Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar approach: A retrospective case series

Risk factors for malalignment after intramedullary nail treatment of distal tibia fractures with associated fibula fractures

PURPOSE

Malalignment of distal tibia fractures can lead to malunion/nonunion or alter the limb mechanical axis which may cause arthritis. Proposed methods to decrease malalignment include fibular fixation or multiplanar interlocking screws, however these remain controversial. This study aimed to identify factors associated with malalignment in distal tibial fractures with associated fibular shaft fractures.

METHODS

A retrospective review was performed of distal tibia fractures with associated fibular shaft fractures treated with intramedullary nailing at two level one trauma centers between 2015 and 2019. Cases involving malalignment (> 5° of deviation from anatomic axis on either coronal/sagittal axis) on final follow-up (minimum three months postoperatively) were compared to those without malalignment with regard to demographics, fracture characteristics, intraoperative characteristics, and complications.

RESULTS

The rate of malalignment was 13%. On multivariate analysis, multiplanar distal interlocking screw fixation (odds ratio [OR], 0.18; 95% confidence interval [CI] 0.03-0.92) was associated with a decreased rate of final malalignment, while nail diameter > 10 mm was associated with a higher rate (OR, 4.05; 95% CI 1.25-13.11). Fibular fixation was not associated with malalignment.

CONCLUSION

Multiplanar distal interlocking screws may protect against malalignment. Fibula fixation does not appear associated with a decreased rate of malalignment in distal tibia fractures treated with intramedullary nails.

LEVEL OF EVIDENCE

III.

The absence of reporting standards and a lack of objective, performance-based outcomes following intramedullary nailing of tibial shaft fractures: findings from a scoping review into 179 articles

PURPOSE

This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes.

METHODS

PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised.

RESULTS

Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes.

CONCLUSION

The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.

Semi-extended extra-synovial (SEES) tibial intramedullary nailing technique: Up to 10 year retrospective analysis of outcomes and anterior knee pain rates

Background

Tibial intramedullary nailing is a common method of fixation for fractures of the tibia, with several approaches described. Anterior knee pain is a common complication following nailing, but the reported incidence of knee pain varies in the literature between 10 % and 86 %. There is considerable variation in incidence between nailing techniques, with an exact aetiology still unknown. We investigated the reported incidence of anterior knee pain in patients undergoing tibial nailing using the semi-extended extra synovial (SEES) technique at a Major Trauma Centre (MTC) in the UK.

Methods

A retrospective review of tibial fractures treated with the SEES technique between December 2012 to February 2021. Data collected included patient demographics, mechanism of injury, fracture characteristics, length of stay, union rates and re-operation rates. Primary outcomes were anterior knee pain rates and patient reported outcome measures (PROM), the Kujala Score. Secondary outcomes were rates of union and complications.

Results

55 fractures were identified in 53 patients. Male: Female ratio was 32:21. The average age was 45.5 years. 96 % were unilateral fractures; with 53 % being right-sided. 21(38 %) fractures were open. Prior to definitive nailing 21 fractures had temporary stabilisation with an external fixator (Ex-Fix) ± wound debridement whilst the rest received plaster backslab immobilisation. 13 of the open fractures required soft tissue cover. 75 % of patients had initial surgery (SEES Nailing/Ex-Fix) within 4 days. There was a 91 % union rate with a median time to full radiographic union of 14 months. One post-operative complication of wound dehiscence was recorded. The mean follow-up time was 13.6 months. 15 % of patients reported anterior knee pain in the postoperative follow-up period. The average Kujala PROM score was 85 (Range: 52-100).

Conclusion/findings

The SEES technique had favourable PROM scores and displayed a lower incidence of anterior knee pain than the traditional infrapatellar approach. Knee pain rates were comparable to suprapatellar approaches without violating the knee joint.

Disclosures

None.

