1
|
DeBaun MR, Barei DP, Ricci WM, Campbell ST. Updated Blocking Techniques for Lower Extremity Medullary Nailing: Beyond the Concavity of Deformity. J Am Acad Orthop Surg 2023; Publish Ahead of Print:00124635-990000000-00720. [PMID: 37294617 DOI: 10.5435/jaaos-d-22-00243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/01/2023] [Indexed: 06/11/2023] Open
Abstract
Modern blocking techniques are useful to achieve anatomic alignment and stable fixation during end-segment nailing. Whether with screws or drill bits, blocking implants can correct both angular and translational deformities. Understanding the biomechanics of blocking implants allows the surgeon to properly plan their placement based on principles rather than dogma. We use case examples to highlight updates in blocking techniques during acute surgical fixation and chronic deformity correction.
Collapse
Affiliation(s)
- Malcolm R DeBaun
- From the Department of Orthopaedic Surgery, Duke University, Durham, NC (DeBaun), Department of Orthopaedics and Sports Medicine, Harborview Medical Center, Seattle, WA (Barei), Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY (Ricci), Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Campbell)
| | | | | | | |
Collapse
|
2
|
Kook I, Park KC, Kim DH, Sohn OJ, Hwang KT. A multicenter study of factors affecting nonunion by radiographic analysis after intramedullary nailing in segmental femoral shaft fractures. Sci Rep 2023; 13:7802. [PMID: 37179404 PMCID: PMC10183035 DOI: 10.1038/s41598-023-34939-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 05/10/2023] [Indexed: 05/15/2023] Open
Abstract
The factors affecting the outcomes of segmental femoral shaft fractures are currently unknown. We evaluated the outcomes of intramedullary (IM) nail fixation and investigated factors affecting nonunion of femoral shaft segmental fractures. A total of 38 patients who underwent IM nail fixation for femoral shaft segmental fractures (AO/OTA 32C2) at three university hospitals with a minimum 1-year follow-up period were retrospectively reviewed. The patients were divided into union (n = 32) and nonunion (n = 6) groups. We analyzed smoking status, diabetes mellitus, location of the segmental fragment, segment comminution, filling of the IM nail in the medullary canal, residual gap at the fracture site, use of a cerclage wire or blocking screws as factors that may affect the surgical outcome. In the union group, the average union time was 5.4 months (4-9 months). In the nonunion group, five patients required additional surgery within an average of 7.2 months (5-10 months) postoperatively, whereas one patient remained asymptomatic and did not require further intervention. On comparing the two groups, insufficient canal filling of the IM nail (union, 25.0%; nonunion, 83.3%; p = 0.012) and the presence of a residual gap at the fracture site after reduction (union, 31.3%; nonunion, 83.3%; p = 0.027) were significantly different. In the multivariate analysis, only insufficient canal filling of the IM nail was found to be a factor affecting nonunion, with an odds ratio of 13.3 (p = 0.036). In this study, a relatively high nonunion rate (15.8%) was observed after IM nail fixation. Insufficient IM nail canal filling and a residual gap at the fracture site post reduction were factors affecting segmental femoral shaft fracture nonunion after IM nail fixation.
Collapse
Affiliation(s)
- Incheol Kook
- Department of Orthopaedic Surgery, Hanyang University Hospital, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Ki-Chul Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri-si, Gyeonggi-do, Republic of Korea
| | - Dong-Hong Kim
- Department of Orthopaedic Surgery, Hanyang University Hospital, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Oog-Jin Sohn
- Department of Orthopaedic Surgery, Yeungnam University Hospital, 170 Hyeonchung-ro, Nam-gu, Daegu, Republic of Korea
| | - Kyu Tae Hwang
- Department of Orthopaedic Surgery, Hanyang University Hospital, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
| |
Collapse
|
3
|
Walcher MG, Day RE, Gesslein M, Bail HJ, Kuster MS. Augmentative Plating versus Exchange Intramedullary Nailing for the Treatment of Aseptic Non-Unions of the Femoral Shaft-A Biomechanical Study in a Sawbone TM Model. J Pers Med 2023; 13:jpm13040650. [PMID: 37109036 PMCID: PMC10142865 DOI: 10.3390/jpm13040650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Non-unions after intramedullary nailing of femoral shaft fractures are a significant problem. Treatment options such as augmenting with plates or exchange nailing have been proposed. The ideal treatment remains controversial. METHODS Augmentative plating using a 4.5 mm LCP or a 3.2 mm LCP leaving the nail in situ was tested biomechanically and compared to exchange intramedullary nailing in a SawboneTM model of a femoral shaft non-union. RESULTS The difference of fracture gap motion in axial testing was small. In rotational testing, the exchange nail allowed for the largest amount of motion. The 4.5 mm augmentative plate was the most stable construct in all loading conditions. CONCLUSIONS Augmentative plating using a 4.5 mm LCP plate while leaving the nail in situ is biomechanically superior to exchange intramedullary nailing. A small fragment 3.2 mm LCP is undersized and does not reduce fracture motion sufficiently in a femoral shaft non-union.
