Search

Background: Our study aims to evaluate the fracture nonunion rate and the functional score of plate and screw fixation, intramedullary nailing and non-surgical treatment in midshaft clavicle fractures patients using a network meta-analysis of data from clinical randomized controlled trials.Material/methods: The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA).Results: 24 randomized controlled trials involving 2161 participants were included. The studies were published between 2007 and 2019. A total of 3 treatment methods-plate and screw fixation, intramedullary nailing and non-surgical treatment- were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the constant score, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the DASH index, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the nonunion rate, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment.Conclusion: Non-surgical treatment has a high rate of nonunion for clavicular fractures with obvious displacement and notable comminution. Surgical treatment reduces the nonunion rate leads to better functional scores at long-term follow-up, although there may be no significant clinical differences. The fracture nonunion rate of plate screw fixation group and intramedullary nail group was low and the functional prognosis was similar. More RCTs focused on clavicular fractures are needed to further substantiate this conclusion. [ABSTRACT FROM AUTHOR]

Introduction: Medial migration of the femoral neck element (FNE) superomedially against gravity with respect to the intramedullary component of the cephalomedullary nail is a complication increasingly recognized to cause femoral head cut-out in intramedullary nailing of pertrochanteric hip fractures. Although cut-outs are common to both intra- and extramedullary fixation, especially in unstable pertrochanteric hip fractures, FNE medial migration in sliding hip screws continues to remain sparse despite increased awareness of the phenomenon. This study aims to investigate whether intramedullary nailing is biomechanically predisposed to FNE medial migration compared to extramedullary fixation with sliding hip screws to account for the discrepancy in reported FNE medial migration rates.Materials and Methods: Twelve fourth-generation synthetic femurs (Sawbones) with unstable intertrochanteric fractures were divided into 2 groups (n=6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA, Synthes) (n=6) in the first group, and the Dynamic Hip Screw (DHS, Synthes) (n=6) in the second group. Both groups were subjected to bidirectional cyclic loading (600N compression loading, 120N tensile loading) at 2 Hz for 5000 cycles. The medial migration distance (MMD) was recorded at the end of the testing cycles.Results: The mean MMD in the PFNA group was 4.56mm (SD 0.69mm) with consistent reproduction of medial migration across all constructs tested. This was significantly more compared to the MMD of 1.17mm (SD 0.69mm) in the DHS group (p<0.001).Conclusion: Intramedullary nailing of unstable intertrochanteric hip fractures is inherently predisposed to FNE medial migration making it more susceptible to consequent cut-out compared to fixation with the DHS. [ABSTRACT FROM AUTHOR]

Aims: Iatrogenic varus malreduction after intramedullary nailing of intertrochanteric fractures (wedge effect) may be more common than previously reported. The aim of study is to determine its incidence and to define easy fluoroscopic landmarks to recognize it intraoperatively.Patients and Methods: We included surgical procedures with residual varus malreduction and sufficient intraoperative fluoroscopy images to assess an intraoperative anatomical reduction at the beginning of the procedure. Two intraoperative fluoroscopic landmarks were defined to assess varus in the anteroposterior view: the position of the greater trochanter (GT) related to the femoral shaft (medialized GT sign), and the position (superior, centre or inferior) of the guide wire in both the neck and the head of the femur (cross wire sign). We describe our current method of treatment to avoid this complication.Results: A total of 369 extracapsular hip fractures were treated using PFNA and Gamma 3 systems. We found 55 (14.9%) fractures with a varus malreduction. Six were underreduced and fixed in varus. Thirty-five (9.48%) were well reduced by closed reduction but suffered a iatrogenic varus displacement when introducing the nail. 31 were female; mean age was 86.6 (range 70-97). Mean postoperative head-shaft angle was 119,2° range (113°-123°). Mean TAD was 24,37 range (14-36 mm).Conclusion: Wedge effect (iatrogenic varus displacement of a well reduced intertrochanteric fracture when introducing the nail) could occur in at least 10% of intertrochanteric fractures. The medialized GT and the "crossing wire sign" seem to be good predictors of iatrogenic varus malalignement. [ABSTRACT FROM AUTHOR]

