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Li S, Su ZH, Zhu JM, Sun WJ, Zhu YC, Wang J, Li K, Ni M, Han S. The importance of the thickness of femoral lateral wall for treating intertrochanteric fractures: a finite elements analysis. Sci Rep 2023; 13:12679. [PMID: 37542169 PMCID: PMC10403567 DOI: 10.1038/s41598-023-39879-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 08/01/2023] [Indexed: 08/06/2023] Open
Abstract
To explore how the thickness of the femoral lateral wall influences the effectiveness of internal fixation systems used to treat intertrochanteric fractures. CT images of the pelvis and femur of a male adult were used to construct an intertrochanteric fracture model (AO/OTA 31-A2) with various thicknesses of the femoral lateral wall (FLW). Four finite element (FE) models were created with the lateral femoral walls being 10 mm, 20 mm, 30 mm, and 40 mm thick. The fracture models were fixed with a dynamic hip screw (DHS), a proximal femoral nail anti-rotation (PFNA), and a proximal femoral locking compression plate (P-FLCP). A simulated vertical load was applied to the femoral head. The stress and displacement of the implant and femur in each model were recorded for comparison. The FE analysis of the intertrochanteric fracture models showed that the PFNA system could provide better stability than the DHS and P-FLCP with the same thickness of FLW. The FLW provided buttress support to the femoral head and neck when using a DHS and PFNA, and the buttress strength was proportional to the thickness of FLW. The maximum stress in the DHS model was recorded on the DHS plate which accommodated the lag screw. For the PFNA model, the maximum stress appeared at the connection between the nail and blade. In the P-FLCP model, the maximum stresses were highly concentrated at the connection between the cephalic nails and the proximal plate. The thickness of the femoral lateral wall should be considered an important factor when selecting a suitable internal fixation system for intertrochanteric fractures. Based on the FE analysis, intramedullary fixation, such as PFNA, experiences lower stress levels and a moderate displacement in comparison to DHS and P-FCLP when used to treat intertrochanteric fractures.
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Affiliation(s)
- Shuang Li
- Department of Orthopaedic Surgery, Pudong New Area Peoples' Hospital, No. 490 Chuanhuan South Road, Pudong New Area, Shanghai, 201299, People's Republic of China
| | - Zhi-Hao Su
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Jia-Min Zhu
- Department of Orthopaedic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wan-Ju Sun
- Department of Orthopaedic Surgery, Pudong New Area Peoples' Hospital, No. 490 Chuanhuan South Road, Pudong New Area, Shanghai, 201299, People's Republic of China
| | - Yi-Chen Zhu
- Department of Orthopaedic Surgery, Pudong New Area Peoples' Hospital, No. 490 Chuanhuan South Road, Pudong New Area, Shanghai, 201299, People's Republic of China
| | - Jian Wang
- Department of Orthopaedic Surgery, Pudong New Area Peoples' Hospital, No. 490 Chuanhuan South Road, Pudong New Area, Shanghai, 201299, People's Republic of China
| | - Kai Li
- Department of Orthopaedic Surgery, Pudong New Area Peoples' Hospital, No. 490 Chuanhuan South Road, Pudong New Area, Shanghai, 201299, People's Republic of China
| | - Ming Ni
- Department of Orthopaedic Surgery, Pudong New Area Peoples' Hospital, No. 490 Chuanhuan South Road, Pudong New Area, Shanghai, 201299, People's Republic of China.
- Department of Orthopaedic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Shuai Han
- Department of Orthopaedic Surgery, Pudong New Area Peoples' Hospital, No. 490 Chuanhuan South Road, Pudong New Area, Shanghai, 201299, People's Republic of China.