Collapse
Affiliation(s)
- Matthias Georg Walcher
- OC Würzburg, Oeggstr. 3, 97070 Würzburg, Germany
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Robert E Day
- Health Technology Management Unit, Royal Perth Hospital, University of Western Australia, 197 Wellington Street, Perth 6000, Australia
| | - Markus Gesslein
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Hermann Josef Bail
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Markus S Kuster
- Perth Orthopaedic Sports Medicine Centre, The University of Western Australia, 31 Outram Street, Perth 6005, Australia
| |
Collapse
|
4
|
Optimal blocking screw placement for retrograde IM nail fixation of distal femur fracture: a standardized biomechanical study of "osteoporotic" synthetic bone. Arch Orthop Trauma Surg 2022; 142:3827-3835. [PMID: 34981191 DOI: 10.1007/s00402-021-04280-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/24/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE Intramedullary (IM) nail use for metaphyseal fracture management is problematic in long bones like the femur because the larger medullary cavity allows increased fracture motion and potentially increased implant failure and malunion/nonunion risk; Achieving effective distal femur fracture fixation is even more difficult in osteoporotic bone. Blocking screws to control IM nail movement are known to be effective for tibia fracture management. Few studies have evaluated IM nail and blocking screw use efficacy for distal femur fracture fixation in osteoporotic bone. METHODS This study used an osteoporosis simulation synthetic bone model to evaluate retrograde IM nail fixation of a standardized non-comminuted, extra-articular distal femur fracture with and without blocking screws. The hypothesis was that use of one or two blocking screws would increase IM nail fixation stability as evidenced by greater peak IM nail load and lesser movement. A servohydraulic device under displacement control collected loading force versus movement deflection data. Shapiro-Wilk tests confirmed data normality. One-way analysis of variance and Tukey post hoc tests were used to compare condition specific loading force and movement differences. RESULT In the coronal plane, blocking screw conditions displayed greater loading ranges (38.3 ± 2 vs. 19.1 ± 2 N, 100.5% difference) (p < 0.0001) and lesser movement (2.0 ± 0.3 vs. 6.86 ± 0.4 mm, 243% difference) (p < 0.0001). In the sagittal plane, the two blocking screw condition displayed a significantly greater loading magnitude (29.9 ± 6 vs. 20.8 ± 2.3 N, 43.8% difference) than the identical control condition without blocking screws (p = 0.018); however, movements were comparable (p = 0.82). Long-axis rotational loading failed to reveal load magnitude differences (p = 0.28); however, two different blocking screw conditions displayed decreased movement (1.32 ± 0.2 vs. 2.05 ± 0.3 mm, 53.8% difference) compared to other conditions (p ≤ 0.018). CONCLUSIONS Use of one or two blocking screws on the medial and lateral sides of the IM nail decreased coronal plane movement in the intramedullary canal. Combining retrograde IM nail implantation with blocking screws reduced medial-lateral IM nail movement and increased fracture stability. These characteristics may help prevent fixation failure, malunion, and even nonunion in patients with a distal femur fracture in osteoporotic bone.