Introduction: Excellent results have been published in the treatment of the trochanteric fractures in the elderly with cephalomedullary nails or compression hip screws but not free of complications. The perforation of the lag screw through the superior cortex of femoral neck or head followed by rotation and varus collapse of the head-neck fragment, also known as cut-out, is one of them. Probably total hip arthroplasty is the most common solution, but there is no systematic technique for treatment. The objective of this study is to evaluate the results obtained in the treatment of this complication using a variable angle femoral plate.Material and Methods: This retrospective study concerns patients over 65 years with peritrochanteric fractures treated with cephalomedullary nail with cut-out failure solved by re-osteosyntesis with variable angle femoral plate between 1st January 2000 and 31 st December 2017. The series includes 29 patients, 26 women and 3 men with average age 87,3. Patients were followed up clinically and radiologically at regular intervals until fracture consolidation at least 9 months.Results: No patients died at the first 9 months after surgery. Fracture mean consolidation has occurred in all patients in 14th weeks (6-20). Operative time was 93,2 minutes (62-129) including removal of nail. No intraoperative complications were observed. Five patients experienced medical complications and two had a superficial wound infection. The mean tip-apex distance (TAD) was 5mm (2-7mm). The neck-shaft angle was 127 degrees. The mean valgization achieved was 32 degrees (15-40). Only one patient needed a second revision surgery due to aseptic hip joint subluxation after 8 weeks of the surgery solved with total hip arthroplasty.Conclusions: The use of variable angle femoral plate in the cut-out treatment is an attractive option which allows the valgization of the fracture to virtually physiological limits and the placement of the cephalic screw in the most sutiable position with good outcomes and few complications. [ABSTRACT FROM AUTHOR]

Introduction: Pertrochanteric femur fracture fixation with use of cephalomedullary nails (CMN) has become increasingly popular in recent past. Known complications after fracture consolidation include peri‑implant fractures following the use of both short and long nails, with fracture lines around the tip of the nail or through the interlocking screw holes, resulting in secondary midshaft or supracondylar femur fractures, respectively. Limited research exists to help the surgeon decide on the use of short versus long nails, while both have their benefits. The aim of this biomechanical study is to investigate in direct comparison one of the newest generations short and long CMNs in a human anatomical model, in terms of construct stability and generation of secondary fracture pattern following pertrochanteric fracture consolidation.Methods: Eight intact human anatomical femur pairs were assigned to two groups of eight specimens each for nailing using short or long CMNs. Each specimen was first biomechanically preloaded at 1 Hz over 2000 cycles in superimposed synchronous axial compression to 1800 N and internal rotation to 11.5 Nm. Following, internal rotation to failure was applied over an arc of 90° within one second under 700 N axial load. Torsional stiffness as well as torque at failure, angle at failure, and energy to failure were evaluated. Fracture patterns were analyzed.Results: Outcomes in the study groups with short and long nails were 9.7 ± 2.4 Nm/° and 10.2 ± 2.9 Nm/° for torsional stiffness, 119.8 ± 37.2 Nm and 128±46.7 Nm for torque at failure, 13.5 ± 3.5° and 13.4 ± 2.6° for angle at failure, and 887.5 ± 416.9 Nm° and 928.3 ± 461.0 Nm° for energy to failure, respectively, with no significant differences between them, p ≥ 0.17. Fractures through the distal locking screw holes occurred in 5 and 6 femora instrumented with short and long nails, respectively. Fractures through the lateral entry site of the head element were detected in 3 specimens within each group. For short nails, fractures through the distal shaft region, not interfacing with the implant, were detected in 3 specimens.Conclusion: From a biomechanical perspective, the risk of secondary peri‑implant fracture after intramedullary fixation of pertrochanteric fractures is similar when using short or long CMN. Moreover, for both nail versions the fracture pattern does not unexceptionally involve the distal locking screw hole. [ABSTRACT FROM AUTHOR]

