Heat-induced segmental necrosis after reaming of one humeral and two tibial fractures with a narrow medullary canal

Reamed versus unreamed intramedullary nailing for the treatment of femoral shaft fractures among adults: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this meta-analysis is to compare the merits and drawbacks between reamed intramedullary nailing (RIN) and unreamed intramedullary nailing (URIN) among adults.

METHODS

We comprehensively searched PubMed, MEDLINE database through the PubMed search engine, Google Scholar, Cochrane Library, Embase, VIPI (Database for Chinese Technical Periodicals), and CNKI (China National Knowledge Infrastructure) from inception to March 2020. Outcomes of interest included nonunion rates, implant failure rates, secondary procedure rates, blood loss, acute respiratory distress syndrome (ARDS) rates, and pulmonary complications rates.

RESULTS

Eight randomized controlled trials were included. The result of nonunion rates shows that the nonunion rate is significantly lower in the RIN group (RR = 0.20, 95% CI = 0.09-0.48, Z = 3.63, P = 0.0003). There were no significant differences for the risk of implant failure rates (RR = 0.55, 95% CI = 0.18-1.69, Z = 1.04, P = 0.30). The secondary procedure rates were significantly lower in the RIN group (RR = 0.28, 95% CI = 0.12-0.66, Z = 2.91, P = 0.004). The result shows that the blood loss of URIN group is significantly lower (RR = 145.52, 95% CI = 39.68-251.36, Z = 2.69, P = 0.007). The result shows that there was no significant difference in the ARDS rates (RR = 1.53, 95% CI = 0.37-6.29, Z = 0.59, P = 0.55) and the pulmonary complications rates between RIN group and URIN group (RR = 1.59, 95% CI = 0.61-4.17, Z = 0.94, P = 0.35).

CONCLUSIONS

Reamed intramedullary nailing would lead to lower nonunion rate, secondary procedure rate and more blood loss. Unreamed intramedullary nailing is related to a higher nonunion rate, secondary procedure rate and less blood loss. No significant difference is found in implant failure rate, ARDS rate and pulmonary complication rate between the two groups.

Piezoelectric tools versus traditional oscillating saw for distal linear osteotomy in hallux valgus correction: Triple-blinded, randomized controlled study

BACKGROUND

The main goal of the surgical correction of the hallux valgus is the morphological correction associated with the functional rebalancing of the first ray. The aim of this triple-blinded, randomized controlled study was to show the efficacy of piezosurgery in performing distal linear osteotomy of the first metatarsal bone in HV correction, in terms of clinical and radiological outcomes at 1-year final follow up.

METHODS AND MATERIALS

This study was performed collecting prospectively pre-operative and post-operative data for all patients. 34 patients were included in the trial and were randomly allocated (1:1) in a Piezoelectric Group (PG) that involved the use of piezoelectric tools and in a Control Group (CG) that provided for the use of a traditional oscillating saw. In both groups, all patients were treated with a distal linear osteotomy of the first metatarsal bone. Clinical and radiographic assessments were performed.

RESULTS

The AOFAS score between the two groups was similar pre-operatively and during the follow-up period, with a slight superiority in the PG at each evaluation. The osteotomy surgical time was registered for both groups. Among the endpoints of the study, the radiological bone healing time was independently assessed by a radiologist that reported a lower mean value in the piezoelectric group compared with the control group.

CONCLUSIONS

This trial has shown that piezoelectric surgery is not inferior to traditional methods from the clinical-functional point of view, but can even lead to an evident reduction of bone healing time with a statistical significance.

LEVEL OF EVIDENCE

Level I.

Humeral head necrosis associated to shaft non-union with massive bone loss: a case report

Humeral non-union is a rare complication in shaft fractures, as well as humeral head necrosis is a possible complication in fracture involving the proximal third especially in four-part fractures. The presence of head osteonecrosis and diaphyseal non-union in the same arm represents a formidable challenge for an orthopaedic surgeon. We could not find any similar report in the literature dealing with this issue thus far. We present a case of a 65 years old woman referred to our hospital being affected by an atrophic humeral diaphyseal non-union with a massive bone loss (>10cm) associated to a humeral head osteonecrosis following a previous surgical procedures with a clear loosening of the hardware. At our institution,she was treated with hardware removal and insertion of a diaphyseal antibiotic spacer with Gentamycin for 2 months suspecting an active septic process at the union site despite negative cultural exams. Finally, she was treated with a cemented modular humeral megaprosthesis. At 20 months follow up, the patient, despite a reduced shoulder range of motion, referred to a pain-free recovery to an almost normal lifestyle, including car driving with no major disturbances. This case suggests that, in extreme selected cases following several failed treatments, megaprosthesis can represent a viable solution, especially in huge bone loss associated to joint degeneration, to ensure an acceptable return to a normal lifestyle.

Surgical Drill Bit Design and Thermomechanical Damage in Bone Drilling: A Review

As drilling generates substantial bone thermomechanical damage due to inappropriate cutting tool selection, researchers have proposed various approaches to mitigate this problem. Among these, improving the drill bit design is one of the most feasible and economical solutions. The theory and applications in drill design have been progressing, and research has been published in various fields. However, pieces of information on drill design are dispersed, and no comprehensive review paper focusing on this topic. Systemizing this information is crucial and, therefore, the impetus of this review. Here, we review not only the state-of-the-art in drill bit designs-advances in surgical drill bit design-but also the influences of each drill bit geometries on bone damage. Also, this work provides future directions for this topic and guidelines for designing an improved surgical drill bit. The information in this paper would be useful as a one-stop document for clinicians, engineers, and researchers who require information related to the tool design in bone drilling surgery.

The Obliteration of Noncritical Size Bone Defects With Bone Dust or Bone Replacement Material (Bioactive Glass S53P4)

HYPOTHESIS

Bone dust (BD) harvested during operation may be suitable as an autologous obliteration material for noncritical size defects. Bioactive glass (BA) can be an alternative.

BACKGROUND

To treat noncritical size defects, BD and BA are commonly used for obliteration techniques. However, the optimal harvesting method and parameters for BD have not been examined. In this study, we analyzed the osseoregenerative potential of both materials.

METHODS

Thirteen female merino sheep (7-yr old) underwent surgery on the frontal calvaria. Three defects were inserted. The first defect was considered a reference and remained unfilled, the second defect was filled with BD from the calvaria bone, and the third defect was filled with BA S53P4. The animals were sacrificed after 3 weeks. To evaluate bone regeneration, we used digital volume tomography, bone density measurement, fluorochrome sequence labeling, and histological analysis.

RESULTS

All analyses showed quantitative and qualitative bone regeneration 3 weeks after operation. The control blank defect showed significantly less new bone growth than the BD-filled defect. Moreover, bone regeneration occurred from the surrounding bone and showed only a defect bridge in the BD-filled defect. The BA completely filled the defect and had the highest density although the same amount of new mineralized bone generated as in the reference.