Functional Outcomes of Tibia Fractures Treated With Intramedullary Interlocking Nails by Suprapatellar Approach: A Prospective Study

Background Tibia fractures are the most common lower extremity fractures. The subcutaneous anatomy of this long bone predisposes it to high fracture frequency in a high-energy trauma. The tibia is a major weight-bearing, long tubular bone that is axially and rotationally unstable when fractured, which ideally necessitates its surgical fixation in adults. Tibia fractures can be treated with a variety of choice of implants and surgical approaches. This study aims to assess the clinical and functional outcomes of a tibia fracture treated with intramedullary interlocking nails by a suprapatellar approach. Methodology A total of 32 patients were selected from patients admitted at Shri B. M. Patil Medical College and Research Centre with tibia fractures between January 2021 and May 2022. All the patients were treated with closed reduction and internal fixation with intramedullary interlocking nails by suprapatellar approach with a semi-extended knee position. All patients were followed up clinically and radiologically at regular intervals of six weeks, three months, six months, and one year. All functional outcomes were assessed based on modified Lysholm knee scores. Results A total of 31 patients showed union at the fracture site. One patient had nonunion and implant failure at the distal locking site, and two patients had persistent anterior knee pain at the end of one year. Functional outcome assessment based on modified Lysholm scores had excellent results, with a mean score of 95. Patients were followed up for a mean of 11.5 months. The mean time of union was observed as 12.5 months. Conclusions Suprapatellar tibia nailing is an effective alternative approach with ease of reduction and decreased intraoperative fluoroscopy time. The entry is in line with the medullary cavity preventing malreduction of proximal and distal tibia fractures. The additional proximal locking option also increases the stability of implant fixation.

Investigating and defining outcomes of suprapatellar versus infrapatellar intramedullary nailing of tibial shaft fractures: a protocol for a pilot randomised controlled trial

Background

Anterior knee pain is often reported following intramedullary nailing of tibial shaft fractures. The aetiology remains unclear, but the surgical approach may play an important role. To date, no biomechanically validated method exists to assess patient outcomes specific to anterior knee pain in this cohort. The central aims of this study are to (1) evaluate the feasibility of a full-scale randomised controlled trial (RCT) investigating the influence of surgical approach on intramedullary nailing of tibial shaft fractures (suprapatellar versus infrapatellar nailing), (2) explore differences in clinical outcomes between the approaches, and (3) explore the development of a biomechanically validated methodology for assessing post-operative anterior knee pain and knee function specific to intramedullary nailing of tibial shaft fractures.

Methods

This pilot study will follow a prospective randomised controlled design at the Royal Adelaide Hospital and The Queen Elizabeth Hospital (South Australia). This study aims to recruit 60 patients between 18 and 60 years old who will be randomly assigned to either the suprapatellar or infrapatellar approach following a decision for intramedullary surgical fixation by the treating surgeon. All nails in this study will be Stryker T2 Alpha nails. Patients will undergo standard radiograph, magnetic resonance imaging, and clinical assessments in-line with their standard operative care, and complete a number of patient-reported and performance-based outcome measures. Performance-based outcome measures will be assessed utilising three-dimensional motion capture techniques. Follow-up time points are 3, 6, 12, and 18 months. Feasibility outcomes include ability to meet enrolment and retention metrics, compliance with all questionnaires and assessment procedures, and the occurrence of any adverse events. The primary clinical outcome is the incidence of anterior knee pain at 12 months after surgery.

Discussion

This study will establish the feasibility and inform the design of a large-scale RCT. Evaluation of all clinical data and patient outcomes will lead to the development of a new tool for assessing patient outcomes in this cohort. Limitations of the study include an unpredictable enrolment rate and loss to follow-up, small sample size, and the unknown ability of three-dimensional motion analysis to pick up the effects of anterior knee pain after tibial nailing.

Trial registration

This trial was prospectively registered on the 7 February 2020 on ANZCTR, ACTRN12620000109909.

The Clamshell Osteotomy for Diaphyseal Malunion in Deformity Correction and Fracture Surgery

Diaphyseal malunion poses a great challenge for the orthopedic surgeon, and an inundation of morbidity for the patient. Diaphyseal malunion can cause altered gait, adjacent joint osteoarthritis and body dissatisfaction. This problem is fraught with complications without surgical intervention. There is a myriad of options for the management of a diaphyseal malunion. The clamshell osteotomy was engendered to ameliorate the difficulty in managing this issue. This technique is a viable option to correct diaphyseal malunion about the femur and tibia. Recently, the indications of a clamshell osteotomy have been expanded to function as a derotational or shortening osteotomy.

Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

OBJECTIVES

To assess the effectiveness of suprapatellar (SP)-nailing versus infrapatellar (IP)-nailing of tibia fractures in anterior knee pain, complications (retropatellar chondropathy, infection, and malalignment) and physical functioning and quality of life. A clinical question-driven and thorough systematic review of current literature is provided.