Collapse
|
5
|
Contemporary management of aseptic diaphyseal tibia non-unions - A systematic review. Orthop Traumatol Surg Res 2022; 108:102990. [PMID: 34146753 DOI: 10.1016/j.otsr.2021.102990] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/22/2020] [Accepted: 02/16/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Tibia fractures are the most common long bone injuries encountered in the trauma population. The majority are treated successfully but non-union remains a common complication. A systematic review of current evidence regarding the management for aseptic diaphyseal tibial non-unions was undertaken. METHODS A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), was conducted. RESULTS A total of 632 publications were screened for inclusion. Full text review of 91 studies resulted in 26 publications being retained for final review. The majority of patients included in the studies either underwent exchange nailing (n=315) or primary intramedullary nailing (n=174) with respective union rates of 88% and 95% being achieved. The highest union rate (97%) was achieved with the use of fine wire external fixation. The major adjuvant treatment modalities were fibula osteotomies (n=372; 41%), fixation dynamization (n=208; 23%) and bone grafting (n=183; 20%). CONCLUSION The lack of standardization in reporting of outcomes and the diversity of management strategies employed precludes definitive conclusions or recommendations. Further research is required to ascertain the ideal treatment strategy in the management of aseptic tibial diaphyseal non-unions. LEVEL OF EVIDENCE IV.
Collapse
|
6
|
Chmali K, ElIdrissi M, Abid H, ElIbrahimi A, Berraho M, ELMrini A. Aseptic nonunion of the tibia treated by plating and bone grafting: retrospective study about 40 cases. J Orthop Surg Res 2022; 17:321. [PMID: 35729609 PMCID: PMC9210817 DOI: 10.1186/s13018-022-03216-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The objective of this study was to evaluate the clinical and radiological results of the treatment of aseptic nonunion of the tibia by plating and bone grafting. Material and Methods This retrospective study included 40 patients with aseptic nonunion of the tibia, treated in the Trauma-Orthopedic department B4 of CHU Hassan II in Fez-Morocco. The average age was 41 years (range 25–60 years). The initial fractures were in the middle third of the tibia for the majority of our patients. We used the ASAMI criteria to assess the results.
Results We found 45 patients with aseptic nonunion of the tibia who were treated by the same surgical team and followed in postoperative consultation for a fixed period of 10 months. Three patients lost to follow-up and two patients refused the treatment. In 37 patients (92.5%), union was obtained after a mean delay of 4.3 months (range 3–7 months). The average time from initial treatment to treatment for nonunion was eight months (range 6–10 months). According to the ASAMI classification, bone results were excellent in 26, good in 8, fair in 3 and poor in 3; functional results were excellent in 10, good in 16, fair in 11 and poor in 3.
Conclusions Our study suggests that the combination of screwed plate and autograft in the treatment of aseptic nonunion of the tibia has provided satisfactory results. A well-codified management of the initial fracture remains the gold key to prevent the occurrence of pseudarthrosis.
Collapse
Affiliation(s)
- Khalid Chmali
- Surgery Department, CHP La Marche Verte, Boulemane, Morocco.
| | | | - Hatim Abid
- Trauma-Orthopedic Department B4, CHU Hassan II, Fez, Morocco
| | | | - Mohamed Berraho
- Laboratory of Epidemiology, Clinical Research and Community Health, USMBA-FMPDF, Fez, Morocco
| | | |
Collapse
|
7
|
Poller (blocking) screw with intramedullary femoral nailing for subtrochanteric femoral non-unions: clinical outcome and review of concepts. Eur J Trauma Emerg Surg 2021; 48:1295-1306. [PMID: 33835188 DOI: 10.1007/s00068-021-01651-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Surgery to treat nonunion resulted from malalignment is challenging since correction and bone union should be achieved simultaneously. To report the clinical outcomes achieved through reconstruction of sub-trochanteric femoral fractures by femoral nailing using a poller screw and to review the current concepts. MATERIALS AND METHODS Fourteen patients (11 men and 3 women; mean age 56.4 years) who were diagnosed with non-union of subtrochanteric femoral fractures and who underwent intramedullary nailing with blocking screws between August 2013 and March 2019, with at least 1 year follow-up, were analyzed retrospectively. The preoperative and postoperative Centrum-Collum-Diaphyseal angle and anterior angulation angle were measured. Bone union time, position and number of poller screws used, and complications were analyzed. Functional assessment was performed by evaluating the Harris hip score. The related literature was searched, and 14 clinical studies on the treatment of sub-trochanteric non-union were analyzed. RESULTS Bone union was achieved in 12/14 cases (85.7%) at the final follow-up within a mean of 6.52 (3-12) months. Bone union was also achieved in two patients lacking bone union at the final follow-up through bone grafting and augmented plating. No cases developed complications, including infection and bone necrosis, and the varus deformity and anterior angulation significantly improved from a preoperative mean of 12.4° and 9.4° to postoperative mean 3.8° and 2.4°, respectively. The mean Harris hip score at the final follow-up was 87.07 (73-98) points. Analysis of published literature revealed high rates of bone union (78-100%) through various fixation methods. CONCLUSION Correction with blocking screws and rigid fixation with intramedullary nailing to treat sub-trochanteric-non-union-caused malalignment can yield good clinical and radiological outcomes.