Externally magnetic-controlled intramedullary telescopic nails for bone lengthening have recently gained popularity due to many advantages when compared to more traditional lengthening methods. Patients requiring lengthening often present with a clinical history of previous multiple surgeries increasing the risk for complications of further procedures. However, studies regarding the treatment of complications following implantation of these devices remain scarce in literature. Therefore, we report our experience with revision surgery after lengthening with a telescopic intramedullary lengthening nail. In 6 out of 20 cases (30%) of lower limb lengthening for leg length discrepancy revision surgery was necessary. Two revisions were necessary due to nail breakage while the other 4 cases required a secondary procedure for non-union. In all cases, revision surgery included standard intramedullary locking nailing with additional autologous bone grafting. The median interval between index and revision surgery was 11.5 months (range 2-15 months). Satisfying clinical results, the intended extend of lengthening and bony consolidation was observed in all 6 patients. We conclude that revision surgery using an intramedullary locking nail with autologous bone grafting after failed telescopic nail-based lengthening represents an useful salvage procedure in these cases. [ABSTRACT FROM AUTHOR]

• Remission of infection was observed in 42.3% of patients. • There was a significant association between classification in stage 2 of Makridis and the highest occurrence of relapse or death. • Enterobacter cloacae was the most frequent agent related to infection. • There was no significant difference between the treatment outcome (remission or relapse) and the occurrence of consolidation. Management of fracture-related infection (FRI) after intramedullary fixation (IF) is a challenge. The aim of the present study is to describe a series of 26 patients with FRI after IF and to evaluate factors possibly related to the outcome. Baseline variables were obtained at the time of IF: age, sex, body mass index, affected bone, open fracture, substance abuse, use of an external fixator, type of nail, reaming, soft-tissue reconstruction and surveillance culture result. After diagnosis of the infection, information was obtained about the time interval between IF and diagnosis and classification according to both the Willeneger and Roth and Makridis systems. Treatment modalities were grouped and analysed according to: use of antimicrobials, surgical debridement, nail removal or retention and spacer use. Cultures of bone or deep soft tissues were performed. Patients were followed up for 12 months, and outcomes (remission, relapse, death and loss of follow-up) were evaluated, as well as fracture consolidation. Remission was observed in 42.3% of patients. There was no significant association between any baseline variable and outcome. There was a significant association between Makridis stage 2 classification and recurrence or death. Treatment strategy was not significantly associated with outcome, and 65.4% of cases had positive culture results, with Enterobacter cloacae as the predominant agent. Consolidation was observed in 81.8% of patients and was not significantly related to the outcome. There was a significant association between Makridis classification and the outcome. Consolidation rate was not associated with the outcome regarding the treatment of the infection. [ABSTRACT FROM AUTHOR]

Background: Diaphyseal fractures of femur and tibia are prominent due to its high incidence and high economic and social impact. Intramedullary nailing (IN) is the surgical procedure of choice. Surgical site infection (SSI) related to this procedure is considered a difficult to treat complication.Aims: Determine the incidence of SSI after IN of femoral and tibial diaphyseal fractures and evaluate possible risk factors.Methods: Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months. Incidence of SSI was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification for open fractures, previous surgical manipulation, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for soft tissue reconstruction, use of negative pressure therapy) and microbiota-related factors (cultures of nasopharyngeal swabs forStaphylococcus aureus and axillary/inguinal/perineal swab for Acinetobacter baumannii).Results: 221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8%. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. In the multiple logistic regression-adjusted analysis, previous use of external fixator and need for muscle or skin flap repair remained associated with SSI.Conclusions: Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of infection. [ABSTRACT FROM AUTHOR]

Purpose: Surgical treatment of displaced midshaft clavicle fractures requires a decision between plate fixation and intramedullary (IM) fixation. Numerous studies report on the biomechanical properties of various repair constructs. The goal of this systematic review was to provide an overview of studies describing the biomechanical properties of the most commonly used surgical fixations of midshaft clavicle fractures. Additionally, we aimed to translate these biomechanical results into clinically relevant conclusions.Methods: A computer-aided search of the EMBASE and PudMed/MEDLINE databases was conducted. Studies included for review compared biomechanical properties of plate fixation with IM fixation and superiorly positioned plates with anteroinferiorly positioned plates for midshaft clavicle fractures.Results: Fifteen studies were eligible for inclusion. Plate fixation seemed to form a more robust construct than IM fixation in terms of stiffness and failure loading. The remaining clavicle was stronger after removal of the IM device than after removal of the plate. Superior plating of transverse fractures generally seemed to provide greater stiffness and strength during bending loads than anteroinferior plating did. The absence of cortical alignment in wedge and comminuted fractures directly influenced the fixation stability for both IM fixation and plate fixation, regardless of location.Conclusion: Each type of fracture fixation has biomechanical advantages and disadvantages. However, exact thresholds of stiffness for inducing healing and failure strength to withstand refractures are unknown. The clinical relevance of the biomechanical studies may be arguable. Since none of the studies investigate the effect of tissue adaptation over time they should be interpreted with caution. [ABSTRACT FROM AUTHOR]