CONCLUSION

BD and BA seemed to be suitable bone replacement materials for obliteration techniques because they completely filled the defects. Thus, BD harvested under standardized conditions provided a higher level of osteoreparation potential for the generation of woven bone and establishment of defect bridges.

Fractures in patients with poliomyelitis: Past or current challenge?

Fractures in poliomyelitic limbs are a challenge to surgeons, due to polio's sequelae and morphological disorders, which make conventional osteosynthesis difficult. We present a retrospective study of 62 patients and 73 non-simultaneous fractures in their lower limbs. Average age was 61,7 years and 53,2% were females. We analyzed the preinjury functional level, etiology of the fracture, fracture pattern, treatment used (be conservative or surgical), and implant used in surgical cases. We treated 85,1% of them surgically and 37,9% of them maintained the same functional situation as before the fracture. 55,4% of them experienced the need to add some mechanical aids after the lesion and 6,8% lost the ability to walk. Most of the surgical treatments employed were similar as the ones used in non-poliomyelitic patients, although some cases required atypical implants, such as a Multiloc (® DePuy Synthes) humeral nail for a tibial shaft fracture, due to narrow bone. Mortality along the 1st year was 2.7%. We found similar functional and radiological results as those described in non-poliomyelitic limbs.

A preclinical large-animal model for the assessment of critical-size load-bearing bone defect reconstruction

Critical-size bone defects, which require large-volume tissue reconstruction, remain a clinical challenge. Bone engineering has the potential to provide new treatment concepts, yet clinical translation requires anatomically and physiologically relevant preclinical models. The ovine critical-size long-bone defect model has been validated in numerous studies as a preclinical tool for evaluating both conventional and novel bone-engineering concepts. With sufficient training and experience in large-animal studies, it is a technically feasible procedure with a high level of reproducibility when appropriate preoperative and postoperative management protocols are followed. The model can be established by following a procedure that includes the following stages: (i) preoperative planning and preparation, (ii) the surgical approach, (iii) postoperative management, and (iv) postmortem analysis. Using this model, full results for peer-reviewed publication can be attained within 2 years. In this protocol, we comprehensively describe how to establish proficiency using the preclinical model for the evaluation of a range of bone defect reconstruction options.

Interlocking nailing of femoral shaft fractures with an extremely narrow medullary canal is associated with iatrogenic fractures

INTRODUCTION

Controversy exists regarding the use of reamed interlocking nailing in femoral shafts with extremely narrow medullary canals (diameter ≤ 9 mm). The aims of this study were to (1) investigate the association of age and sex on femoral canal diameter in patients with a simple femoral shaft fracture and (2) compare the outcomes and complications of interlocking nailing between wide and extremely narrow intramedullary canals.

PATIENTS AND METHODS

For the purposes of this retrospective cohort study, consecutive patients with simple femoral shaft fractures were recruited between January 2009 and December 2016. The patient demographic data were analyzed. Then, fractures treated with interlocking nailing were divided into the wide group (canal diameter > 9 mm) and narrow group. The primary outcome was union rate, and the secondary outcomes were complications such as thermal necrosis, fat embolism syndrome, iatrogenic fracture, and implant failure.

RESULTS

This study included 340 femoral shaft fractures. The average canal diameter was 9.97 ± 1.79 mm, with significantly wider canals in men than in women. Overall, 289 of the patients had undergone interlocking nail fixation, and a similar union rate and complications were noted between the wide canal and narrow canal groups, with the exception of the incidence of iatrogenic fracture.

CONCLUSIONS

Femoral shaft fractures associated with extremely narrow medullary canals are more common in women than in men. There was a similar union rate found when using interlocking nailing in a femoral shaft fracture in cases with extremely narrow and wider canals. Iatrogenic fracture is the only significant risk when using interlocking nailing in femoral shafts with extremely narrow canals.

Thermal Osteonecrosis Caused by Bone Drilling in Orthopedic Surgery: A Literature Review

Thermal osteonecrosis is the in situ death of bone tissue as a result of excessively high temperatures. While the exact temperature at which thermal osteonecrosis occurs has not yet been determined, 50°C is the accepted critical value, as bone regeneration is almost completely impaired from this point on. Thermal osteonecrosis is a significant concern in orthopedic surgery, as it can compromise the bone-implant interface in fracture fixation, which, by definition, is a complication.

A literature review was undertaken of the pertinent literature concerning heat generation from bone drilling and how this heat affects bone tissue. The Pubmed, ScienceDirect, and secondary (Cochrane Library) databases were searched up to December 2017 using keywords with the appropriate use of Boolean operators. Both simple text word searching and thesaurus searching were used to maximize the number of relevant articles retrieved. Reference tracking was performed via the retrieved articles to further extend the boundaries of the search. The level of evidence was Level V.

It was identified that factors affecting heat generation during bone drilling were multifactorial and did not act independently of each other. Good quality evidence exists that both bone drilling parameters and the drill itself affect heat generation in bone during bone drilling. However, external irrigation is the most important variable and should always be used to keep the bone temperature below the critical value of 50°C.

Future studies should focus on how the parameters of bone drilling interact with each other and how this influences heat generation in bone drilling. There is also a lack of in vivo studies on the human bone; this too should be further investigated.

Technical aspects and complications in the surgical treatment of poliomyelitis-affected lower limb fractures

OBJECTIVE

Post-polio patients present problems such as small and deformed bones, with narrow intramedullary canal and osteoporosis, affecting surgical treatment. The aim of this article is to describe the main preoperative and intraoperative complications of the surgical treatment of fractures in this population.

MATERIAL AND METHODS

A retrospective analysis was conducted between 1995 and 2014. Data obtained from the medical records included patient age, fracture pattern (AO/OTA), device used, technical aspects of the surgery that changed compared to a standard procedure, and the presence of intraoperative skeletal complications.

RESULTS

Sixty-four patients with 78 fractures were included in the study. Forty-seven percent of the fractures were at the proximal femur. The main complications of hip arthroplasty (14 patients) were absent hip abductors and intraoperative instability (3), bad cup fixation (3) and intraoperative periprosthetic fracture (2). The main problems of intramedullary nailing were due to a narrow canal and previous bone deformity. Main problems reported when plating included difficulty to fit a precontoured plate, and oversized hardware.

CONCLUSION

Given the large number of intraoperative complications, in preoperative planning we must include nails of small diameter and length, locking plates and external fixators, and, in the case of hip arthroplasty, long and thin stems and restrictive or dual mobility acetabular systems.

Salvage of an osteocutaneous thermonecrosis secondary to tibial reaming by the induced membrane procedure

Osteocutaneous thermonecrosis is a rare but devastating complication of tibial reaming, which can cause large and infected bone and cutaneous defects. The case presented here illustrates that the induced membrane technique described by Masquelet is a valuable option in treating this complication.