Collapse
|
8
|
Outcome Analysis of Intramedullary Nailing Augmented with Poller Screws for Treating Difficult Reduction Fractures of Femur and Tibia: a Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6615776. [PMID: 33869628 PMCID: PMC8035000 DOI: 10.1155/2021/6615776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/23/2021] [Accepted: 03/21/2021] [Indexed: 11/17/2022]
Abstract
Purpose Poller screws may serve as an adjunctive reduction tool and aid fracture reduction while augmented with intramedullary (IM) nailing for treating diaphyseal or metaphyseal fractures of the femur and tibia. However, there is no consistent conclusion about whether the method of using IM nailing augmented with poller screws is more advantageous than using IM nailing alone. Methods A total of 96 patients who received IM nailing with or without supportive poller screw for treating long-bone fractures in lower limbs and who experienced difficulties in performing reduction or IM insertion during the surgical process were included in this retrospective cohort study (33 patients with poller screws in group A versus 63 patients without poller screws in group B). Patient demographics including age, gender, and body mass index; injury-related data including fracture location, classification, and injury mechanism; operation-related data including American Society of Anesthesiologists, duration of operation, poller screw time, method of anesthesia, and volume of intraoperative hemorrhage; outcomes including fracture healing time; and incidence of outcomes of nonunion, malunion, infection, and secondary surgical procedures were evaluated. Results Fracture healing time of patients in group A was significantly shorter than that of group B (18.3 ± 4.8 weeks versus 24.3 ± 3.0 weeks, p = 0.023). Union rate was higher (100.0% versus 87.3%, p = 0.048), and malunion rate and secondary surgical procedure rate were lower (both are 3.0% versus 19.0%, p = 0.031) in group A than that of group B. Conclusion Poller screw augmentation of IM nailing is a favourable option to shorten fracture healing time and to reduce complication rates in terms of nonunion, malunion, and secondary surgical procedure in the treatment of both diaphyseal/metaphyseal fractures of the femur or tibia while compare with those treated by IM nailing alone.
Collapse
|
9
|
Tennyson M, Krkovic M, Fortune M, Abdulkarim A. Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture. EFORT Open Rev 2020; 5:189-203. [PMID: 32296553 PMCID: PMC7144892 DOI: 10.1302/2058-5241.5.190040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous. We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling. Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only. The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03–0.07), coronal plane malunion (5%, CI: 0.03–0.08), deep (5%, CI: 0.03–0.11) and superficial (6%, CI: 0.03–0.11) infections, and secondary procedures (8%, CI: 0.04–0.18). When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits.
Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040
Collapse
Affiliation(s)
- Maria Tennyson
- Department of Trauma & Orthopaedic Surgery, Cambridge University Hospital, Cambridge, UK
| | - Matija Krkovic
- Department of Trauma & Orthopaedic Surgery, Cambridge University Hospital, Cambridge, UK
| | - Mary Fortune
- The Department of Public Health & Primary Care, Strangeways Research Laboratory, Cambridge, UK
| | - Ali Abdulkarim
- Department of Trauma & Orthopaedic Surgery, Cambridge University Hospital, Cambridge, UK
| |
Collapse
|
10
|
Jin YF, Xu HC, Shen ZH, Pan XK, Xie H. Comparing Augmentative Plating and Exchange Nailing for the Treatment of Nonunion of Femoral Shaft Fracture after Intramedullary Nailing: A Meta-analysis. Orthop Surg 2020; 12:50-57. [PMID: 31894655 PMCID: PMC7031579 DOI: 10.1111/os.12580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/14/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022] Open
Abstract
Objective The aim of this meta‐analysis was to systematically evaluate the efficacy of augmentative plating (AP) and exchange nailing (EN) in the treatment of nonunion of femoral shaft fracture. Methods For the present meta‐analysis, PubMed, EMBASE, and the Cochrane Library were searched to identify relevant articles up to April 2019. Two investigators independently evaluated the quality of original publications following the guidelines proposed by the Cochrane Handbook. Data were extracted from the studies and analyzed using Review Manager 5.3. Results Five studies were included in this meta‐analysis, with a total of 506 patients. There were 232 patients in the AP group and 276 patients in the EN group. The AP group was associated with higher union rate (OR, 11.66; 95% CI, 4.31–31.50; P < 0.01), shorter union time (SMD, −1.10; 95% CI, −2.09 to −0.11; P = 0.03), shorter operation time (SMD, −0.55; 95% CI, −0.88 to −0.21; P < 0.01), less blood loss (SMD, −1.72; 95% CI, −3.33 to −0.11; P < 0.01), and fewer complications (OR, −0.11; 95% CI, −0.16 to −0.07; P < 0.01) than the EN group. Conclusion The results of the meta‐analysis showed that AP is found to be superior for nonunion of femoral shaft fractures in both intraoperatively (ie, shorter operation time and less blood loss) and postoperatively (ie, higher union rate, shorter union time, and lower complication rate). Overall, AP was superior to EN in the treatment of nonunion of femoral shaft fractures after intramedullary nailing (IMN).
Collapse
Affiliation(s)
- Yao-Feng Jin
- Department of Orthopaedics Surgery, The Second Affiliated Hospital of Jiaxing University, Zhejiang, China
| | - Hai-Chao Xu
- Department of Orthopaedics Surgery, The Second Affiliated Hospital of Jiaxing University, Zhejiang, China
| | - Zhong-Hai Shen
- Department of Orthopaedics Surgery, The Second Affiliated Hospital of Jiaxing University, Zhejiang, China
| | - Xue-Kang Pan
- Department of Orthopaedics Surgery, The Second Affiliated Hospital of Jiaxing University, Zhejiang, China
| | - Hui Xie
- Department of Orthopaedics Surgery, The Second Affiliated Hospital of Jiaxing University, Zhejiang, China
| |
Collapse
|
11
|
Abstract
OBJECTIVES (1) Identify factors that predict blocking screw placement in the treatment of a distal femur fracture with retrograde nail fixation and (2) determine whether acceptable alignment and stability were achieved in fractures that received blocking screws. DESIGN Retrospective Comparative Study. SETTING Level I Trauma Center. PATIENTS/PARTICIPANTS Between 2011 and 2017, we identified 84 patients with distal third femur fractures treated with a retrograde femoral nail. Data were analyzed according to those who did (BLOCK, n = 30) and did not (NO BLOCK, n = 54) receive blocking screws. Patients in both groups were treated by orthopaedic trauma surgeons; postoperative weight-bearing radiographs were obtained of every patient. INTERVENTION Fixation using a retrograde femoral nail with or without blocking screws. Blocking screws were placed at the discretion of the treating surgeon to reduce malaligned fractures or improve stability. MAIN OUTCOME MEASUREMENTS (1) Demographics, radiographic apparent bone gap (RABG), space available for the nail (SAFN), and distal segment length [as a ratio of bicondylar width (BCW)]; and (2) post-operative alignment and stability (change in alignment over time). RESULTS Patients treated with blocking screws had a higher body mass index (BMI) (BLOCK: 29.0, NO BLOCK 25.7, P = 0.03). In addition, the BLOCK group had larger RABGs (BLOCK: 8.2 mm, NO BLOCK: 3.6 mm, P = 0.02), more SAFN (BLOCK: 51.4 mm, NO BLOCK: 39.8 mm, P = 0.02), and shorter distal segments (BLOCK: 1.7 × BCW, NO BLOCK: 2.0 × BCW, P = 0.01). In a multivariable logistic regression, the combination of these factors was significantly predictive of blocking screw placement with a large effect size (R = 0.36, P < 0.01). A distal segment length ≤ ×2 BCW was 77% sensitive for blocking screw placement, and a BMI ≥25 kg/m was 70% sensitive. Negative predictive values for blocking screw placement were distal segment length > ×2 BCW (79%), BMI <25 kg/m (77%), RABG <4 mm (76%), and SAFN <50 mm (71%). Patients that received blocking screws had acceptable postoperative alignment and stability, similar to fractures that did not receive blocking screws (P > 0.05). CONCLUSIONS This retrospective study of distal femur fractures treated with retrograde nails identified several factors that can be used to predict when blocking screw placement may be useful for increasing stability and maintaining alignment in distal third femur fractures treated with retrograde IM nails. Patients treated with blocking screws had a higher BMI, greater cortical bone loss, more SAFN, and shorter distal segments. There was no difference in postoperative alignment or stability between the 2 groups. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
12
|
Dabash S, Zhang DT, Rozbruch SR, Fragomen AT. Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction. Strategies Trauma Limb Reconstr 2019; 14:77-84. [PMID: 32742418 PMCID: PMC7376586 DOI: 10.5005/jp-journals-10080-1430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Historically, blocking screws have been used to assist in acute reduction of fractures during intramedullary (IM) nailing. The reverse-rule-of-thumbs (RROT) for blocking screws was introduced to facilitate internal lengthening nail use in deformity correction and limb lengthening. Our study investigated the ability of blocking screws, using same principle, to accurately correct long-bone deformity with and without lengthening and to prevent lengthening-induced deformity. Materials and methods This is an institutional review board (IRB)-approved retrospective study on 86 patients who had IM nail-assisted limb reconstruction of femur or tibia with blocking screws. Surgeries were performed for deformity correction, limb lengthening, or deformity correction and limb lengthening. Data on the following variables were collected: number of blocking screws, distance of each blocking screw to osteotomy, distance of osteotomy from joint line, and amount of lengthening. Mechanical axis deviation (MAD) and joint alignment parameters were measured preoperatively and at the final postoperative follow-up. The primary outcome was the ability to obtain desired MAD and joint orientation angles. Accuracies were reported as postoperative measurements relative to goal. Association for the Study and Applications of the Methods of Ilizarov (ASAMI) scores were collected. Results The accuracy of deformity correction was within 6 mm from goal, while joint orientation was corrected to within 1.5° of goal. Number of blocking screws did not significantly impact accuracy. Distance of blocking screw to osteotomy and amount of lengthening did not affect accuracy. In femurs, osteotomies greater than 10 cm from the joint line were more accurate in MAD goal (p = 0.017). This result was not replicated in tibias. ASAMI scores were excellent or good. Conclusion Using RROT configuration, blocking screws were effective in correcting deformities of lower extremity long bones and in preventing deformity during limb lengthening. If positioned correctly, number of screws and their distance to osteotomy did not affect accuracy. Amount of lengthening did not impact accuracy. Distal femoral osteotomy less than 10 cm from knee joint may be challenging even with using blocking screws. How to cite this article Dabash S, Zhang DT, Rozbruch SR, et al. Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction. Strategies Trauma Limb Reconstr 2019;14(2):77–84.
Collapse
Affiliation(s)
- Sherif Dabash
- Department of Orthopaedic Surgery, Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, New York, USA; Department of Orthopaedic Surgery, Weill Medical College of Cornell University, The Hospital for Special Surgery, New York, USA
| | - David T Zhang
- Department of Orthopaedic Surgery, Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, New York, USA; Department of Orthopaedic Surgery, Weill Medical College of Cornell University, The Hospital for Special Surgery, New York, USA
| | - S Robert Rozbruch
- Department of Orthopaedic Surgery, Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, New York, USA; Department of Orthopaedic Surgery, Weill Medical College of Cornell University, The Hospital for Special Surgery, New York, USA
| | - Austin T Fragomen
- Department of Orthopaedic Surgery, Limb Lengthening and Complex Reconstruction Service, The Hospital for Special Surgery, New York, USA; Department of Orthopaedic Surgery, Weill Medical College of Cornell University, The Hospital for Special Surgery, New York, USA
| |
Collapse
|
13
|
Vaughn JE, Shah RV, Samman T, Stirton J, Liu J, Ebraheim NA. Systematic review of dynamization vs exchange nailing for delayed/non-union femoral fractures. World J Orthop 2018; 9:92-99. [PMID: 30079298 PMCID: PMC6068728 DOI: 10.5312/wjo.v9.i7.92] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/24/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the literature on efficacy of dynamamization vs exchange nailing in treatment of delayed and non-union femur fractures.