The geometry of the femur is important in the final position of an intramedullary implant; we hypothesised that the femoral geometry changes with age and this may predispose the elderly to anterior mal-positioning of these implants. We used CT DICOM data of 919 intact left femora and specialist software that allowed us to defined landmarks for measurement reference - such as the linea aspera - on a template bone that could be mapped automatically to the entire database. We found that older (>80 years) cortical bone is up to 1.5 mm thinner anteriorly and 2 mm thinner posteriorly than younger (<40 years) bone but the rate of change of posterior to anterior cortex thickness is greater in the older bone. We also found the isthmus in the elderly to be more distal and less substantial than in the younger bone. This study has demonstrated femoral geometry changes with age that may explain our perception that the elderly are at increased risk for anterior mal-positioning of intramedullary implants. [ABSTRACT FROM AUTHOR]

Femoral neck fractures have been reported as a cause for failure in patients with a hip resurfacing arthroplasty. However, the incidence and management of fractures of the femoral shaft with an ipsilateral hip resurfacing arthroplasty is relatively absent in current literature. Although, the gold standard for the fixation of a closed femoral shaft fracture is with the use of an intramedullary nail, this can be a challenge in the presence of a hip resurfacing arthroplasty. We describe the case of anterograde intramedullary nail fixation for a femoral shaft fracture in a patient with an ipsilateral hip resurfacing arthroplasty in situ. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to determine the long-term incidence of infrapatellar nerve damage after tibial nailing and its relation to anterior knee pain. We retrospectively evaluated 71 patients in whom 72 isolated tibial shaft fractures were treated with an intramedullary nail. The mean follow-up time was 84 months. Twenty-seven patients (38%) complained of chronic anterior knee pain. Infrapatellar nerve damage was found in 43 patients (60%). Of the 27 patients with knee pain, 21 (78%) had sensory deficits in the distribution area of the infrapatellar nerve, compared to 22 of the 45 patients (49%) without knee pain (p =0.025). Patient and fracture characteristics showed no significant differences between the two groups. At time of follow-up a total of 33 nails were removed of which twelve were taken out because of knee pain. The pain persisted in seven of these twelve patients (58%). The incidence of iatrogenic damage to the infrapatellar nerve after tibial nailing is high and lasting. Injury to this nerve appears to be associated with anterior knee pain after tibial nailing. [Copyright &y& Elsevier]

Abstract: Introduction: Cerebral emboli have been detected during intramedullary orthopaedic procedures. The quantity of emboli produced and their clinical effects are currently not known. This study aimed to quantify the intra-operative cerebral embolic load using transcranial Doppler ultrasound during the intramedullary stabilisation of femoral and tibial diaphyseal fractures. Clinical cognitive function was also assessed after surgery and any relationship to the cerebral embolic load determined. Patients and methods: Prospective cohort study of 20 patients with femoral or tibial diaphyseal fractures treated with reamed intramedullary nailing. The intra-operative cerebral embolic load was measured using transcranial Doppler ultrasound of the middle meningeal artery. Cognitive function was assessed 3 days after surgery using a range of validated neuropsychological tests. The cognitive results were compared to predicted scores matched for age and intelligence quotient as is the standard method of cognitive assessment after trauma. Results: Four patients had detectable cerebral emboli with counts of only 2, 3, 3, and 9 respectively. A significantly poorer than predicted cognitive score occurred in immediate and delayed memory recall tests. However there was no significant difference in any cognitive function score between those patients who had detectable cerebral emboli and those who did not. Discussion: Small numbers of cerebral emboli were detected during intramedullary stabilisation of lower limb long bone fractures but with no apparent cognitive effect. This poor correlation is similar to recent studies performed on arthroplasty patients and also conforms to the extensive cardiac surgery literature which would indicate that such low levels of systemic embolisation are unlikely to consistently produce cerebral clinical effects. [Copyright &y& Elsevier]

