Peroneal nerve damage by oblique proximal locking screw in tibial fracture nailing: a new emerging complication?

Comparison of Open Reduction and Internal Fixation with Plate and Titanium Elastic Intramedullary Nail in Treating Pediatric Humeral Fracture

Objective

To investigate the therapeutic efficacy of titanium elastic intramedullary nail (TEN) and open reduction and internal fixation with plate (ORIF) in the treatment of humeral fracture in children.

Methods

A retrospective study was carried out in a total of 69 patients who were admitted to the hospital from January 2013 to December 2018. These patients, including 41 males and 28 females, were aged from 6 to 12 years old with a median of 8 years. These patients were diagnosed with humeral fracture and underwent the surgery of ORIF (n = 22) or TEN (n = 47). The intraoperative bleeding, operation time, length of stay (LOS), and fracture healing time were compared between the two groups. The therapeutic effect was assessed by the shoulder range of motion, the elbow range of motion, the UCLA shoulder function score, and the Mayo elbow performance score (MEPS) 6 months after the surgery.

Results

The intraoperative bleeding (97.20 ± 27.83 mL vs 185.60 ± 37.50 mL, P < 0.05), the operation time (53.70 ± 11.87 min vs 73.50 ± 13.33 min, P < 0.05), and the fracture healing time (9.30 ± 4.23 weeks vs 13.45 ± 3.67 weeks, P < 0.05) in the TEN group was significantly decreased than those in the ORIF group. There was no significant difference in the LOS between the two groups. The length of follow‐up is 3 and 6 months. The shoulder range of motion (110.88° ± 15.82° vs 98.37° ± 16.22° at 3 months and 162.88° ± 17.29° vs 117.65° ± 19.38° at 6 months, both P < 0.05), the elbow range of motion (105.23° ± 2.81° vs 87.12° ± 4.73° at 3 months and 137.47° ± 4.82° vs 109.67° ± 5.83° at 6 months, both P < 0.05), and the UCLA shoulder function score (28.58 ± 4.74 vs 21.64 ± 7.23 at 3 months and 33.05 ± 3.27 vs 25.78 ± 3.87 at 6 months, both P < 0.05), and the MEPS (80.76 ± 3.53 vs 65.33 ± 9.43 at 3 months and 97.48 ± 1.23 vs 88.22 ± 3.65 at 6 months, both P < 0.05) in the TEN group were greater than those in the ORIF group. In the TEN group, complications occurred in three of 47 cases (6.38%), including one case (2.13%) of bone nonunion and two cases (4.25%) of irritation response around the nail. In the ORIF group, complications occurred in four of 22 cases (18.18%), including one case (4.55%) of delayed healing, one case (4.55%) of deep infection, and two cases (9.08%) of radial nerve injury. The complication rate was not significantly different between the two groups.

Conclusion

TEN can be a good technique for the treatment of humeral fracture in children, with the advantages of less intraoperative bleeding, shorter operative time, quicker healing, and better recovery of shoulder range of motion and elbow range of motion.

Oblique proximal locking screw in tibial fracture intramedullary nailing: a clinical imaging study of proximity to common peroneal nerve

Intramedullary nailing (IMN) is the treatment of choice in the surgical management of most tibia shaft fractures. The aim of the study was to evaluate the proximity of the common peroneal nerve (CPN) to the oblique proximal locking screw inserted from the anteromedial to the posterolateral direction. We identified all the patients who underwent the IMN of the tibia between 2008 and 2018. Patients who underwent post-operative computed tomography for any reason were identified. Patients were included if the CPN was visible on the axial slices, the proximal oblique locking screw was used, or the line of the drilling could be reconstructed. Twenty-nine patients met the inclusion criteria. The median length of the intramedullary nail was 345 mm. The median nail diameter was 10 mm. The median number of proximal interlocking screws was 2. All scans were reviewed by the musculoskeletal radiologist for verifying the visibility and marking of the CPN. The mean screw trajectory angle to the CPN was 9° (± 9°). Most of the drilling trajectories passed posterior to the CPN (79%). The depth of the intramedullary nail was on average - 8 mm (± 10 mm). A negative correlation was observed between the depth of the nail and the distance from the CPN (P < 0.001). During the insertion of the oblique proximal locking screw from the anteromedial to the posterolateral direction, the CPN is potentially at risk if the drill is allowed to plunge or an incorrectly long screw is used. Sinking the nail provides a better margin of safety.

Proximity and Risks of the Anterior Neurovascular and Tendinous Anatomy of the Distal Leg Relative to Anteriorly Applied Distal Locking Screws for Tibia Nailing: A Plea for Open Insertion

PURPOSE

To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing.

DESIGN

Retrospective.

SETTING

ACS level I trauma center.

PATIENTS/PARTICIPANTS

Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs.

MAIN OUTCOME MEASUREMENTS

Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy.

RESULTS

All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line.

DISCUSSION

The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.

The first description in the literature, of a complication during the extraction of a retrograde expandable intra-medullary nail in three patients

Ankle fractures in elderly people are low-energy fractures characterised by fragility. In the majority, they are unstable and challenging to manage.

Retrograde expandable intra-medullary nails (Fixion®, Biomet Merck Limited) inserted through the calcaneum across the sub-talar and ankle joints into the tibia have been successfully used in the treatment of fragility fractures and non-unions of the distal tibia and ankle, where the use of an antegrade locked nail would not provide adequate fracture stability for union.