DATA SOURCE

PubMed and Embase databases were searched for studies published between 2010 and 2020 relating to SP and IP-nailing of tibia fractures. The study is performed in concordance with PRISMA-guidelines.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled trials, prospective and retrospective observational studies reporting on outcomes of interest.

DATA EXTRACTION

Data extraction was performed independently by 2 assessors. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal.

DATA SYNTHESIS

Continuous variables are presented as means with SD and dichotomous variables as frequency and percentages. The weighted mean, standardized weighted mean differences, and 95% confidence interval were calculated. A pooled analysis could not be performed because of differences in outcome measures, time-points, and heterogeneity.

RESULTS

Fourteen studies with 1447 patients were analyzed. The weighted incidence of anterior knee pain was 29% after SP-nailing and 39% after IP-nailing, without reported significance. There was a significant lower rate of malalignment after the SP-approach (4% vs. 26%) with small absolute differences in all planes. No substantial differences were observed in retropatellar chondropathy, infection, physical functioning, and quality of life.

CONCLUSIONS

This systematic review does not reveal superiority of either technique in any of the respective outcomes of interest. Definitive choice should depend on the surgeon's experience and available resources.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

[Treatment of tibial shaft fracture with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach]

Objective

To investigate the effectiveness of intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach for tibial shaft fracture.

Methods

Between July 2018 and September 2019, 22 patients with tibial shaft fracture treated with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach. There were 15 males and 7 females, with an average age of 46.4 years (range, 25-68 years). The fractures were caused by falling in 7 cases, by traffic accident in 14 cases, and by a heavy object in 1 case. Sixteen patients were closed fractures and 6 were open fractures. According to the AO classification, there were 4 cases of 42-A1 type, 2 cases of 42-A2 type, 3 cases of 42-A3 type, 3 cases of 42-B2 type, 4 cases of 42-B3 type, 2 cases of 42-C1 type, 3 cases of 42-C2 type, and 1 case of 42-C3 type. Twenty cases complicated with fibular fractures. The time from injury to operation was 2-15 days (mean, 7.5 days). The fracture healing time, complications, the incidence of anterior knee pain during the follow-up were observed; and knee joint functions were evaluated by Lysholm score at last follow-up.

Results

The operation time was 50-140 minutes (mean, 85 minutes). Two cases experienced incision exudation which healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 8-23 months (mean, 14.9 months). X-ray films reexamination showed that all fractures healed with the healing time of 12-20 weeks (mean, 14.4 weeks). Four patients (18.18%) experienced the anterior knee pain. No patellofemoral instability was observed during the follow-up period. Lysholm score of knee function was 85-100 (mean, 94.3) at last follow-up.

Conclusion

Application of the intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach is effective for tibial shaft fractures, which can not only realize the effective fixation of the fracture, but also avoid the adverse factors including re-displacement and anterior knee pain in the application of the intramedullary nailing fixation via the sub-patellar approach.

Minimally invasive plate osteosynthesis (MIPO) for mid-shaft fracture of the tibia (AO/OTA classification 42): A retrospective study

BACKGROUND

There is abundance of literature regarding the treatment of tibial mid-shaft fracture, and intramedullary nailing (IMN) is described as the treatment of choice. However, problems such as malunion and knee pain are known disadvantages of this approach. Minimally invasive plate osteosynthesis (MIPO) technique is another treatment option for tibial mid-shaft fracture.The purpose of this study is to evaluate the clinical, radiological results, and complication rates of tibial mid-shaft fractures treated with MIPO technique.

MATERIALS AND METHOD

Thirty-seven skeletally mature patients who underwent MIPO for a mid-shaft fracture of tibia (AO/OTA classification 42) from June 2016 to May 2018 were retrospectively reviewed. A total of 37 patients (12 females, 25 males) with a mean age of 52.7 years (range 28-78 years) were included. The clinical and radiological outcomes, such as the Jeju Lower Extremity Trauma Scale (JLETS), time to callus formation, time to bony union, and complications such as delayed union, malunion, nonunion, and infection were assessed.

RESULTS

Bony union was achieved in all cases but one (36 cases). Average callus formation was observed in 10.7 (6.5-14.5) weeks. The average time to union was 19.8 (11.5-26.5) weeks. The average JLETS score was 46.9 (40-53) point. Malunion deformities were observed in 3 cases (8.1%). Two superficial infection cases all resolved spontaneously. There was no statistically significant difference in clinical and radiographic outcomes by different AO/OTA fracture types.