Abstract: Background: One of the complications of forearm shaft fracture is refracture. Elastic stable intramedullary nailing represents an alternative method for refracture treatment to cast immobilisation for another five to seven weeks. Operative treatment often necessitates an open reduction in most cases due to blocked or narrowed medullary canals. The purpose of this study was to examine the expense of the operative procedure, technique (closed or open intramedullary nailing) and postoperative complications in diaphyseal forearm refractures. Methods: We retrospectively examined the expense of operative procedure in 21 children with diaphyseal forearm refractures treated with ESIN. Results: In 18 cases, closed reduction with nailing was possible; three required an open reduction. In nine patients a closed medullary cavity was present; only two of them needed an open reduction. None of the patients had complications (wound healing, osteomyelitis, rupture of the extensor pollicus longus). Swelling appeared in four patients, paraesthesia of the thumb in one. Free functional movement was achieved in all children. Long term results: No re-refracture occurred. One patient suffered from meteorosensitivity. Twelve are able to do the same sporting activities as before injury. Conclusion: ESIN seems to be one choice for treatment in refracture of the forearm, as in most cases the operative reduction can be performed in a closed way by means of “tricks and hints”. [Copyright &y& Elsevier]

Abstract: Background: The subtrochanteric fracture constitutes approximately 5–10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures. Objective: To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL. Setting: Four university hospitals. Design: A prospective cohort study with a 2-year follow-up. Patients and methods: Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ-5Dindex score). Results: The EQ-5Dindex score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months. Conclusions: A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs). [Copyright &y& Elsevier]

Summary: 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. [Copyright &y& Elsevier]

Summary: We report a case of division of the deep peroneal nerve resulting from a drill used in the insertion of an oblique proximal locking screw in an AIM tibial intramedullary nail (DePuy). Operative findings and anatomical study indicate there is a risk of damage to the peroneal nerve associated with the oblique proximal locking screws used in this nail design. If a patient has peroneal nerve palsy after nailing of the tibia, the possibility of nerve division should be considered, so that early exploration and repair of the nerve can be performed. [Copyright &y& Elsevier]

Summary: A systematic review was performed to assess the relative merits of reamed and unreamed antegrade femoral nailing. To be included, a study had to be prospective, randomised or pseudorandomised, comparing reamed and unreamed antegrade femoral nailing in adults. Where more than one study from the same institution was available, only the study with longest follow-up was included. A literature search found 2044 possible articles. Of these, eight studies compared reamed and unreamed femoral nailing. The methodology of these articles was independently assessed by all the three authors. Five studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, the data were not combined. If there was no significant heterogeneity, a combined odds ratio or weighted mean difference was calculated using a fixed effects model, and a Z-test was performed to test the overall effect. Six hundred and forty-seven femoral fractures (315 reamed; 332 unreamed) were entered into the included studies. Unreamed nailing was quicker and associated with significantly less blood loss (P < 0.00001). Reaming significantly reduced the time to union (P = 0.00001), non-union (P = 0.002), delayed union (P = 0.005), technical problems (P = 0.01) and reoperation rate (P = 0.001). The use of reamed femoral nails gives significant advantages over unreamed femoral nails. [Copyright &y& Elsevier]

Summary: A systematic review was performed to assess reamed and unreamed tibial nailing. Only prospective, randomised studies comparing reamed and unreamed tibial nailing in adults were included. A literature search found 1200 possible articles. There were seven comparative studies. These articles were independently assessed by all three authors. Three studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, data from the studies was not combined. If there was no significant heterogeneity, a combined odds ratio was calculated using a fixed effects model and a Z-test was performed to test the overall effect. Two hundred and ninety-one tibial shaft fractures were entered into the included studies. Two hundred and eighty (96%) were followed up (148 reamed; 132 unreamed). There was an increased non-union rate when the tibia was not reamed (p=0.02). Screw breakage was more common in the unreamed group (p<0.0001). This study could find little difference in the incidence of other complications following reamed or unreamed tibial nailing. [Copyright &y& Elsevier]