Inflammatory response after nailing

Intramedullary nailing, as the gold standard stabilisation method of most long bones, has been tailed by its extensive use as the basic tool of investigating the immune response to trauma in many large and small animal models, as well as at the clinical setting. Over the last few decades a complex map of interactions between pro and anti-inflammatory pathways has been the result of these significant global research efforts. Parallel to the evolution of modern nailing and reaming techniques, significant developments at the fields of other disciplines relevant to trauma care, has improved the contemporary management of injured patients, challenging previous concepts and altering clinical barriers. The current article aims to summarise the current understanding of the effect of instrumenting the medullary canal after trauma, and hint on potential future directions.

Heat Generation During Bone Drilling: A Comparison Between Industrial and Orthopaedic Drill Bits

OBJECTIVES

Cortical bone drilling for preparation of screw placement is common in multiple surgical fields. The heat generated while drilling may reach thresholds high enough to cause osteonecrosis. This can compromise implant stability. Orthopaedic drill bits are several orders more expensive than their similarly sized, publicly available industrial counterparts. We hypothesize that an industrial bit will generate less heat during drilling, and the bits will not generate more heat after multiple cortical passes.

METHODS

We compared 4 4.0 mm orthopaedic and 1 3.97 mm industrial drill bits. Three types of each bit were drilled into porcine femoral cortices 20 times. The temperature of the bone was measured with thermocouple transducers. The heat generated during the first 5 drill cycles for each bit was compared to the last 5 cycles. These data were analyzed with analysis of covariance.

RESULTS

The industrial drill bit generated the smallest mean increase in temperature (2.8 ± 0.29°C) P < 0.0001. No significant difference was identified comparing the first 5 cortices drilled to the last 5 cortices drilled for each bit. The P-values are as follows: Bosch (P = 0.73), Emerge (P = 0.09), Smith & Nephew (P = 0.08), Stryker (P = 0.086), and Synthes (P = 0.16). The industrial bit generated less heat during drilling than its orthopaedic counterparts. The bits maintained their performance after 20 drill cycles.

CONCLUSIONS

Consideration should be given by manufacturers to design differences that may contribute to a more efficient cutting bit. Further investigation into the reuse of these drill bits may be warranted, as our data suggest their efficiency is maintained after multiple uses.

How Safe Is High-Speed Burring in Spine Surgery? An In Vitro Study on the Effect of Rotational Speed and Heat Generation in the Bovine Spine

STUDY DESIGN

In vitro animal cadaveric study.

OBJECTIVE

To identify the appropriate rotational speed and safe bone distance from neural tissue during bone burring in spinal surgery.

SUMMARY OF BACKGROUND DATA

Bone burring is a common step in spinal surgery. Unwanted frictional heat produced during bone burring may result in thermal injury to the bone and adjacent neural structure. One of the important parameters influencing the bone temperature rise during bone burring is rotational speed.

METHODS

This laboratory-based animal study used bovine spine bones, and the tests were conducted using a steel round burr. The bone temperature was measured simultaneously with thermocouple at the distances of 1 mm, 3 mm, and 5 mm from the burring site during the burring process. The bone burring was done with 4 different rotational speeds of 35,000 revolutions per minute (rpm), 45,000 rpm, 65,000 rpm, and 75,000 rpm.

RESULTS

This study showed that increasing the rotational speed significantly elevated bone temperature. The threshold temperature of 47°C was reached when bone was burred for 10 seconds, with a rotational speed of 45,000 rpm. The mean bone temperature measured at a distance 1 mm from the burring site for all 4 rotational speeds was always higher than that measured at a distance of 3 mm and 5 mm and this difference was statistically significant (P < 0.001). There was no significant difference between the mean bone temperature measured at a distance of 3 mm and 5 mm (P > 0.05).

CONCLUSION

Taking 47°C as the threshold temperature for causing significant impairment to the regenerative capacity of bone, a rotational speed of lower than 45,000 rpm is preferable so as to minimize thermal injury to bone tissue. We also concluded that a 3-mm distance between the site of burring and the neural tissue is a safe distance.

LEVEL OF EVIDENCE

N/A.

Trephine Use During Revision Total Hip Arthroplasty Resulting in Diaphyseal Osteonecrosis and Stress Fracture: A Case Report

CASE

A fifty-three-year-old woman presented with a fracture of an extensively porous-coated femoral component. Revision was performed with use of trephine reamers to remove the distal portion of the stem. Despite radiographs that showed an acceptable position of the revision stem, she experienced substantial thigh pain at four months postoperatively, which persisted at twelve months. A technetium-99m bone scan demonstrated a 5-cm photopenic region, suggestive of thermal osteonecrosis. Two months later, there was evidence of callus formation, which is consistent with a stress fracture. The fracture was treated with protected weight-bearing; it healed with nonoperative management and resolution of the pain.

CONCLUSION

A diaphyseal stress fracture secondary to thermal osteonecrosis associated with trephine use developed after removal of a broken femoral component; it healed without surgical intervention.

Expert tibia nail for subtrochanteric femoral fracture to prevent thermal injury

INTRODUCTION

Subtrochanteric femoral fractures are relatively uncommon, accounting for 7-15% of all hip fractures and treatment of these fractures are considered challenge for orthopaedic surgeons. Although several treatment options are reported with up to 90% of satisfactory results, the choice of the appropriate implant is still a matter of debate. Some authors reported thermal injury after reaming for intramedullary nail fixation in patients with narrow medullary canal.

PRESENTATION OF CASE

A 21-year-old female patient was admitted to our hospital because of right subtrochanteric femoral fracture. The narrowest diameter of medullary canal of her femur was about 7mm but she refused open reduction and internal fixation with plate due to large scar formation. We used expert tibia nail instead of femoral intramedullary nail to prevent thermal injury.

DISCUSSION

Subtrochanteric femoral fractures are difficult to treat because of their biomechanical and anatomical characteristics. Although several implants are reported for the surgical treatment of these fractures, intramedullary nails have been advocated due to their biological and biomechanical advantages. However, under certain circumstances with associated injury or anatomic difference we might consider another treatment options.

CONCLUSION

Expert tibia nail may be considered one of the treatment options for subtrochanteric femoral fracture with narrow medullary canal. We also emphasize the importance of preoperative evaluation of the medullary canal size for these risky fractures.

