidation of the fracture, with a mean time of 4.5 months for the severely comminuted fractures and seven months for the fractures that had a loss of bone. At follow-up, all forty-seven patients had normal motion of the hip, and forty-five had normal motion of the knee. Of the remaining five patients, four had a non-union that eventually healed (three after a second locked nailing and one after a third) and one had a septic non-union that eventually healed after removal of the nail and screws, débridement, and immobilization with an external fixator. Based on this experience, we concluded that this form of treatment has many advantages. The risk of infection and non-union is low, the incidence and severity of malunion are reduced, the hospital stay is short, and early mobilization of the patient is possible.
The clinical mechanical failures of small diameter intramedullary interlocking nails were evaluated to determine the relationship of failure modes to the type or location of tibial fractures. Methods were developed to duplicate failure modes in vitro in standardized tests to simulate the clinical situations. Where standard test methods were inadequate, new methods were developed to provide quantifiable, reliable methods of evaluating potential clinical performance. The modes and rates of mechanical failure in the clinical series were consistent among participating centers: (1) In diaphyseal fractures with secondary trauma, the intramedullary nail bent at the fracture site where the working length was unsupported; (2) failures that occurred several weeks after nailing were the result of fatigue fractures of the locking screws, usually at the distal end; and (3) nail and screw failures occurred most commonly in proximal and distal tibial fractures. The strength of the 8- and 9-mm sizes of Synthes and Russell-Taylor nails were comparable.
A prospective study of sixty-five orthopaedic procedures performed with fluoroscopic assistance was undertaken to determine the risk to the primary orthopaedic surgeon with regard to radiation. Radiation was monitored with the use of a universal film badge placed outside the collar of a lead apron, and a gas-sterilized thermoluminescent dosimeter ring worn on each hand. The rings were changed with every operation, but the same film badge was transferred from surgeon to surgeon. The hand dominance of the surgeon, the duration of the operative procedure, the type of operation, and the total time that fluoroscopy had been used were noted. The study was conducted during twenty-one intramedullary nailing procedures (thirteen involving distal locking), forty open reductions with internal fixation (plates and screws), and four external-fixation procedures. All of the badges and rings were submitted for a report regarding radiation exposure. No relationship was found between a ring with a positive reading for exposure to radiation and the duration of the operation. Similarly, there was no correlation between a positive reading and the surgeon's hand dominance. The mean duration of the fluoroscopy was 2.3 minutes for the group for which the rings did not show a positive reading and 4.7 minutes for the group for which the rings did show a positive reading. This was a significant difference (p < 0.0001). There was no positive reading for exposure to radiation from any ring that had been worn during a procedure in which the fluoroscope had been used for less than 1.7 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)
An H-shaped device was invented to facilitate placement of the distal interlocking screws during closed femoral nailing. Eleven sound cadaveric femurs were experimentally nailed before the application of the device in 15 patients with a femoral shaft fracture. In all experimental cases the insertion of the distal screws proved to be easy. In 11 of 15 patients with a femoral fracture, distal locking was achieved using the H-device. These primary results should stimulate further clinical application of the device.
Recently, radiation-independent aiming devices for the tibia which compensate for insertion-related implant deformation have been developed, but the benefits of such systems have not been determined. This study prospectively evaluated the duration of the nailing procedure, the length of radiation time, and the accuracy of interlocking screw placement with a radiation-independent distal aiming system and the free-hand technique. In an oblique cadaveric tibial fracture, a surgeon inexperienced with either technique performed a statically locked intramedullary nailing. For the aiming system and free-hand technique respectively, the total operation time was 25.4 +/- 11.3 vs 30.9 +/- 14.3 min (P = 0.029), the distal locking time was 16.7 +/- 8.6 vs 21.9 +/- 10.5 min (P = 0.004), the total fluoroscopy time was 9 +/- 5 vs 93 +/- 34 s (P < 0.0001), the distal locking fluoroscopy time was 0 versus 88 +/- 33 s (P < 0.0001), and the screw destruction was -0.7 +/- 5.2 vs 26.8 +/- 31.6 microns (P = 0.001). The failure rate was 1.6% (1 of 60 screws) in both groups. These results suggest that aiming devices can eliminate the need for radiation during distal interlocking screw placement.
Although the free hand technique remains the most popular method for distal interlocking screw insertion, proximally mounted radiation independent devices that compensate for implant deformation recently have been developed for the femur. However, the benefits of such systems have not been determined. This study prospectively compared the duration of the nailing procedure, the length of radiation time, and the accuracy of interlocking screw placement when using a radiation independent distal aiming system with those using the free hand technique. In 20 paired intact anatomic specimen femurs, one surgeon experienced only in the free hand technique performed statically locked intramedullary nailing using the two methods. For the aiming system and free hand technique, respectively, the total operation time was 19.1 +/- 8.4 minutes versus 20.9 +/- 11.3 minutes, the distal locking time was 6.6 +/- 2.4 minutes versus 4.8 +/- 1.5 minutes, the total fluoroscopy time was 23 +/- 17 seconds versus 69 +/- 34 seconds, and the distal locking fluoroscopy time was 0 versus 37 +/- 15.5 seconds. There were no failures in either group. Drill nail contact and distal screw damage were greater with the free hand technique. This study suggests that the main advantages of the aiming arm compared with the free hand technique include the elimination of radiation during distal interlocking and more precise screw placement with decreased insertion related hardware damage.
A new, image-intensifier mounted target device for closed interlocking nailing is described. The aim of locating the distal holes with the least radiation exposure is achieved. The proposed device has been designed to be mounted on the image-intensifier, is absolutely stable, eliminates the need for a specialised X-ray technician and allows the surgeon to be away from the radiation beam (direct or scattered). It also permits image intensification in the anteroposterior view, without losing the target. The device has proved its reliability in the operating room during closed interlocking nailing procedures.