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Çağlar C, Akçaalan S, Bozer M, Akkaya M. Adult Proximal Humeral Locking Plate Is a Good Alternative Option in the Treatment of Adolescent Subtrochanteric Femur Fractures: A Case Series and Literature Review. Hip Pelvis 2022; 34:245-254. [PMID: 36601609 PMCID: PMC9763829 DOI: 10.5371/hp.2022.34.4.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Management of pediatric subtrochanteric femur fractures (SFFs) is difficult. The aim of this study was to evaluate the outcomes of adolescent SFFs treated with adult proximal humeral locking plates (PHLPs). Materials and Methods A retrospective analysis of 18 adolescents (11 male, 7 female) with a diagnosis of SFF who underwent internal fixation with a PHLP was conducted. Data regarding injury mechanism, fracture pattern, and time to union were recorded for all patients. In addition, a clinical and functional evaluation of patients was performed using the Harris hip score (HHS), Iowa hip score (IHS), modified Merle d'Aubigne-Postel score (MMAPS), Flynn criteria, and hip range of motion (ROM). Results The mean age of the patients was 12.72±2.05 years (range, 10-16 years). Radiological observation was performed for evaluation of five different injury mechanisms and different fracture patterns in patients. The mean postoperative HHS was 92.27±5.61, the mean IHS was 90.88±6.46, and the mean MMAPS was 17.22±0.94. According to the Flynn criteria, excellent results were achieved in 14 cases and satisfactory results were obtained in four cases. Measurements of the patients' mean hip ROM values were as follows: 17.77±3.52° in extension, 115.27±6.74° in flexion, 43.05±3.48° in abduction, 27.50±4.28° in adduction, 42.22±4.60° in internal rotation, and 42.22±3.91° in external rotation. Conclusion Surgery performed on adolescent patients using an adult PHLP showed good, safe results. Therefore, it should be considered as an alternative option.
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Affiliation(s)
- Ceyhun Çağlar
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey
| | - Serhat Akçaalan
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Merve Bozer
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Mustafa Akkaya
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Wang JH, Chuang HC, Su WR, Chang WL, Kuan FC, Hong CK, Hsu KL. The characteristics and influence of iatrogenic fracture comminution following antegrade interlocking nailing for simple femoral shaft fractures, a retrospective cohort study. BMC Musculoskelet Disord 2022; 23:456. [PMID: 35568932 PMCID: PMC9107635 DOI: 10.1186/s12891-022-05418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
AIM The incidence and characteristics of iatrogenic comminution (IC) are unknown, and the influence of IC on fracture union is unclear. This study was aimed to investigate the (1) incidence and characteristics of IC and (2) the outcomes of IC following antegrade interlocking nailing of simple femoral shaft fractures. METHODS We retrospectively collected data on patients who experienced simple femoral shaft fractures and underwent antegrade interlocking nailing between February 2009 and December 2016. The incidence and characteristics of IC were examined. According to the presence of IC, patients were divided into two groups: an IC group and a non-IC (NIC) group. Demographic information and nonunion rates were compared between the two groups. Potential risk factors for IC (age, gender, body mass index (BMI), nail fit ratio, reduction technique, and greater trochanter nail entry) were analyzed using univariate and multivariate logistic regression. The aforementioned variables, along with IC occurrence, were also assessed as potential risk factors for nonunion at 12 and 24 months after operation using multivariate logistic regression. RESULTS Of the 211 total patients, IC occurred in 20.9% (n = 44) of patients. Most ICs were found at the level of the isthmus, and involved the medial cortex. Compared with the NIC group, higher nonunion rates were observed in the IC group at 12 months (31.8% vs. 12.5%, p = 0.002) and 24 months (18% vs. 6.5%, p = 0.017) after surgery. Age older than 35 years old was related with the occurrence of IC in univariate analysis. Multivariate analysis found no risk factor associated with IC. Open reduction technique, IC occurrence and higher BMI were identified as the risk factors of nonunion at 12 months and 24 months after surgery in multivariate analysis. CONCLUSION IC is a non-rare complication in antegrade interlocking nailing of simple femoral shaft fractures and was associated with higher nonunion rate. Age older than 35 years old showed a trend toward increasing risk of iatrogenic fracture comminution. In multivariate analysis, open reduction technique, IC occurrence and higher BMI significantly correlated with fracture nonunion. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jou-Hua Wang
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Chun Chuang
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Lun Chang
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital DouLiou Branch, National Cheng Kung University, Douliu, Yunlin, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Division of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital DouLiou Branch, National Cheng Kung University, Douliu, Yunlin, Taiwan
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan.
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
- Division of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital DouLiou Branch, National Cheng Kung University, Douliu, Yunlin, Taiwan.