Primary fracture management involves removing the nail at least 3–4 months after radiological check. In cases of treatment of non-unions a longer treatment period is often required before removal of nail is considered.

We present three patients where breakage of the Fixion® nail during surgery caused problems in nail extraction.

Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures

BACKGROUND

Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking.

METHODS

All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations.

RESULTS

Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6-54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18-68 min) for tibial fractures and 55 min (range 47-150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity.

CONCLUSION

The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.

Sonography of orthopedic hardware impingement of the extremities

The purpose of this pictorial essay is to describe the sonographic appearance of orthopedic hardware impingement of the extremities. Sonography is not limited by metallic artifacts, can show the orthopedic hardware, and can be used to assess damage of adjacent soft tissues, including tendons, synovial bursas, muscles, nerves, and vessels. Its dynamic capabilities permit assessment of orthopedic hardware impingement present only in certain joint positions, during muscle contractions, and during tendon movements. Local pain elicited with application of pressure from the transducer confirms the diagnosis. Sonographically guided injections of steroid-anesthetic mixtures have both diagnostic and therapeutic effects.

Sonographic assessment of orthopedic hardware impingement on soft tissues of the limbs

Ultrasonography allows high-resolution imaging with real-time correlation to patients' pain, and it is an indispensable tool for assessing disorders associated with soft tissue impingement by orthopedic hardware. The sonographic examination in these cases begins with static studies, and images are then obtained during active and passive joint mobilization designed to reproduce the conflict with the orthopedic hardware. Ultrasonography is particularly useful for documenting hardware-induced injury to tendons and synovial bursae, but also those of muscles and vascular structures. The frequency of hardware-soft tissue conflict varies with the site and type of surgical procedure, but in all cases ultrasonography plays an essential role in identifying this type of conflict and assessing the soft tissue lesions it causes.

A case of extension loss of great toe due to peroneal nerve compression by an osteochondroma of the proximal fibula

The authors present a case of extension loss of great toe caused by entrapment neuropathy of a peroneal nerve due to an osteochondroma of the proximal fibula. Plain radiographs revealed no bony abnormality around the foot or ankle, but a sessile exophytic bony growth at the proximal fibula. A positive Tinel sign in this area led us to a suspicion of compressive neuropathy of the peroneal nerve, and a subsequent electrophysiologic study confirmed the entrapment neuropathy. The peroneal nerve was decompressed by excisional biopsy. At 3 months postoperatively, normal full extension of the great toe was completely restored. The current case deserves attention in that the only clinical manifestation of peroneal nerve entrapment neuropathy by the osteochondroma at the fibular neck was extension loss of great toe.

Peroneal nerve damage by bicortical tibial screw in ACL reconstruction

Arthroscopically assisted anterior cruciate ligament reconstruction is regarded as a minimally invasive surgery with low morbidity but complications still occur. Reports of neurovascular injuries related to graft harvesting, tunnel placement, or graft fixation are limited. A rare case of peroneal nerve injury related to hardware used for graft fixation in the tibial in a 28-year-old female patient who underwent an anterior cruciate ligament reconstruction surgery using a patellar tendon graft (bone-tendon-bone graft) is presented. Post-operatively, the patient presented with clinical signs of peroneal nerve damage and a reduced range of motion of the knee. Plain radiographs of the knee showed the bicortical screw which used for tibial fixation of the graft, penetrating the fibula and projecting beyond the lateral cortex of the fibular neck. The patient was treated with removal of the hardware and the graft. Intensive physiotherapy resulted in gradual improvement and at 6 months after the second operation the patient regained full range of motion of the knee and almost full muscle strength performing her daily activities without any difficulty and she is at the moment unwilling to undergo further procedure.

Expandable nailing system for tibial shaft fractures

OBJECTIVE

To evaluate and present our current clinical experience in the treatment of closed and open tibial shaft fractures using the expandable intramedullary nailing system.

DESIGN

Prospective study.

SETTING

One level-1 trauma centre.

PARTICIPANTS

Twenty-six patients with acute tibial shaft fractures with at least 10 cm of intact cortex on both sides of the fracture.

INTERVENTION

Internal fixation using the Fixion expandable intramedullary nail (Disc-O-Tech Medical Technologies Ltd., Herzliya, Israel).

MAIN OUTCOME MEASUREMENTS

Operative and fluoroscopy time, healing time and perioperative complications were recorded.

RESULTS

Twenty-six tibial fractures were treated (OTA classification: 3 type A1, 8 A2, 8 A3, 3 B1, 3 B2, and 1 B3), six of which were open. All fractures healed by week 18.5 with an mean of 12.8+/-3.8 weeks. The operating time ranged from 20 to 50 min with an mean of 40+/-12.17 min. The fluoroscopy time ranged from 6 to 22s with a mean of 10+/-5s. In one case the nail failed to expand, as detected by X-ray control, and had to be exchanged intraoperatively. Two patients reported anterior knee pain during the follow up, but did not wish any further treatment. In a low demanding patient rotational malalignment was noted and no further action needed.

CONCLUSION

According to the results of this study, the use of the Fixion nailing system, where indicated, is associated with minimal complications and very good functional outcomes in fractures OTA types A and B. The advantages of the expandable nail include the decrease in the operating and fluoroscopy time and the simplicity of its application.