A meta-analysis of reamed versus unreamed intramedullary nailing for the treatment of closed tibial fractures

Controversy exists regarding the clinical outcomes of reamed vs unreamed intramedullary nailing in the treatment of closed tibial fractures. This study assessed the effects of reamed vs unreamed intramedullary nailing for closed tibial fractures. The authors searched PubMed, EMBASE, BIOSIS, and the Cochrane Controlled Trials Register for randomized and quasi-randomized controlled clinical trials from January 1980 to June 2012 comparing reamed with unreamed intramedullary nailing for closed tibial fracture in adults. Primary outcomes were nonunion, delayed union, malunion, secondary procedure, failure of implants, compartment syndrome, infection, and knee pain. Eight randomized and 1 quasi-randomized clinical trials (1229 fractures) were included. No statistically significant differences were found between reamed and unreamed nailing groups in delayed union (P=.20), malunion (P=.28), infection (P=.36), compartment syndrome (P=.36), and knee pain (P=.93). The unreamed group had a higher rate of fracture nonunion than the reamed group (P=.02). The subgroup analysis of implant failures (broken screws vs broken nails) indicated that reamed nailing significantly reduced the risk of screw breakage (P<.001); however, there was no significant difference between reamed and unreamed intramedullary nailing in nail breakage (P=.94). The subgroup analysis of a secondary procedure showed that the reamed intramedullary nailing resulted in significantly lower risks of implant exchange (P=.01) and dynamization (P=.04); however, there was no significant difference in bone grafting rate (P=.73). Evidence comparing reamed with unreamed intramedullary nailing for closed tibial fractures indicates that reamed intramedullary nailing may lead to significantly lower risks of nonunion, screw failure, implant exchange, and dynamization without increasing operative complications.

Novel hybrid drilling protocol: evaluation for the implant healing--thermal changes, crestal bone loss, and bone-to-implant contact

OBJECTIVES

To evaluate a new hybrid drilling protocol, by the analysis of thermal changes in vitro, and their effects in the crestal bone loss and bone-to-implant contact in vivo.

MATERIALS AND METHODS

Temperature changes during simulated osteotomies with a hybrid drilling technique (biologic plus simplified) (test) versus an incremental drilling technique (control) were investigated. One hundred and twenty random osteotomies were performed (60 by group) in pig ribs up to 3.75-mm-diameter drill to a depth of 10 mm. Thermal changes and time were recorded by paired thermocouples. In a parallel experiment, bilateral mandibular premolars P2, P3, P4, and first molar M1 were extracted from six dogs. After 2-month healing, implant sites were randomly prepared using either of the drilling techniques. Forty eight implants of 3.75 mm diameter and 10 mm length were inserted. The dogs were euthanized at 30 and 90 days, and crestal bone loss (CBL) and bone-to-implant contact (BIC) were evaluated.

RESULTS

The control group showed maximum temperatures of 35.3 °C ± 1.8 °C, ΔT of 10.4 °C, and a mean time of 100 s/procedure; meanwhile, the test group showed maximum temperatures of 36.7 °C ± 1.2 °C, ΔT of 8.1 °C, and a mean time of 240 s/procedure. After 30 days, CBL values for both groups (test: 1.168 ± 0.194 mm; control: 1.181 ± 0.113 mm) and BIC values (test: 43 ± 2.8%; control: 45 ± 1.3%) were similar, without significant differences (P > 0.05). After 90 days, CBL (test: 1.173 ± 0.187 mm; control: 1.205 ± 0.122 mm) and BIC (test: 64 ± 3.3%; control: 64 ± 2.4%) values were similar, without significant differences (P > 0.05). The BIC values were increased at 90 days in both groups compared with the 30-day period (P < 0.05).

CONCLUSIONS

Within the limitations of this study, the new hybrid protocol for the preparation of the implant bed without irrigation, increase the temperature similarly to the incremental conventional protocol, and requires twice the time for the completion of the drilling procedure in vitro. Crestal bone loss and bone-to-implant contact in the hybrid drilling protocol are comparable with the conventional drilling protocol and do not affect the osseointegration process in vivo.

Reamed versus unreamed intramedullary locked nailing in tibial fractures

The purpose of this prospective observational study is to identify whether or not reaming of tibial shaft fractures has benefits over unreamed intramedullary locked nailing. Eighty-four adult patients with recent open and closed tibial shaft fractures were treated with reamed or unreamed intramedullary locked nail fixation. We followed up for 12 months 39 of 43 patients in the unreamed and 38 of 41 patients in the reamed group, respectively. There were no significant differences between the two groups regarding the average time to healing for both clinical (3.2 vs 3.4 months, p = 0.65) and radiological (4.1 vs 4.5 months, p = 0.43) evaluations. The mean duration of surgery was shorter (p = 0.025) for the unreamed group 43 min (SD 18) compared to 55 (SD 27), but the main determinants were the fracture type and the surgeon's experience. We conclude that reamed nailing proved beneficial, but the impact on overall outcome is not superior to unreamed nailing.

System evaluation on reamed and non-reamed intramedullary nailing in the treatment of closed tibial fracture

PURPOSE

To systematically evaluate the clinical efficacy of reamed and nonreamed intramedullary nailing in treatment of closed tibial fractures with Cochrane systematic review methods.

METHODS

According to the Cochrane systematic review methods, literatures were retrieved from Cochrane library, PubMed, EMbase and other database. Randomized controlled trials (RCTs) and quasi-randomized controlled clinical trials about reamed and nonreamed intramedullary nailing in the treatment of closed tibial fractures were collected and RevMan 5.0 was chosen for meta-analysis.

RESULTS

A total of seven studies were included in this meta-analysis. Reamed intramedullary nailing was better than nonreamed intramedullary nailing in nonunion rate [P = 0.02, RR = 0.46, 95% CI: (0.24, 0.91)] and implant failure rate [P <0.0001, RR = 0.36, 95% CI: (0.22, 0.57)]. No statistically significant difference was observed in malunion rate, compartment syndrome rate, postoperative infection [P = 0.18, RR = 0.50, 95% CI: (0.18, 1.383); P = 0 43, RR = 0.77, 95% CI: (0.40, 1.48); P = 0.27, RR = 0.38, 95% CI: (0.01, 7.87)].

CONCLUSION

Compared with the nonreamed intramedullary nailing, reamed intramedullary nailing can lead to better outcome in the treatment of closed tibial fractures.

Clinical outcome of ream versus unream intramedullary nailing for femoral shaft fractures

Background

Stabilization of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults; however, to ream or not to ream is still being debated.

Objectives

The primary objective of this study was to determine clinical results following unreamed versus ream intramedullary nailing of femoral fractures.

Patients and Methods

Between January 2008 and August 2009, 50 patients with femoral shaft fractures were treated with unreamed or reamed femoral nails in our clinic. From this prospective single centre study, 16 patients were excluded due to insufficient follow-up data. According to the AO classification, fractures in this study were either type A or B. Dynamic proximal locking was performed in all cases. The remaining 34 patients were divided into two groups of 17 with ream or unream nailing. During and after the operation, we evaluated some variables in whole series.