- Department of Orthopaedics, National Cheng Kung University Hospital, No.138, Sheng Li Road, 704, Tainan, Taiwan.
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Albareda J, Ibarz E, Mateo J, Suñer S, Lozano C, Gómez J, Redondo B, Torres A, Herrera A, Gracia L. Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study. Injury 2021; 52 Suppl 4:S61-S70. [PMID: 33707035 DOI: 10.1016/j.injury.2021.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful. MATERIAL AND METHODS This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation. RESULTS The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%. CONCLUSIONS The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.
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Affiliation(s)
- J Albareda
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - E Ibarz
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - J Mateo
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital. Zaragoza, Spain
| | - S Suñer
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - C Lozano
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - J Gómez
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital.
| | - B Redondo
- Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Torres
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Herrera
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - L Gracia
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
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Comparative analysis of the biomechanical behavior of anterograde/retrograde nailing in supracondylar femoral fractures. Injury 2020; 51 Suppl 1:S80-S88. [PMID: 32067772 DOI: 10.1016/j.injury.2020.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/08/2020] [Indexed: 02/02/2023]
Abstract
Supracondylar femoral fractures account for a noticeable percentage of the femoral shaft fractures, affecting two etiological groups: high energy trauma in young men, with good bone quality, and older women with osteoporotic femur. Surgical treatment of those kind of fractures remains controversial, with different surgical options such as plate and sliding barrel locking condylar plate, less invasive stabilization system (LISS) or intramedullary nailing, which has emerged as a new fixation choice in the treatment of that type of fractures. The present work performs a comparative study about the biomechanical behavior of anterograde and retrograde nailing in supracondylar femoral fractures type A, in order to determine the best choice of nailing and locking configuration. A three-dimensional finite element model of the femur was developed, modeling femoral supracondylar fracture and different nailing configurations, both for anterograde and retrograde nails. The study was focused on the immediately post-operative stage, verifying the appropriate stability of the osteosynthesis. The obtained results show a better biomechanical behavior for anterograde nails, providing a better stability from the point of view of global movements, lower stresses in screws, and less stress concentration in cortical bone. So, for the analyzed fractures and osteosyntheses types, anterograde nailing has demonstrated to be a better surgical option, being an excellent indication in supracondylar fractures of femur, with clear benefits compared to retrograde nailing, providing a better stabilization which enables for a more satisfactory fracture healing.
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Tucker SM, Wee H, Fox E, Reid JS, Lewis GS. Parametric Finite Element Analysis of Intramedullary Nail Fixation of Proximal Femur Fractures. J Orthop Res 2019; 37:2358-2366. [PMID: 31254411 DOI: 10.1002/jor.24401] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 06/06/2019] [Indexed: 02/04/2023]
Abstract
Proximal femur fracture fixation with intramedullary nailing relies on stability at the fracture site and integrity of the fixation construct to achieve union. The biomechanics that dictate fracture site stability and implant stress depend on fracture type as well as implant features such as nail length, nail diameter, presence of distal fixation screws, and material composition of the implant. When deciding how to fix a fracture, surgeons have choices in these implant-related design variables. This study models all combinations of a range of implant variables for nine standard AO/OTA proximal femur fractures using finite element analysis. Under simulated maximum load during gait, the maximum stress in the implant and screws as well as interfragmentary motions at the fracture site in the axial and shear directions were computed. The results were separated by fracture type to show the influence of each design variable on measured biomechanical outcomes. Filling the reamed canal with the largest fitting nail diameter reduced axial and shear interfragmentary motion for all fracture types. Nail length was less predictive of shear interfragmentary motion for most simulated fracture types than other construct variables. Furthermore, gapping at the fracture site predisposed the construct to higher implant stresses and larger interfragmentary motions. Clinical significance: Biomechanical outcomes from this computational study can aid in surgical decision-making for optimizing hip fracture fixation with IM nailing. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2358-2366, 2019.
