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

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.

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.

Intramedullary Nail Fixation of Tibial Shaft Fractures: Suprapatellar Approach

Intramedullary nailing is the most popular and widely used method for treating tibial shaft fractures. Intramedullary nailing involves minimal surgical dissection, allowing preservation of blood supply by not disrupting the soft tissue around the fracture. The procedure is performed with the following steps: (1) the patient is positioned supine on the radiolucent operating table with a bump under the ipsilateral hip; (2) a 4 to 6-cm longitudinal incision is made 2 to 4 cm directly proximal to the superior pole of the patella; (3) the quadriceps tendon is sharply incised at its midline and split longitudinally; (4) a cannula device with a blunt trocar and protective sleeve is inserted into the knee joint between the articular surface of the patella and the trochlea of the distal part of the femur, after which a second pin can be inserted through the cannula device and into the distal part of the femur to stabilize the cannula and keep it from backing out; (5) a 3.2-mm guide pin is inserted and placed resting at the junction of the articular surface and the anterior cortex of the tibia at the appropriate starting point in line with the intramedullary canal; (6) the guide pin is advanced 8 to 10 cm into the proximal part of the tibia, the inner centering sleeve is removed, and the cannulated entry drill is passed over the pin through the outer protective sleeve and used to ream down to the metadiaphyseal level of the proximal part of the tibia; (7) the fracture is reduced; (8) a ball-tipped guidewire is centrally passed across the fracture down to the level of the distal tibial physeal scar; (9) incremental reaming is performed, and the appropriate-size tibial nail is inserted down the tibial canal; (10) the appropriate nail position is confirmed radiographically, and distal interlocking screws are placed with a freehand technique, after which the proximal aiming arm is attached to the insertion handle and interlocking screws are drilled, measured, and placed into the proximal part of the tibia as well; and (11) all incisions as well as the quadriceps tendon are closed. Intramedullary nail fixation is a safe and effective method for treating tibial shaft fractures, and with appropriate surgical technique good outcomes and reproducible results can be expected. This soft-tissue-sparing method of fracture fixation achieves biomechanical stabilization of the fracture using a load-sharing device that allows for earlier postoperative ambulation.

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.

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.

Tourniquet in surgery of the limbs: a review of history, types and complications

CONTEXT

A tourniquet is a device that is used frequently in most orthopaedic surgeries but this routine device can lead to serious complications so we decided to review and declare it for safe instruction and use.

EVIDENCE ACQUISITION

We searched the word "tourniquet" in PubMed and Google and reviewed all full text English articles and abstracts of non-English articles. In addition, we read all the reference pages of articles to find the new references.

RESULTS

The use of tourniquet in orthopedic surgery can lead to serious but rare complications that can be prevented by its correct knowledge and use.

CONCLUSIONS

At present, there is not enough evidence to discontinue the routine uses of tourniquets.

Effect of minimally invasive percutaneous plates versus interlocking intramedullary nailing in tibial shaft treatment for fractures in adults: a meta-analysis

OBJECTIVE

The aim of this article was to determine the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults.

METHOD

Literature searches of the Cochrane Library, PubMed, EMBASE, the Chinese Biomedical Literature database, the CNKI database, Wanfang Data, and the Weipu Journal database were performed up to August 2013. Only randomized and quasi-randomized controlled clinical trials comparing the use of percutaneous plates and interlocking intramedullary nails for tibial shaft fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards.

RESULTS

Eleven trials were included. Compared with interlocking intramedullary nailing, minimally invasive percutaneous plates shortened fracture healing time and resulted in lower rates of postoperative delayed union and pain. There was no significant difference between the two methods with regard to the rates of excellent and good Johner-Wruh scoring, the rate of reoperation, and other complications.

CONCLUSIONS

Overall, insufficient evidence exists regarding the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults. Low-quality evidence suggests that minimally invasive percutaneous plates could shorten fracture healing time, decrease the rate of postoperative delayed union, and decrease pain levels compared with interlocking intramedullary nailing. There is no significant difference between the two groups in terms of functional recovery scores, reoperation, and other complications. Further research that includes high-quality randomized controlled, multicenter trials is required to compare the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults.

Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review

INTRODUCTION

Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults.

METHODS

Cochrane Central Register of Controlled Trials (October 2010), PubMed (October 2010) and EMBASE (October 2010) were searched. Randomized and quasi-randomized controlled clinical trials were included. After independent study selection by two authors, data were collected and extracted independently. The methodological quality of the studies was assessed. Pooling of data was undertaken where appropriate.

RESULTS

Seven trials with 952 patients (965 fractures) were included. Compared with unreamed nailing, reamed nailing was significantly lower reoperation rate (RR 0.25, 95% CI 0.11-0.59, P = 0.002), lower non-union rate (RR 0.20, 95% CI 0.05-0.77, P = 0.02) and lower delay union rate(RR 0.30, 95% CI 0.14-0.64, P = 0.002). There was no significant difference when comparing reamed nailing with unreamed nailing for implant failure (RR 0.51, 95% CI 0.16-1.61, P = 0.25), mortality(RR 0.94, 95% CI 0.19-4.58, P = 0.94) and acute respiratory distress syndrome(RR 1.53, 95% CI 0.37-6.29, P = 0.55). Unreamed nailing was significantly less blood loss (SMD 119.23, 95% CI 59.04-180.43, P = 0.0001).

CONCLUSION

Reamed intramedullary nailing has better treatment effects than unreamed intramedullary nailing for shaft fracture of femur in adults.

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.

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).