Results

After statistical analyzes, we found that there were no differences in radiologic union time (P = 1) or full weight bearing time (P = 0.73) between ream and unream nailing. Nail breakage or iatrogenic fractures during nail insertion did not occur and we did not have any fat emboli in both groups but one secondary loss of reduction occurred in the unream group. Superficial infection after the operation was seen in one case which was treated successfully with antibiotics. In the ream group surgical time was about thirty minutes longer and differences were significant (P = 0.000). Patients had to pay more for ream nailing but the difference was not significant. We found no statistical difference between union time with or without reaming; on the other hand, there was significant increased operation length, blood loss and systemic changes in BP or So2 in the ream group versus the unream group.

Conclusions

We advocate that unream nailing in traumatic femoral shaft fractures is a simple, safe and effective procedure with significant advantages, especially in multitrauma patients.

Cortical bone drilling and thermal osteonecrosis

BACKGROUND

Bone drilling is a common step in operative fracture treatment and reconstructive surgery. During drilling elevated bone temperature is generated. Temperatures above 47°C cause thermal osteonecrosis which contributes to screw loosening and subsequently implant failures and refractures.

METHODS

The current literature on bone drilling and thermal osteonecrosis is reviewed. The methodologies involved in the experimental and clinical studies are described and compared.

FINDINGS

Areas which require further investigation are highlighted and the potential use of more precise experimental setup and future technologies are addressed.

INTERPRETATION

Important drill and drilling parameters that could cause increase in bone temperature and hence thermal osteonecrosis are reviewed and discussed: drilling speed, drill feed rate, cooling, drill diameter, drill point angle, drill material and wearing, drilling depth, pre-drilling, drill geometry and bone cortical thickness. Experimental methods of temperature measurement during bone drilling are defined and thermal osteonecrosis is discussed with its pathophysiology, significance in bone surgery and methods for its minimization.

Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes?

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: "fixed" and "bio", avoidance of reaming for the antegrade technique and utilization of "semi-reaming" for the retrograde technique, guidelines for reducing complications, setting the best "timing" for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures.

Thermal necrosis after simultaneous tibial osteotomy and total knee arthroplasty using press-fit extension-stem

One-staged tibial corrective osteotomy and total knee arthroplasty is a challenging but effective treatment for arthritic knees with extra-articular deformity. Although osteocutaneous thermal necrosis is accepted as a complication of intramedullary reamed nailing following long bone fractures, only 15 cases have been reported in the English literature at present. This report illustrates a rare case of thermal necrosis in a patient undergoing tibial corrective osteotomy coincident with long-stemmed total knee arthroplasty. Excessive reaming with a machine reamer is hypothesized as the cause of this serious complication. In this report, we highlight this rare but serious complication after long-stemmed total knee arthroplasty.

The biology of intramedullary reaming

In this review we focus on the local biologic and physiologic effects of intramedullary reaming of long bones. Among the topics discussed are the consequences for vascularity, as well as the pathophysiology of intramedullary pressure generation and temperature increase. Reaming techniques and their suggested effects on bone formation are outlined. Moreover, techniques for avoiding local and systemic complications are summarized.

Establishment of a preclinical ovine model for tibial segmental bone defect repair by applying bone tissue engineering strategies

Currently, well-established clinical therapeutic approaches for bone reconstruction are restricted to the transplantation of autografts and allografts, and the implantation of metal devices or ceramic-based implants to assist bone regeneration. Bone grafts possess osteoconductive and osteoinductive properties; however, they are limited in access and availability and associated with donor-site morbidity, hemorrhage, risk of infection, insufficient transplant integration, graft devitalization, and subsequent resorption resulting in decreased mechanical stability. As a result, recent research focuses on the development of alternative therapeutic concepts. The field of tissue engineering has emerged as an important approach to bone regeneration. However, bench-to-bedside translations are still infrequent as the process toward approval by regulatory bodies is protracted and costly, requiring both comprehensive in vitro and in vivo studies. The subsequent gap between research and clinical translation, hence, commercialization, is referred to as the "Valley of Death" and describes a large number of projects and/or ventures that are ceased due to a lack of funding during the transition from product/technology development to regulatory approval and subsequently commercialization. One of the greatest difficulties in bridging the Valley of Death is to develop good manufacturing processes and scalable designs and to apply these in preclinical studies. In this article, we describe part of the rationale and road map of how our multidisciplinary research team has approached the first steps to translate orthopedic bone engineering from bench to bedside by establishing a preclinical ovine critical-sized tibial segmental bone defect model, and we discuss our preliminary data relating to this decisive step.

Intramedullary nailing of combined/extended fractures of the humeral head and shaft

OBJECTIVES

To evaluate the use of intramedullary nailing in the management of both "combined" and "extended" fractures of the humeral head and shaft.

DESIGN

Retrospective case series study.

SETTING

Level I trauma center.

PATIENTS AND INTERVENTION

Twenty-one consecutive patients who underwent intramedullary nail insertion for "extended" or "combined," closed, nonpathologic fractures of the humeral head and shaft between October 1999 and December 2006 were included in the study. Two patients were lost to follow up and one died before fracture healing.

MAIN OUTCOME MEASUREMENTS

Evaluation of outcomes was assessed with the use of the Constant score.

RESULTS

There were no neurovascular problems or infections. Eighteen fractures united from 4 to 7 months postoperatively. One case of avascular necrosis of the humeral head, one case of acromion impingement, and one case of unacceptable loss of reduction occurred. Shoulder range of motion was not regained fully in any case and mild shoulder discomfort remained in eight patients. The mean Constant score for all 18 patients was 74.4 (range, 20-95) for the affected side and 89.17 points for the uninjured side. The percentage created from the mean affected/unaffected side scores was 83.4%.

CONCLUSIONS

Intramedullary nailing for proximal humeral fractures associated with shaft extension or segmental involvement appears to offer a reliable treatment option.

Osteocutaneous thermal necrosis of the leg salvaged by TSF/Ilizarov reconstruction. Report of 7 patients

Injudicious reaming of the tibial shaft can lead to extreme local hyperthermia, which in turn can result in the rare but catastrophic complication of segmental bone and soft tissue necrosis (osteocutaneous thermal necrosis). This is a retrospective study showing osteocutaneous thermal necrosis occurring after tibial intramedullary reaming salvaged by Ilizarov reconstruction in seven patients from the collective experience of four limb reconstruction centres. All patients were males, with an average age of 51.8 years (range, 30-70 years), who had undergone intramedullary reaming during the treatment of closed tibial fractures. In all patients, circumferential bone and variable contiguous soft tissue necrosis developed a few days after reaming. Bone and soft tissue reconstruction was subsequently performed using a circular external fixator (Ilizarov apparatus or Taylor spatial frame) a mean of four months after injury in six patients; in one case, reconstruction was undertaken four years after the original injury. Two complications (secondary tissue breakdown at a bone transport site; premature consolidation) necessitated cessation of bone transport at one of two bone transport levels in two patients. All patients eventually healed with a good functional result after an average of 11.5 months in the fixator (range, 10-13 months).