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Affiliation(s)
- Scott M Tucker
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Hwabok Wee
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Edward Fox
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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Zhang X, Cheng X, Yin B, Wang J, Li S, Liu G, Hu Z, Wu W, Zhang Y. Finite element analysis of spiral plate and Herbert screw fixation for treatment of midshaft clavicle fractures. Medicine (Baltimore) 2019; 98:e16898. [PMID: 31441868 PMCID: PMC6716701 DOI: 10.1097/md.0000000000016898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 07/13/2019] [Accepted: 07/28/2019] [Indexed: 11/25/2022] Open
Abstract
Both spiral plate and Herbert screw fixations have been clinically adopted for treating midshaft displaced clavicle fractures. However, the biomechanical properties of the 2 implant fixations have not yet been thoroughly evaluated. Here we report the results of a finite element analysis of the biomechanical properties of midshaft clavicle fractures treated with Herbert screw and spiral plate fixation. Hebert screw fixation showed stress distribution similar to intact clavicle under all loading conditions, but provided less stability than did spiral plate fixation. Postoperatively, excessive shoulder activities and weight-bearing should be avoided. Spiral plate fixation provides greater stability, but is associated with stress shielding. These results demonstrate that Herbert screw fixation is suitable for the treatment of simple displaced clavicluar fractures, but excessive shoulder activity and weight-bearing should be avoided after the operation. Therefore, spiral plate fixation may be preferred for patients requiring an early return to activity.
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Affiliation(s)
- Xiaojuan Zhang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
- Department of Endocrinology, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
| | | | - Bing Yin
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
| | - Jianzhao Wang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
| | - Sheng Li
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
| | - Guobin Liu
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
| | - Zusheng Hu
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
| | - Weiwei Wu
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
| | - Yingze Zhang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province
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Preventing Wedge Deformities When Treating Intertrochanteric Femur Fractures With Intramedullary Devices: A Technical Tip. J Orthop Trauma 2018; 32:e112-e116. [PMID: 29040234 DOI: 10.1097/bot.0000000000001033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Intertrochanteric femur fractures are common injuries associated with significant patient morbidity and mortality and high societal costs. Although intramedullary devices have shown promises for treating a wide range of intertrochanteric femur fractures, improper technique can lead to malalignment, fracture displacement, and/or iatrogenic fractures. In particular, a "wedge effect" has been described, in which the passage of conical reamers and the intramedullary nail itself results in the distraction of intertrochanteric fragments with lateralization of the shaft from the femoral neck and varus malalignment. Here, we describe the mechanism by which this deformity is generated and describe techniques for preventing it, including the use of a modified starting point and an alternative to the conical opening reamers.
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Sadagatullah AN, Nazeeb MN, Ibrahim S. Incidence of Varus Malalignment Post Interlocking Nail in Proximal Femur Shaft Fractures Comparing Two Types of Entry Points. Malays Orthop J 2017; 11:31-35. [PMID: 29326763 PMCID: PMC5753525 DOI: 10.5704/moj.1711.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Osteosynthesis of the femur using an interlocking nail is the gold standard for treating diaphyseal fractures of the femur. There are two established entry points for the antegrade interlocking nails which is the piriformis fossa or the greater trochanter. It has been reported that varus malalignment was frequently seen in proximal femur fracture which were treated with interlocking nail utilizing the greater trochanter entry point. The study was done to find out if the problem was of significance. Materials and Methods: This was a retrospective study which included 179 patients with femur fractures which were treated from January 2013 till September 2015 in one Hospital. They were treated with interlocking nail either by utilizing the piriformis fossa (PF) or the greater trochanter (GT) entry points. Post-operative radiographs of the femur were used to measure the varus deformity. Results: Out of 179 patients, there were 5 patients who were reported to have unacceptable varus malalignment (2.79%). These 5 patients were out of the 88 (5.68%) patients utilizing the greater trochanter as the entry point. The same 5 patients were out 90 patients that were diagnosed with proximal femur shaft fractures (5.55%). Analysis with logistic regression was statistically not significant. Conclusion: There was higher rate of varus malalignment seen in proximal femur shaft fractures treated with interlocking nails utilizing the greater trochanter entry point. The incidence of varus malalignment was not significant statistically.