The AO nail mounted 'distal locking aiming device', developed to obtain radiation independent distal locking, has an unproven efficacy in a large clinical setting. This prospective study compares the efficacy and learning curve of the distal aiming device with the popular 'free hand technique'.
Distal locking in thirty cases of statically locked intramedullary femur nailing using the distal aiming device for rotationally stiff unslotted AO SUN nails was prospectively compared with the same number using the free-hand technique with regard to duration, radiation exposure, accuracy of screw placement, and learning curve.
For the free-hand technique and the distal aiming system respectively, the average distal locking time was 35.8+/-18.6 versus 19.3+/-9.8 minutes, and the average number of images taken to achieve distal locking was 11.5+/-3.4 versus 3.8+/-3.5. The decrease in average distal locking time by 46.1% and in radiation by 70.0% with the distal aiming system is statistically significant at P<0.001. There were three failures of the distal aiming device and these were converted to the free-hand technique. The learning curve for the distal aiming device was shorter and more predictable than that with the free hand technique. We also analyse the failures and associated pitfalls with the system.
We found the AO distal locking aiming device to be an accurate, radiation-independent jig with a short and predictable learning curve.
Intramedullary nailing is the standard treatment for closed and some open unstable diaphyseal tibia fractures. Fluoroscopy, while essential for proper nail placement can subject the surgical team and patient to substantial radiation. A new targeting system for tibia nail distal interlocking was developed by Orthofix to limit fluoroscopy. This prospective clinical study compares the Orthofix targeting system versus a free-hand technique for the tibial nail distal interlocking. Fifty eight consecutive patients with sixty tibial fractures amenable for nail fixation were randomly assigned into two equal groups: Group 1: Orthofix distally based distal targeting device and Group 2: a free-hand technique. In all the cases stabilization was achieved with a reamed statically locked tibial nail. Recorded data included accuracy of screw placement, duration of surgery prior to and during distal interlocking, and the fluoroscopy time prior to and during distal interlocking. Both groups revealed comparable fracture patterns. In all fractures the technical aspects of the surgical treatment were performed without complications. There was no statistically significant difference between the groups in the mean time of surgery prior to (62.02 vs. 61.01 min, P=0.92) and during distal interlocking (17.06 vs. 19.08 min, P=0.55), or in the total surgical time (81 vs. 85 min), respectively. Neither was there a statistically significant difference in the mean fluoroscopy time prior to distal interlocking (69 vs. 81 s, p=0.22) nor in the total fluoroscopy time (84 vs. 117 s). There was however, a statistically significant difference between the Orthofix and free-hand groups with regards to the mean fluoroscopy time during distal interlocking (15 vs. 36 s, P=0.01, respectively). This study demonstrates that the distally based distal targeting device by Orthofix for tibial nailing can significantly decrease the mean fluoroscopy time necessary to complete distal interlocking versus free-hand technique.
The procedure for distal interlocking of intramedullary nails can be difficult and time consuming. Following nail insertion, the problems associated with the location of the distal holes and correct screw placements are well known. Numerous techniques and devices have been proposed to aid distal targeting, in attempts to overcome some of the associated problems. The development of the techniques and devices continues. A review of the literature is therefore timely, in order to provide awareness of the current situation. An overview is presented of the various distal targeting methods reported in the literature.
The intramedullary nail or rod is commonly used for long-bone fracture fixation and has become the standard treatment of most long-bone diaphyseal and selected metaphyseal fractures. To best understand use of the intramedullary nail, a general knowledge of nail biomechanics and biology is helpful. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints that allow for secondary fracture healing. Like other metallic fracture fixation implants, a nail is subject to fatigue and can eventually break if bone healing does not occur. Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter. Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics. Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing.
One of the most demanding steps of an intramedullary nailing is the distal locking. The aim of this study is to evaluate clinically and prospectively a new targeting guide. Twenty-five patients were treated consecutively in two different trauma centres (level one and one general hospital) by two different surgeons who were instructed on using the new device. Reduction of the fracture, intramedullary nailing and proximal locking are performed according to standard procedures. Then the new targeting device is used for distal locking. Evaluations are focused on the time it takes to perform the distal locking, the duration of the irradiation exposure and the duration of the complete procedure. In terms of duration, our results are comparable to those reported in the literature but this new device has more advantages than any other system. This new device is fully mechanical and is solidly linked to the patient. It can be used with any existing radioscopic equipment in any hospital. The guide is manually adjustable out of the X-ray field avoiding the surgeon being irradiated. The procedure is easy to learn and reproducible.
Distal locking of tibial nails: a new device to reduce radiation exposure
- G Anastopoulos
- P G Ntagiopoulos
- D Chissa
- G Loupasis
- A Asimakopoulos
- E Athanaselis
Anastopoulos G, Ntagiopoulos PG, Chissa D, Loupasis G, Asimakopoulos A, Athanaselis E, et al. Distal locking of tibial nails:
a new device to reduce radiation exposure. Clin Orthop Relat
Res 2008;466:216-20.
Nail over nail technique for distal locking of femoral intramedullary nails
- R Rohilla
- R Singh
- Magu Narender
- A Devgun
- R Sirwach
- A Gulla
Rohilla R, Singh R, Magu Narender, Devgun A, Sirwach R,
Gulla A. Nail over nail technique for distal locking of femoral
intramedullary nails. Int Orthop 2009;33:1107-12.
Distal locking of tibial nails: a new device to reduce radiation exposure
- Anastopoulos