CONCLUSION

The MIPO technique with locking compression plate provides stable fixation and satisfactory clinical and radiological results for mid-shaft fractures of tibia irrespective of the fracture type. Future study should aim to compare MIPO and IMN cases directly to clarify the differences and similarities between the two treatment modalities.

Anterior knee pain and functional outcome following different surgical techniques for tibial nailing: a systematic review

Purpose

The aim of this systematic review was to compare knee pain and function after tibial nail insertion through an infrapatellar, semi-extended and suprapatellar technique.

Methods

A search was carried out to identify articles with an exact description of the method used for insertion of the tibial nail and description of the outcome parameters (knee pain or function). Data on study design, population, rate and severity of anterior knee pain and function scores were extracted. Pooled rates and scores were calculated.

Results

67 studies with 3,499 patients were included. The pooled rate of patients with anterior knee pain was 38% (95% CI 32–44) after nail insertion through an infrapatellar approach and 10% (95% CI 1–26) after insertion through a suprapatellar approach. Pooled analysis was not possible for the semi-extended technique. Knee pain scores as measured by visual analogue score (0–10) ranged from 0.2 (95% CI − 0.1–0.5) for general knee pain to 3.7 (95% CI 1.3–6.1) for pain during kneeling. Pooled estimates for the Lysholm score were 87 points (range 77–97) for the infrapatellar technique and 85 points (range 82–85) for the suprapatellar technique. Iowa Knee scores were 94 (range 86–96) and Anterior Knee Pain Scale scores were 76 (range 75–80) after infrapatellar nail insertion.

Discussion

Depending on the technique used, the proportion of patients with knee pain after tibial nailing varied between 10 and 38%. The actual measured knee pain scores were, however, surprisingly low. Knee function was good for both the infra- and suprapatellar technique.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01458-2) contains supplementary material, which is available to authorized users.

Clinical and radiographic outcomes after antegrade intramedullary nail fixation of humeral fractures

INTRODUCTION

Humerus fractures are frequent, accounting for about 3-4% of all fractures in adults. Treatment for fractures of the diaphyseal and proximal meta-epiphyseal regions remains controversial: there is no unanimity in the scientific community about the superiority of surgical treatment over non-surgical treatment and which is the best between possible surgical treatments. Among the choices for surgical treatment the most commonly used implants are the locking-compression plate and the intramedullary nailing. The purpose of this study was to perform a clinical and radiographic follow-up in patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of anterograde intramedullary nailing with a straight-shaped nail.

PATIENTS AND METHODS

A clinical and radiographic follow-up was performed in 56 patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of antegrade intramedullary nailing using Synthes MultiLoc® system. Clinical data were collected using subjective quality of life assessment forms (SF12-v2), quality of life related to specific disabilities assessment forms (Quick-DASH, ASES score, WORC) and objective functional assessment forms (Constant-Murley score). The radiographic Follow-Up was performed at 30, 90 and 180 days from the date of the surgery.

RESULTS

Almost all patients were able to return to a satisfactory quality of life, comparable with the one before the traumatic episode. The functional results were assessed as excellent or good with almost complete recovery of the range of motion and moderate recovery of strength. The residual pain encountered was moderate or zero. The average QuickDASH score was 17.7 ± 4.3 (range 9.1 - 27.3). The average ASES score was 73.8 ± 8.1 (range 58.3 - 88.3). The average WORC score was 543.3 ± 100 [74% ± 4.8%] (range 310 - 740). The mean Constant-Murley score was 69.6 ± 4.6 (range 61 - 84). All patients had a fair or good consolidation of the fracture on radiographic examinations. The calculated RUST score was 4.2 ± 0.4 (range 4-5) 30 days after surgery, 6.1 ± 0.9 (range 4- 8) 90 days after surgery and 9.8 ± 1.5 (range 7-12) to 180 days after surgery. No major complications were found.

CONCLUSIONS

Treatment of the diaphyseal and proximal meta-epiphyseal humeral fractures with antegrade intramedullary nail provides excellent subjective and objective clinical results and good radiographic results. However, clinical studies with larger number of patients and longer follow-up are necessary.

Treatment of distal femur fractures with VA-LCP condylar plate: A single trauma centre experience

INTRODUCTION

Given the recent criticisms in the literature regarding Synthes Variable Angle Locking Compression Condylar Plate (VA-LCP), the purpose of this study was to evaluate functional outcome, fracture healing, and complications of distal femoral intra-articular fractures using this device.