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Affiliation(s)
- A N Sadagatullah
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - M N Nazeeb
- Department of Orthopaedics, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | - S Ibrahim
- Department of Orthopaedics, Hospital Sultan Ismail, Johor Bahru, Malaysia
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Gabarre S, Albareda J, Gracia L, Puértolas S, Ibarz E, Herrera A. Influence of gap size, screw configuration, and nail materials in the stability of anterograde reamed intramedullary nail in femoral transverse fractures. Injury 2017; 48 Suppl 6:S40-S46. [PMID: 29162240 DOI: 10.1016/s0020-1383(17)30793-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Femoral shaft fractures are among the most severe injuries of the skeleton. They are associated with high morbidity and mortality. The most appropriate treatment depending on the type of fracture and location level should be chosen. A finite element model of the femur has been developed, analyzing various types of fractures in the subtrochanteric and diaphyseal supracondylar area, with several gap sizes, being stabilized with a single combination of screws for the intramedullary nail. The mechanical strength of the nail against bending and compression efforts was studied comparing two materials for the nail: stainless steel and titanium alloy. Beside the finite elements (FE) simulations, a clinical follow-up was carried out, considering a sample of 55 patients, 24 males, and 31 females, with mean age of 52.5 years. Localizations of fractures were 22 in the right femur and 33 in the left one, respectively. A good agreement between clinical results and the simulated fractures in terms of gap size was found. Non-comminuted fractures have a mean consolidation time of 4.1 months, which coincides with the appropriate mobility at fracture site obtained in the FE simulations, whereas comminuted fractures have a higher mean consolidation period estimated in 7.1 months, corresponding to the excessive mobility at fracture site obtained by means of FE simulations. The obtained results between both nail materials (stainless steel and titanium alloy) show a higher mobility when using titanium nails, which produce a higher rate of strains at the fracture site, amplitude of micromotions and bigger global movements compared to stainless-steel nails. Steel nails provide stiffer osteosyntheses than the titanium nails. In conclusion, anterograde locked nail is particularly useful in the treatment of a wide range of supracondylar fractures with proximal extension into the femoral diaphysis.
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Affiliation(s)
- Sergio Gabarre
- Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain
| | - Jorge Albareda
- Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital, Zaragoza, Spain; Aragón Health Research Institute, Zaragoza, Spain; Department of Surgery, University of Zaragoza, Zaragoza, Spain.
| | - Luis Gracia
- Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain; Aragón Institute for Engineering Research, Zaragoza, Spain
| | - Sergio Puértolas
- Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain; Aragón Institute for Engineering Research, Zaragoza, Spain
| | - Elena Ibarz
- Department of Mechanical Engineering, University of Zaragoza, Zaragoza, Spain; Aragón Institute for Engineering Research, Zaragoza, Spain
| | - Antonio Herrera
- Aragón Health Research Institute, Zaragoza, Spain; Department of Surgery, University of Zaragoza, Zaragoza, Spain
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Robotic technique improves entry point alignment for intramedullary nailing of femur fractures compared to the conventional technique: a cadaveric study. J Robot Surg 2017; 12:311-315. [PMID: 28801793 DOI: 10.1007/s11701-017-0735-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
We aimed to test whether a robotic technique would offer more accurate access to the proximal femoral medullary cavity for insertion of an intramedullary nail compared to the conventional manual technique. The medullary cavity of ten femur specimens was accessed in a conventional fashion using fluoroscopic control. In ten additional femur specimens, ISO-C 3D scans were obtained and a computer program calculated the ideal location of the cavity opening based on the trajectory of the medullary canal. In both techniques, the surgeon opened the cavity using a drill and inserted a radiopaque tube that matched the diameter of the cavity. The mean difference in angle between the proximal opening and the medullary canal in the shaft of the femur was calculated for both groups. Robotic cavity opening was more accurate than the manual technique, with a mean difference in trajectory between the proximal opening and the shaft canal of 2.0° (95% CI 0.6°-3.5°) compared to a mean difference of 4.3° (95% CI 2.11°-6.48°) using the manual technique (P = 0.0218). The robotic technique was more accurate than the manual procedure for identifying the optimal location for opening the medullary canal for insertion of an intramedullary nail. Additional advantages may include a reduction in total radiation exposure, as only one ISO-C 3D scan is needed, as opposed to multiple radiographs when using the manual technique.