Biological rationale for the intramedullary canal as a source of autograft material

Bone harvested by intramedullary reaming offers a minimally invasive alternative to harvesting bone from the iliac crest, which has long been considered the gold standard for autogenous bone grafting. The biologic potential of intramedullary reaming material has been studied both in vitro and in vivo. The material provides osteogenic, osteoinductive, and osteoconductive properties that are comparable to the material harvested from the iliac crest. In addition to the ability to obtain a large volume of bone, the graft harvested by the Reamer-Irrigator-Aspirator has been shown to be rich in growth factors, including BMP-2, TGF-beta1, IGF-I, FGFa, and PDGFbb.

Reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures: a subgroup analysis of randomised trials

The choice between reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures is an ongoing controversy. We carried out a comprehensive search strategy. Six eligible randomised controlled trials were included. Three reviewers independently assessed methodological quality and extracted outcome data. Analyses were performed using Review Manager 5.0. The results showed lower risks of tibial fracture nonunion and implant failures with reamed nails compared to unreamed nails in closed tibial fractures [relative risk (RR): 0.41, 95% confidence interval (CI): 0.21-0.89, P = 0.008 for nonunion and RR: 0.35, 95% CI: 0.22-0.56, P < 0.0001 for implant failures], but no statistical differences in risk reduction of malunion, compartment syndrome, embolism and infection. Our results suggested no statistical differences in risk reduction of all the complications evaluated between reamed and unreamed nails in open tibial fractures. In conclusion, our study recommended reamed nails for the treatment of closed tibial fractures. But the choice for open tibial fractures remains uncertain.

Thermal necrosis complicating reamed intramedullary nailing of a closed tibial diaphysis fracture: a case report

A case report of thermal necrosis of the tibia after reamed intramedullary nailing is presented. Given the consequences of this complication, the proper use of reaming technique and equipment is emphasized.

Effects of bur wear during implant site preparation: an in vitro study

BACKGROUND

Few studies have investigated the influence of drilling on bone healing. After the drilling of bone and placement of dental implants a sequence begins of cellular and molecular events which represents a combined response of wound healing. The bone healing around dental implants is a complex phenomenon and influences the proliferation and differentiation of pre-osteoblasts into osteoblasts, together with the activation of periosteal and endosteal lining cells, and initiates the production and mineralization of osteoid matrix followed by the organization of the bone-implant interface. The objective of this study is to quantify the temperature changes in cortical bone and marrow spaces during implant site preparation in bovine rib bone. A total 10 harvested bovine ribs and 6 10.5 x 3.5 new drills for implant insertion with external irrigation (Bone System, Milano, Italy) were used in this study. The implant sites were prepared with 10 mm long drills at 500 rpm under abundant external irrigation with saline solution at 37 degrees C. Each drill was used for 10, 30, 60, 90 and 120 implant site preparations; each drill was then observed under SEM for evaluation of the damage of the cutting edge after 10, 30, 60, 90 and 120 preparations. There was an higher and statistically significant increase in the temperature in the cortical bone; this increase in temperature increases with the number of the times of drill use. The drill wear seemed to play a major role in heat production and could explain the observed increased temperature of the bone.

Results of the T2 humeral nailing system with special focus on compression interlocking

BACKGROUND

The outcome of interlocking nailing of humeral shaft fractures is controversial. Variations in implants, operative technique and follow-up parameters hinder comparative studies. The aim of this investigation was to evaluate the T2 humeral nailing system according to clinical results, and to recognise advantages and disadvantages of compression interlocking.

METHODS

A total of 36 consecutive humeral shaft fractures were treated with an interlocking humeral nail. In 23 cases the antegrade and in 14 cases the retrograde approach was used. Compression locking was performed in 21 and static locking in 15 cases.

RESULTS

At 22-month follow-up, bone consolidation was present in 35 cases; in 5 cases complications developed. There was no significant difference between compression and static locking nor between the antegrade and retrograde approach regarding complications, Constant shoulder score, mean Morrey elbow score, SF-12 physical score or SF-12 mental score.

CONCLUSION

Antegrade and retrograde interlocking nailing of humeral shaft fractures with the T2 nailing system can result in good functional outcome and unimpaired quality of life. Compression interlocking can minimise the fracture gap and increase the biomechanical stiffness. Potential disadvantages of compression interlocking include possible bending or loosening of the locking screw in the dynamic oblong hole. An additional static locking screw should be used on the humerus after compression interlocking.

Cortical heat generation using an irrigating/aspirating single-pass reaming vs conventional stepwise reaming

OBJECTIVE

To compare the heat generation and pressure generation of a prototype irrigating aspirating intramedullary reaming system to traditional stepwise reaming.

DESIGN

This in vitro study used 8 pairs of fresh-frozen human cadaver tibias. Thermocouples were mounted in the mid-diaphysis and distal diaphysis. A pressure transducer was placed distally to assess intramedullary pressure, a load cell measured axial load was applied by the surgeon, and the entire construct was placed in a 37 degrees C saline bath. One specimen from each pair underwent single-pass reaming with the prototype reamer irrigator aspirator (RIA), and the contralateral limb underwent standard stepwise reaming. All variables were recorded.

RESULTS

There were no significant differences in pressure applied to the load cells during reaming. The maximum temperatures reached in the distal diaphysis in the RIA group (42.0 +/- 9.1 degrees C) were significantly lower (P = 0.025) than in the standard reaming group (58.7 +/- 15.9 degrees C). The maximum pressure generated in the distal tibia in the RIA group (32.7 +/- 39.4 kPa) was significantly higher (P = 0.019) than in the standard reaming group (17.0 +/- 32.6 kPa).

CONCLUSIONS

This study demonstrated substantially decreased temperatures with the RIA prototype when compared with standard stepwise reaming. It appears that the continuous flow of room temperature saline irrigant into the system manages to cool the cortical bone, despite the aggressive nature of a single-pass reaming method. However, in this model, contrary to the findings of other studies, the RIA system did generate higher pressures in the distal tibial metaphysis, perhaps as a result of congestion within the outflow of the RIA system. The results of this study confirm that cortical heat generation is not a problem but definitely indicate further development of this prototype aspirator function is warranted, followed by careful in vivo evaluation.