METHODS Ultimately, 31 peer-reviewed articles with 644 exchanged nailing patients and 131 dynamization patients were identified and analyzed. The following key words were inputted in different combinations in order to search the field of publications in its entirety: “non-union”, “delayed union”, “ununited”, “femur fracture”, “femoral fracture”, “exchange nailing”, “dynaiz(s)ation”, “secondary nailing”, “dynamic”, “static”, and “nail revision”. The initial search yielded over 150 results, and was refined based on the inclusion criteria: Only studies reporting on humans, non-unions and delayed unions, and the usage of exchange nailing and/or dynamization as a secondary treatment after failed IM nailing. The resulting 66 articles were obtained through online journal access. The results were filtered further based on the exclusion criteria: No articles that failed to report overall union rates, differentiate between success rates of their reported techniques, or articles that analyzed less than 5 patients.
RESULTS Exchange nailing lead to fracture union in 84.785% of patients compared to the 66.412% of dynamization with statistically comparable durations until union (5.193 ± 2.310 mo and 4.769 ± 1.986 mo respectively). Dynamically locking exchange nails resulted in an average union time of 5.208 ± 2.475 mo compared to 5.149 ± 2.366 mo (P = 0.8682) in statically locked exchange nails. The overall union rate of the two procedures, statically and dynamically locked exchange nailing yielded union rates of 84.259% and 82.381% respectively. Therefore, there was no significant difference between the different locking methods of exchange nailing for union rate or time to union at a significance value of P < 0.05. The analysis showed exchange nailing to be the more successful choice in the treatment of femoral non-unions in respect to its higher success rate (491/567 EN, 24/57 dynam, P < 0.0001). However, there was no significant difference between the success rates of the two procedures for delayed union fractures (25/27 EN, 45/55 dynam, P = 0.3299). Nevertheless, dynamization was more efficient in the treatment of delayed unions (at rates comparable to exchange nailing) than in the treatment of non-unions.
CONCLUSION In conclusion, after examination of factors, dynamization is recommended treatment of delayed femur fractures, while exchange nailing is the treatment of choice for non-unions.
Collapse
Affiliation(s)
- Jacob E Vaughn
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH 43614, United States
| | - Ronit V Shah
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH 43614, United States
| | - Tarek Samman
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH 43614, United States
| | - Jacob Stirton
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH 43614, United States
| | - Jiayong Liu
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH 43614, United States
| | - Nabil A Ebraheim
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH 43614, United States
| |
Collapse
|
14
|
Abstract
Exchange nailing has proven to be a reliable surgical technique for the management of aseptic femoral shaft nonunions. Similar to primary intramedullary nail fixation for femur fractures, exchange nailing for aseptic hypertrophic nonunions of the femur relies on successful navigation of the starting point and proper nail trajectory to minimize coronal and sagittal plane deformities. Compared with the supine position, the lateral decubitus position has the advantage of allowing gravity to displace the soft tissue around the piriformis start site to facilitate nail entry. In addition, the C-arm position and access to the affected limb from both sides by the surgeon and surgical assistant facilitate visualization of existing deformities and the ability to perform correction maneuvers. The purpose of this review is to highlight technical pearls associated with exchange nailing in a lateral decubitus position. Although other techniques are available, and should be used when indicated, exchange nailing provides patients with the opportunity to an early return to activity, improvement in pain and disability, and ultimate bony union.