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Abstract
The use of intramedullary nails for the treatment of long bone fractures has become increasingly frequent over the last decade with gradually expanding indications and technological advances. Improved biomechanics relative to plates and less direct fracture exposure are some of the potential benefits of intramedullary nails. However, persistent insertion-related pain is common and may limit satisfactory long term outcomes. The etiologies of this phenomenon remain unclear. Proposed theories for which there is a growing body of supporting evidence include hardware prominence, suboptimal nail entry points leading to soft tissue irritation and structural compromise, local heterotrophic ossification, implant instability with persistent fracture micromotion, and poorly defined insertional strain. Many factors that lead to insertion-related pain are iatrogenic, and careful attention to detail and refined surgical techniques will optimize outcomes.
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Ni M, Niu W, Wong DWC, Zeng W, Mei J, Zhang M. Finite element analysis of locking plate and two types of intramedullary nails for treating mid-shaft clavicle fractures. Injury 2016; 47:1618-23. [PMID: 27311550 DOI: 10.1016/j.injury.2016.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 05/23/2016] [Accepted: 06/01/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Both plate and intramedullary nail fixations, including straight and anatomic nails, have been clinically adopted for the treatment of displaced mid-shaft clavicle fractures. However, the biomechanical performances of these fixations and implants have not been well evaluated. This study aims to compare the construct stability, stress distribution and fracture micro-motion of three fixations based on finite element (FE) method. METHODS The FE model of clavicle was reconstructed from CT images of a male volunteer. A mid-shaft fracture gap was created in the intact clavicle. Three fixation styles were simulated including locking plate (LP), anatomic intramedullary nail (CRx), and straight intramedullary nail (RCP). Two loading scenarios (axial compression and inferior bending) were applied at the distal end of the clavicle to simulate arm abduction, while the sternal end was fixed. RESULTS Under both conditions, the LP was the stiffest, followed by the CRx, and the RCP was the weakest. LP also displayed a more evenly stress distribution for both implant and bone. RCP had a higher stress compared with CRx in both conditions. Moreover, all implants sustained higher stress level under the loading condition of bending than compression. CONCLUSIONS The plate fixation significantly stabilizes the fracture gap, reduces the implant stress, and serves as the recommended fixation for the mid-shaft clavicle fracture. The CRx is an alternative device to treat clavicle shaft fracture, but the shoulder excessive activities should be avoided after operation.
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Affiliation(s)
- Ming Ni
- Tongji Hospital, Tongji University School of Medicine, Shanghai, China; Pudong New Area People's Hospital, Shanghai 201299, China; Interdisciplinary Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Wenxin Niu
- Yangzhi Rehabilitation Hospital, Tongji University School of Medicine, Shanghai, China
| | - Duo Wai-Chi Wong
- Interdisciplinary Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Wei Zeng
- CEAS-Biomedical Engineering (BME), University of Cincinnati, 2901 Woodside Dr., Cincinnati, OH 45221, USA; CEAS-School of Aerospace Systems, University of Cincinnati, 2851 Woodside Dr., Cincinnati, OH 45221, USA
| | - Jiong Mei
- Tongji Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Ming Zhang
- Interdisciplinary Division of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong SAR, China
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Assaghir Y. Retrograde entry portal for femoral interlocking nailing in femoral nonunion after plate failure: a prospective comparative study with antergrade portal. J Orthop Traumatol 2016; 18:77-82. [PMID: 27439956 PMCID: PMC5310996 DOI: 10.1007/s10195-016-0416-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/26/2016] [Indexed: 11/25/2022] Open
Abstract
The piriformis fossa is the ideal portal of entry for antegrade interlocking nailing. Localizing this portal can be difficult and its eccentricity leads to complications. This prospective comparative study was designed to compare an innovative way to obtain the ideal portal from inside the medullary canal in cases of plate failure and compare it to the classic antegrade portal. It included 41 cases (19 antegrade and 22 retrograde). The retrograde portal was significantly better in terms of entry time, radiation time, blood-loss, and wound length. The proper portal was rapidly and easily achieved in all retrograde cases without complications; while four in antegrade cases had complications. Minimum follow-up was 2 years. Level of evidence III.