Intramedullary fixation of tibial shaft fractures using an expandable nail

Interlocking intramedullary nails are the gold standard for treating tibial fractures. We compared the clinical and economic factors associated with tibial fracture fixation using either interlocking intramedullary or expandable nails. From 2000 to 2002, 53 patients with 53 diaphyseal tibial fractures of similar characteristics (AO/OTA 42A1-B3) were randomly and prospectively treated with either interlocking (n = 26) or expandable nails (n = 27). Patients were followed for a minimum of 2 years. The mean surgical duration was 104 minutes with interlocking nails and 52.9 minutes with expandable nails. Rehospitalizations were required in 12 patients (46%) and reoperations were required in nine patients (35%) with interlocking nails. Only one patient (3%) with an expandable nail required rehospitalization and reoperation. Union was achieved after 17 weeks (mean) with interlocking nails and 11.5 weeks with expandable nails. The beneficial economic ramifications of using expandable nails were a 39% reduction in overall surgical and hospital expenses. Expandable nails showed important clinical advantages for tibial fracture fixation, and complications related to lengthy operations, reoperations, and rehospitalizations were substantially reduced. Overall treatment cost was substantially lower with expandable nails. Based on these advantages, simplicity in use, and short surgical time, we recommend an expandable nail for treating tibial (AO Type A, B) shaft fractures.

Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation

Large bony defects and non-unions are still a complication in trauma and orthopedic surgery. Treatment strategies include the use of autogenous materials (iliac crest), allogenic bone, bone substitutes, and currently stimulation with growth factors such as BMP-2, BMP-7 or the growth factors containing platelet-rich plasma (PRP). Another source of bone graft material might be the cuttings produced during intramedullary reaming. The aim of this study was to compare the quantity of various growth factors found within iliac crest, bony reaming debris, reaming irrigation fluid, and platelet-rich plasma. Iliac crest and reaming debris and irrigation samples were harvested during surgery. PRP was prepared from blood. The growth factors in the bony materials (iliac crest or reaming debris) and of the liquid materials (platelet-poor plasma (PPP), platelet-rich plasma (PRP) or reaming irrigation) were compared. Elevated levels of FGFa, PDGF, IGF-I, TGF-beta1 and BMP-2 were measured in the reaming debris as compared to iliac crest curettings. However, VEGF and FGFb were significantly lower in the reaming debris than from iliac crest samples. In comparing PRP and PPP all detectable growth factors, except IGF-I, were enhanced in the platelet-rich plasma. In the reaming irrigation FGFa (no measurable value in the PRP) and FGFb were higher, but VEGF, PDGF, IGF-I, TGF-beta1 and BMP-2 were lower compared to PRP. BMP-4 was not measurable in any sample. The bony reaming debris is a rich source of growth factors with a content comparable to that from iliac crest. The irrigation fluid from the reaming also contains growth factors.

Physical and technical aspects of intramedullary reaming

Intramedullary pressure during reaming is influenced by various factors, including those of the patient, such as bone morphology and location and type of fracture, and those related to reaming technique and instruments. Through intensive research, technical developments and the use of modern materials, intramedullary pressure caused by modern reaming systems can be reduced to a minimum and, perhaps, completely avoided through use of the reaming-irrigation-aspiration system.

Histology of osteosynthesis associated bone infection

The introduction to this paper summarizes the small amount of information currently published on the histological changes that accompany posttraumatic osteomyelitis in man in addition to other information to aid understanding of this topic. The development of three cases of posttraumatic osteomyelitis and the histological analysis of important tissue areas harvested during debridement are described in detail. Two of the patients suffered from diaphyseal fractures, one of which was nailed and the other plated. The third patient had an epi-metaphyseal fracture, which was later plated with the additional use of an autogenous bone graft. The histological examination consisted of embedding the undecalcified tissue specimens in methylmethacrylate and cutting with a diamond saw or a special microtome. Bone necrosis, damaged soft tissue around it, and penetration of bacteria are the prominent etiological features for the onset of osteomyelitis. The distribution of bone necrosis depends mainly on trauma, the care of the surgeon, and the type of osteosynthesis. Loose dead bone and bone pieces demarcated by osteoclastic activity are transformed into sequestra surrounded by tissue that exhibits different infection activities according to the state of spontaneous development or treatment. Remodeling of bone necrosis from the living bone is slow and depends on many factors. New bone formation is mainly subperiosteal, embedding osteomyelitic areas if the periosteum is not destroyed.

Intramedullary fixation of tibial shaft fractures using an expandable nail: early results of 54 acute tibial shaft fractures

OBJECTIVE

To evaluate and present our experience using the expandable nail system for the treatment of acute tibial shaft fractures.

DESIGN

Retrospective study.

SETTING

Two level-1 trauma centers-University teaching hospitals.

METHODS

Fifty-four consecutive patients were treated by this nail system for acute tibial shaft fracture. Two nail diameters were used, 8.5 mm and 10 mm. Operation, hospitalization and healing times, reaming versus nonreaming, isolated versus multiple injuries, and reoperations were recorded and analyzed statistically.

RESULTS

Follow-up was obtained either until fracture healing or for a minimum of 1 year with an average of 14 months (12 to 24). All fractures healed in an average time of 72 days (21 to 204). The average healing times for patients treated with 8.5-mm and 10-mm nails were 77.2 days (27 to 204) and 63.4 days (21 to 121), respectively. Average operative time was 103 minutes (40 to 185) if reamed and 56 minutes (30 to 80) if unreamed. Average healing times were 65.4 days (21 to 190) if reamed and 79.5 days (42 to 204) if unreamed. There were 11 complications (20.4%) related to the nailing: 3 deep infections, 2 superficial infections, 2 bone shortenings of 1 cm secondary to nail protrusion in the knee, 1 compartment syndrome, 1 fracture propagation, 1 distal malalignment, and 1 delayed union. Hardware was removed in 6 patients (3 infections, 2 patients' request and 1 protrusion into the knee), and 1 additional patient underwent exchange nailing due to a delayed union.

CONCLUSIONS

The expandable nail offers the theoretical advantages of improved load sharing and rotational control without the need for interlocking screws. This study demonstrates satisfactory healing and alignment for the treatment of tibial shaft fractures using this device. However, caution must be exercised when using this nail in cases of significant comminution and in cases where the fracture pattern involves the more proximal or distal aspect of the tibial shaft.

Diagnosis and treatment of infections associated with fracture-fixation devices

The pathogenesis of infections associated with fracture-fixation devices is related to microorganisms growing in biofilms, which render these infections difficult to treat. These infections are classified as early (<2 weeks), delayed (2-10 weeks) or late infections (>10 weeks) according to the implant surgery. Most infections are caused by staphylococci and are acquired during trauma (in penetrating injuries) or subsequent fracture-fixation procedures. A combination of clinical, laboratory, histopathology, microbiology, and imaging studies are usually needed to accurately diagnose infection. Magnetic resonance imaging (MRI) and computed tomography (CT) scans are often used to diagnose infection and plan surgical treatment. Positron emission tomography (PET) and PET-CT are promising new tools for diagnosing implant-associated osteomyelitis. The treatment goal is achieving bone consolidation and avoiding development of chronic osteomyelitis. Successful treatment requires adequate surgical procedures combined with 6-12 weeks of antimicrobial therapy acting on adhering stationary-phase microorganisms. In chronic osteomyelitis, orthopedic and plastic- reconstructive surgery is combined in the same procedure or within a short time span. In this article, pathogenesis, classification, diagnosis, and treatment of infections associated with intramedullary nails, external-fixation pins, plates, and screws are reviewed.