METHODS

Patients with distal femoral fractures treated with 4.5 mm VA-LCP Curved Condylar Plate were included in this retrospective study. Follow-ups were at 4 weeks, 3 months, 6 months and 1 year. For the clinical and functional assessment of the knee, WOMAC, Koos Knee Survey, the Knee Score Society and the SF-12 questionnaire were used. Radiographically we assessed the fracture healing and the angles of the operated limb compared to the healthy contralateral limb. Complications have also been described.

RESULTS

Forty-two patients with distal femoral fractures were included in the study. The mean follow-up was 8 months. Most cases (57%) reported a type 33-A fracture. Radiological healing was achieved in 33 cases; the mean time required to heal was 13 weeks. Three patients had an early postoperative complication and four cases had a late complication. Five cases required additional surgical procedures. Most patients (47.2%) achieved a complete flexion of 130° or more. WOMAC mean value 27.4%, KSS mean value 77.6 for the clinical part and 60 for the functional part, KOOS mean score 60.1, SF-12 mean score 46.1 for MCS and 35.5 for PCS.

DISCUSSION

The results of this retrospective study suggest that VA-LCP Curved Condylar Plates have a good functional outcome and fracture healing similar to other standard distal femoral locking plates. VA technology allows greater versatility in fractures internal fixation regardless of the plate design. Fixation devices or Prosthesis implants previously placed may be avoided, as in periprosthetic fractures. Moreover, we have not recorded any early mechanical damage.

CONCLUSIONS

Osteosynthesis with Synthes 4.5 mm VA-LCP Curved Condylar Plate demonstrated to have no early mechanical failure rate with good clinical and radiological results.

Suprapatellar nailing in proximal third tibial fractures - Clinicoradiological outcome

AIMS AND OBJECTIVES

To evaluate the clinical and radiological outcome of proximal third tibia fractures managed by suprapatellar nailing with a minimum follow-up of 12 months.

METHODOLOGY

In our retrospective cohort study of 43 consecutive proximal third tibia fractures from January 2015 to September 2018 treated with intramedullary nailing through suprapatellar approach in semiextended knee position were included. The patients were followed up regularly at 6 weeks, 3 months, 4.5 months, 6 months, 12 months and every 6 months thereafter. At each visit patients were assessed for union, shortening and rotational alignment. The clinical outcome was analysed using Lower Extremity Functional Scale (LEFS) and anterior knee pain. The radiological outcomes are analysed by evaluating the radiographs for progression of fracture union and tibial alignments.

RESULTS

After fulfilling the exclusion and inclusion criteria, 43 out of 60 consecutive proximal third tibia fracture were included in the study with an average age of 38.4 years (20-71 years), follow up of 20.4 months (12-45 months) after the index procedure. The radiological union was achieved in 7.3 months (4-13 months). At the end of 1 year follow up, the average LEFS was 89.4% (60%-95%). 4 patients had Malunion - with 1 valgus and 3 anterior angulations, 8 delayed unions and 1 non-union (with bone loss- which required bone grafting). All the fractures united eventually. No incidence of anterior knee pain.

CONCLUSION

We recommend suprapatellar nailing in proximal third tibial fractures when meticulously performed using the current surgical principles and techniques with proper implant selection. It results in excellent clinical and radiological outcomes with minimal complications when compared to other modalities of management. Suprapatellar nailing is a viable option for proximal third tibia fractures due to its inherent advantages of positioning, perfect nail entry and placement. Additionally, noteworthy absence of anterior knee pain is an additional benefit of this technique.

Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre

Aims The aim of this study was to assess functional outcome, at medium-term follow up, in patients undergoing intra-medullary nailing of tibial shaft fractures, using the supra-patellar approach. Materials and methods The study included patients with intra-medullary nailing, for diaphysial tibia fractures, between March 2013 to August 2015. An initial audit compared short-term functional outcomes at 15 months, between the supra and infra-patellar approaches, using a cohort of 20 patients (10 in each group). Subsequently, a larger cohort of 22 patients with supra-patellar nailing, were reviewed for medium term assessment of their functional outcomes at average 60 months (50 - 78 months) and the results between all 3 groups were compared. All patients were assessed using the Kujala and Oxford Knee Scores. Results The mean age of the cohorts was 38 years (18-87years). The mean follow-up was 15 months for the initial audit and 60 months for the medium-term results. The initial audit showed that the supra-patellar group had statistically significantly better Oxford and Kujala scores when compared to infra-patellar group (p < 0.05). At 5 years following supra-patellar nailing, the medium-term cohort showed improved outcome scores compared to the infra-patellar group at 1 year (p < 0.01) but showed no difference with the supra-patellar group at 1 year (p value >0.1). Conclusion Our study suggests that patients undergoing supra-patellar tibial nailing have better outcomes at 15 months compared to traditional infra-patellar nailing and more importantly, they continue to do well even at 5 years, despite perceived risks associated with this technique.