We report on four cases in which the diagnosis of compartment syndrome was delayed by the administration of patient controlled analgesia (PCA) following intramedullary nailing of tibial shaft fractures. We believe that this poses a diagnostic problem and can lead to lasting sequelae as decompression is delayed. We recommend extra vigilance with the use of PCA in patients with intramedullary nailing following tibial shaft fractures. [Copyright &y& Elsevier]

Abstract: Locked Intramedullary Nailing is an established method of treatment for tibial shaft fractures. Locking of tibial nails is however not without its drawbacks. Locking is time consuming, and is associated with a noteworthy complication rate. The Fixion IM nailing system is an expandable nail designed to eliminate some of these drawbacks. We have performed a systematic review of the literature to determine the safety and efficacy of this system. Publications examining the use of the Fixion system were identified from the MEDLINE and the Cochrane databases. Forty-one citations were generated by the MEDLINE search. Of these, two quasi-randomised trials and eight case series satisfied our selection criteria and were reviewed. Overall the average réopération rate for the Fixion nail was 10.2%. Shortening occurred in 3%of cases and fracture propagation was reported in 2% of cases. The Fixion cohort united at an average of 12.2 weeks and the average operative time was 54 minutes. The Fixion system eliminated complications and reoperations associated with the use of locking screws. Further studies in the form of randomised controlled trials are needed to evaluate the Fixion system against conventional locked nails. [Copyright &y& Elsevier]

Abstract: Treatment of intramedullary infections of long bones is based upon the principles of surgical debridement, irrigation, fracture site stabilization, soft tissue coverage, and antibiotic administration. Reaming of the medullary canal is an essential component of surgical debridement because it removes intramedullary debris and infected bone surrounding the removed intramedullary device and within the intramedullary canal. The Reamer-Irrigator-Aspirator (RIA) has distinct features that appear to be beneficial for management of intramedullary infections. It allows reaming under simultaneous irrigation and aspiration, which minimizes the residual amount of infected fluid and tissue in the medullary canal and the propagation of infected material. The disposable reamer head is sharp, which combined with the continuous irrigation may attenuate the increased temperature associated with reaming and its potential adverse effects on adjacent endosteal bone. The disadvantage of the RIA is increased cost because of use of disposable parts. Potential complications can be avoided by detailed preoperative planning and careful surgical technique. The RIA should be used with caution in patients with narrow medullary canals and in infections involving the metaphysis or a limited part of the medullary canal. Reaming of the canal is performed with one pass of the RIA under careful fluoroscopic control. Limited information is available in the literature on the results of the RIA for management of intramedullary infections of long bones; however preliminary results are promising. The RIA device appears to be an effective and safe tool for debridement of the medullary canal and management of intramedullary infections of the long bones. Further research is needed to clarify the exact contribution of the RIA in the management of these infections. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare the intramedullary pressures developed during reaming of cadaveric femurs with the Synthes Reamer/Irrigator/Aspirator (RIA) reamer and the Zimmer Pressure Sentinel (PS) reamer, controlling for the force and speed of reaming. Method: Fifteen matched pairs of frozen unpreserved femurs were used in the study. Two pressure transducers and two thermocouples were screwed into holes drilled into the femoral shaft. The femurs were stabilized in the vertical position by mechanically attaching them to a custom jig equipped with a load cell to detect the vertical component of force applied to the reamer. Proximally a linear voltage displacement transducer (LVDT) was attached to the reamer to record the continuous position of the reamer. All femurs were reamed to a diameter 2 mm larger than the narrowest point of the canal. Proximal and distal pressures, proximal and distal temperatures, applied vertical force and displacement were measured continuously throughout the reaming process. Maximum and minimum, and average proximal and distal pressures for each reamer were obtained and compared using paired t-tests. Averages were also calculated and compared in the same manner. A p-value of <0.05 was considered statistically significant. Results: The maximum, minimum and average intramedullary pressures during reaming were significantly lower with the RIA system than the PS reamer. In general, the pressures produced by the RIA system were consistently below atmospheric pressure for the majority of the reaming time. This was not true for the PS system. No appreciable temperature changes were observed during any of the trials. Conclusion: The RIA reaming system significantly reduces the intramedullary pressures produced during the reaming process compared to the PS reaming system. [ABSTRACT FROM AUTHOR]