Bohrmehl: Eine Quelle vitaler Zellen!

Reaming debris is generated in the course of intramedullary reaming of long bones. Up to now there has been little information about the composition of reaming debris. Especially, it remains to be elucidated if reaming debris contains vital cells. The goal of the present vitro investigation has been the harvest of cells from human reaming debris and the subsequent characterization of the cells. 21 specimens of human reaming debris have been investigated. Each specimen has been divided into two parts. One part has been examined by means of transmission electron microscopy while the other part of each specimen has been transferred into culture dishes. The developing cell cultures were characterized by using FACS analysis and were incubated within osteogenic, adipogenic and chondrogenic differentiation media. The results of electron microscopy have revealed the presence of both, vital cells and massively altered cells. Cell growth occurred after initial plating of all specimens. The cells which were grown within the culture dishes could be characterized as mesenchymal stem cells on the basis of their morphology, differentiation capacity and antigen profile. Based upon these results reaming debris has to be regarded as a source of vital mesenchymal stem cells. It remains to be elucidated, if reaming debris can be used as an alternative to bone tissue grafting.

Does graded reaming affect the composition of reaming products in intramedullary nailing of long bones?

Reaming products taken during intramedullary nailing were examined to identify possible differences in their composition depending on the reaming percentage. Reaming products were taken from 39 fresh closed tibial and femoral diaphyseal fractures in patients with an average age of 29 years. According to histology, reaming products mainly consisted of bone trabeculae, viable or nonviable, and bone marrow stroma. A statistically significant reverse correlation exists between viable bone mass percentage and reaming progress. Reaming 1 mm less than the minimum canal diameter provides a higher viable bone mass percentage, which might be an important factor in the bone healing process.

Complications of locked nailing in humeral shaft fractures

BACKGROUND

The purpose of this study was to investigate the complications of humeral locked nailing.

METHODS

Between 1994 and 2000, 161 humeral shaft fractures (98 acute fractures and 63 delayed unions or nonunions) in 159 patients treated with humeral locked nails were followed up for an average of 25.4 months. There were 89 men and 70 women, with an average age of 53.5 years. Acute fractures included 68 closed, 18 type I, 8 type II, 3 type IIIA, and 1 type IIIB open fractures. Thirty-six nonunions had previous operations. In general, acute fractures were treated with closed nailing and nonunions were treated with open nailing with bone grafting. Since 1998, interfragmentary wiring has been added in nonunions to compress the fracture.

RESULTS

In total, 30 patients had 31 significant complications. Nine of them were persistent nonunions, six from acute fractures and three from nonunions. Fracture gap was associated with a significantly higher risk of nonunion. The risk of operative comminution was significantly higher in retrograde nailing, and operative comminution resulted in a significantly higher risk of nonunion. Seven of the nine nonunions underwent revisional nailing and achieved eventual union. Removal of the protruded screws was performed in two cases. Other complications included shoulder impairment, elbow impairment, angular malunion, and post-nailing radial nerve palsy.

CONCLUSION

Many complications of humeral locked nailing can be prevented by improving the implant design or surgical techniques. The patients with persistent nonunion can be reliably treated by revisional nailing and bone grafting.

Current practice in the intramedullary nailing of tibial shaft fractures: an international survey

BACKGROUND

Tibial fractures are the most common of all long bone fractures. Although many tibial fractures may be managed conservatively, a certain subset, including unstable fractures and open fractures, require operative stabilization. Intramedullary nails have become the popular choice of implant in the treatment of tibial shaft fractures. The variability in outcomes with tibial shaft fractures may reflect technical aspects of the surgical procedure and perioperative care regimens among surgeons. Identifying the distribution of surgeons' preferences in nailing technique, and the rationale for their choices, will aid in focusing educational activities for the orthopedic community and planning future clinical trials. Our objectives were to clarify surgeons' opinions regarding technical aspects of surgery and perioperative care after intramedullary nailing of closed and open tibial shaft fractures, and to identify predictors of surgeons' preferences in technique and perioperative care.

METHODS

This study was a cross-sectional survey using focus groups, key informants, and sampling to redundancy strategies to develop a survey to examine surgeons' preferences in the treatment of tibial shaft fractures. The survey was pilot tested for clarity and content validity. We mailed this survey in July 2000 to 577 orthopedic surgeons who have an interest in trauma care. These were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, or European AO International affiliated trauma centers. We used several strategies to improve response rates including personalized cover letters, stamped return envelopes, follow-up telephone calls, and repeat mailing of questionnaires. Main outcome measures included technical issues such as reduction, exposure, intramedullary reaming, and interlocking screws; and factors associated with surgeons' preferences such as age, fellowship, academic practice, and geographic location.

RESULTS

Four hundred forty-four surgeons (77%) responded. Sixty percent of respondents had an academic practice, 84% supervised residents, and 65.1% had fellowship training in trauma. Approximately half (51.5%) of surgeons used a tourniquet. The odds that a surgeon in Asia or Africa used tourniquets was 10 times that of a North American surgeon (p = 0.004 and p = 0.002, respectively). Patellar tendon retraction and an inferior-based entry portal was the popular choice among surgeons (70.1% and 70.8%, respectively). Surgeons from Australia (odds ratio [OR] = 50, p < 0.001), South America (OR = 9.0, p < 0.001), Europe (OR = 3.7, p = 0.001), and Asia (OR = 3.8, p = 0.006) were significantly more likely to use a patellar splitting approach compared with North American surgeons. In the perioperative care of open tibial shaft fractures, there was consensus in the use of intravenous antibiotics and wound irrigation (96.5% and 95.6%, respectively). However, we found considerable variability in surgeons' preference in wound irrigation pressures (high, 38.7%; low, 45.4%). Surgeons in South America were 10 times more likely to use low-pressure irrigation than North American surgeons (p = 0.0005). In grade IIIB open tibial shaft fractures, 94% of surgeons believed wound closure should be obtained within the first 7 days after the injury. A surgeon's geographic location was a significant predictor of the timing of soft tissue coverage (p = 0.001).

CONCLUSION

Consensus in the use of irrigation and intravenous antibiotics in open fractures was achieved among surgeons. However, there remains considerable variability in the surgical technique of intramedullary nailing, the duration of antibiotic use, and the timing of wound closure in open tibial fracture care. Continued education and large multicenter trials are needed to establish best practice in the operative treatment of tibial shaft fracture.