Impacted Steel Sleeves for a minimally invasive approach in intramedullary nailing

A custom-made instrument set of Steel Sleeves was developed to assist the insertion of reamers and intramedullary devices for fixation of long bone fractures or lengthening procedures with intramedullary nails. By use of the Steel Sleeves, migration of the entry point is prevented and protection of the bone and soft tissue at the entry point is guaranteed. In addition, the principle of a closed working channel for trans-articular approaches can be provided. In this article, a description of properties and clinical application of custom-made steel sleeve instrument set is provided.

Intraoperative customization of intramedullary nails - First results

INTRODUCTION

Intramedullary nailing is a valuable treatment option for many types of fractures. Furthermore nailing is applicable for osteosynthesis following osteotomy in deformity correction. For intraoperative fine-tuning of alignment in intramedullary (IM) nailing procedures, a bending device for customization of IM nails under sterile conditions was developed. We have performed a retrospective clinical study to analyze and describe the technical requirements, indications and limitations for intraoperative customization of IM nails.

MATERIALS AND METHODS

In 41 cases of deformity correction with IM nailing, we applied intraoperative sterile bending of IM nails. The patient age ranged from 13 to 64 years. We evaluated the radiological outcome (precision of the intervention) of 31 completed cases, comparing the preoperative planning with the final result on long-standing radiographs (LSR). The diameter of the nails ranged from 8,5mm to 13mm. Cases with fracture or non-union treatment with intraoperative application of the bending device were excluded and analyzed separately.

RESULTS

All removed implants were examined - none of them showed any signs of material fatigue. The amount of intraoperative bending of the nails was 1° to 12°. A high level of precision was achieved, with a median postoperative axis deviation to the preoperative planning of 3,5mm. In a polio patient with limited bone quality, the implant removal caused an undisplaced cortical crack. There were no other complications. There was uneventful and fast bone healing in all patients.

CONCLUSIONS

Intraoperative customization of intramedullary nails is a valuable technique for precise alignment control with IM nailing. With this technique, the benefits of IM nailing can be used for a wide range of indications, including deformity correction. The sterile bending device is safe and easy to handle. It is strong enough to bend all commercially available IM nails. Monofocal or linear bending in multiple planes is possible. However, when defining the site of bending, one must consider the removal of the implant in the future.

Intramedullary nailing through a suprapatellar approach. Evaluation of clinical outcome after removal of the device using the infrapatellar approach

Background and aim of the work: Since 2006, It has been developed the possibility to introduce a tibia nail through a suprapatellar access. However, the removal of device must be carried out using the classic infrapatellar approach. The aim of this study is to evaluate the clinical scores of a group of patients that removed a tibial nail by infrapatellar approach, previously introduced through a suprapatellar access. Methods: Seven patients received removal, through infrapatellar access, of tibial nail previously introduced by suprapatellar approach. Despite being VAS <5, patients requested the device to be removed. The variables studied were the distance between the apex of the nail and the tibial plateau (TPD) and between the apex of the nail and the anterior tibia (ATD), oxford knee score (OKS), Kujala score (KJS), Visual Analog Scale (VAS) and SF 36 before surgery and 1 year. A1 year of follow up the Sidky-Buckley questionnaire was administered. The follow-up was 1 year. Results: The mean VAS was 2.8 before surgery and 0.5 at 1 year after surgery, OKS average pre-surgery is 38 (good), while at 1 year it becomes 44 (excellent). The Sidky-Buckley questionnaire showed that all patients would have the intramedullary nail removed again. The widest improvement in all parameters is seen in the two patients with less distance from the tibial plateau. Conclusions: Although the patients had received initial suprapatellar access and a second infrapatellar for the removal of the device, no complications were reported regarding the use of the two accesses. (www.actabiomedica.it)