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Affiliation(s)
- Yasser Assaghir
- Orthopaedic Department, Sohag Faculty of Medicine, Sohag University, Sohâg, 82425, Egypt.
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Biomechanical comparison of locking plate and crossing metallic and absorbable screws fixations for intra-articular calcaneal fractures. SCIENCE CHINA-LIFE SCIENCES 2016; 59:958-64. [PMID: 27349998 DOI: 10.1007/s11427-016-0010-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/14/2016] [Indexed: 01/30/2023]
Abstract
The locking plate and percutaneous crossing metallic screws and crossing absorbable screws have been used clinically to treat intra-articular calcaneal fractures, but little is known about the biomechanical differences between them. This study compared the biomechanical stability of calcaneal fractures fixed using a locking plate and crossing screws. Three-dimensional finite-element models of intact and fractured calcanei were developed based on the CT images of a cadaveric sample. Surgeries were simulated on models of Sanders type III calcaneal fractures to produce accurate postoperative models fixed by the three implants. A vertical force was applied to the superior surface of the subtalar joint to simulate the stance phase of a walking gait. This model was validated by an in vitro experiment using the same calcaneal sample. The intact calcaneus showed greater stiffness than the fixation models. Of the three fixations, the locking plate produced the greatest stiffness and the highest von Mises stress peak. The micromotion of the fracture fixated with the locking plate was similar to that of the fracture fixated with the metallic screws but smaller than that fixated with the absorbable screws. Fixation with both plate and crossing screws can be used to treat intra-articular calcaneal fractures. In general, fixation with crossing metallic screws is preferable because it provides sufficient stability with less stress shielding.
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Bayoglu R, Okyar AF. Implementation of boundary conditions in modeling the femur is critical for the evaluation of distal intramedullary nailing. Med Eng Phys 2015; 37:1053-60. [DOI: 10.1016/j.medengphy.2015.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 08/08/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
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Zeng L, Wei H, Liu Y, Zhang W, Pan Y, Zhang W, Zhang C, Zeng B, Chen Y. Titanium Elastic Nail (TEN) versus Reconstruction Plate Repair of Midshaft Clavicular Fractures: A Finite Element Study. PLoS One 2015; 10:e0126131. [PMID: 25965409 PMCID: PMC4428894 DOI: 10.1371/journal.pone.0126131] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 03/30/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The biomechanical characteristics of midshaft clavicular fractures treated with titanium elastic nail (TEN) is unclear. This study aimed to present a biomechanical finite element analysis of biomechanical characteristics involved in TEN fixation and reconstruction plate fixation for midshaft clavicular fractures. METHODS Finite element models of the intact clavicle and of midshaft clavicular fractures fixed with TEN and with a reconstruction plate were built. The distal clavicle displacement, peak stress, and stress distribution on the 3 finite element models were calculated under the axial compression and cantilever bending. RESULTS In both loading configurations, TEN generated the highest displacement of the distal clavicle, followed by the intact clavicle and the reconstruction plate. TEN showed higher peak bone and implant stresses, and is more likely to fail in both loading configurations compared with the reconstruction plate. TEN led to a stress distribution similar to that of the intact clavicle in both loading configurations, whereas the stress distribution with the reconstruction plate was nonphysiological in cantilever bending. CONCLUSIONS TEN is generally preferable for treating simple displaced fractures of the midshaft clavicle, because it showed a stress distribution similar to the intact clavicle. However, TEN provides less stability, and excessive exercise of and weight bearing on the ipsilateral shoulder should be avoided in the early postoperative period. Fixation with a reconstruction plate was more stable but showed obvious stress shielding. Therefore, for patients with a demand for early return to activity, reconstruction plate fixation may be preferred.
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Affiliation(s)
- Langqing Zeng
- Department of Orthopaedics, Zhuhai People’s Hospital, Jinan University Affiliated Zhuhai Hospital, Guangdong, China
| | - Haifeng Wei
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yanjie Liu
- Department of Orthopaedics, The First People’s Hospital Of Foshan, Guangdong, China
| | - Wen Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yao Pan
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Changqing Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bingfang Zeng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunfeng Chen
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- * E-mail:
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