Collapse
|
15
|
Abstract
OBJECTIVES This multicenter study was designed to evaluate whether tibia fracture nonunions treated with exchange nailing proceed to union faster with dynamically- versus statically-locked nails, or with fibular osteotomy versus no fibular osteotomy. DESIGN Retrospective, chart-review, multicenter study. SETTING Multicenter review of 6 level 1 trauma centers. PATIENTS/PARTICIPANTS Patients who had a tibia fracture treated with an intramedullary nail that progressed to nonunion, and were subsequently treated with exchange nailing, were identified. All patients that met inclusion criteria and subsequently progressed to union were included in the study. INTERVENTION Patients underwent tibial exchange nailing to repair nonunions, with screws in either a dynamically- or statically-locked configuration with or without fibular osteotomy. MAIN OUTCOME MEASURES The primary outcome measure was a comparison of time to healing of tibial nonunion comparing different screw configurations and fibular osteotomy. RESULTS Fifty-two patients underwent an exchange nail procedure and their outcomes were used for the primary analysis. Patients with dynamically-locked nails proceeded to union 7.9 months after revision surgery compared with 7.3 months for those with statically-locked nails, but this was not statistically significant (P = 0.68). Patients with fibular osteotomy proceeded to union 2.9 months faster than those without fibular osteotomy, and this trended toward significance (P = 0.067). Obese patients healed on average 8.8 months after surgery compared with 6.8 months for nonobese patients (P = 0.27). Closed fractures healed after 6.4 months compared with 7.7 months for open fractures (P = 0.40). CONCLUSIONS There was no significant difference in time to union between patients who had a dynamic screw configuration compared with a static screw configuration for their exchange nail. Patients who underwent fibular osteotomy proceeded to union faster than those without an osteotomy. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
16
|
Muthusamy S, Rozbruch SR, Fragomen AT. The use of blocking screws with internal lengthening nail and reverse rule of thumb for blocking screws in limb lengthening and deformity correction surgery. Strategies Trauma Limb Reconstr 2016; 11:199-205. [PMID: 27665618 PMCID: PMC5069203 DOI: 10.1007/s11751-016-0265-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/11/2016] [Indexed: 12/19/2022] Open
Abstract
Internal lengthening nail (ILN) is a recent development in limb lengthening and deformity correction specialty. The ILN has the distinct advantage of combining acute deformity correction with gradual lengthening of bone. While using ILN, the short metaphyseal bone fragment may develop a deformity at the time of osteotomy and nail insertion or during bone lengthening because of the wide medullary canal. These deformities are typically predictable, and blocking screws (Poller screws) are helpful in these situations. This manuscript describes the common deformities that occur in femur and tibia with osteotomies at different locations while using ILN in antegrade and retrograde nailing technique. Also, a systematic approach to the appropriate use of blocking screws in these deformities is described. In addition, the “reverse rule of thumb” is introduced as a quick reference to determine the ideal location(s) and number of blocking screws. These principles are applicable to limb lengthening and deformity correction as well as fracture fixation using intramedullary nails.
Collapse
Affiliation(s)
- Saravanaraja Muthusamy
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - S Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Austin T Fragomen
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| |
Collapse
|
17
|
Ma YG, Hu GL, Hu W, Liang F. Surgical factors contributing to nonunion in femoral shaft fracture following intramedullary nailing. Chin J Traumatol 2016; 19:109-12. [PMID: 27140219 PMCID: PMC4897920 DOI: 10.1016/j.cjtee.2016.01.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To explore the possible surgical factors related with nonunion in femoral shaft fracture following intramedullary nailing. METHODS We retrospectively analyzed totally 425 patients with femoral shaft fracture in level I urban trauma center, including 254 males and 171 females, with an average age of 37.6 (ranging from 21 to 56) years old. The inclusion criteria included: (1) traumatically closed fracture of femoral shaft, with pre- operative films showing non-comminuted fracture, such as transverse fracture, oblique fracture or spiral fracture; (2) closed reduction and fixation with interlocking intramedullary nail at 3-7 days after trauma; (3) complete follow-up data available. The relationship between the following factors (fracture site, reduction degree, direction of nail insertion and nail size) and nonunion was studied. RESULTS The incidence of femoral nonunion was 2.8% in patients with closed simple fracture undergoing interlocking intrameduallary nailing, including 11 cases of hypertrophic nonunion. Nonunion was related significantly to distal fracture, unsatisfactory reduction and unreamed nail (p < 0.05). There was no significant difference between antegrade nail and retrograde nail (p > 0.05). CONCLUSIONS Nonunion in femoral shaft facture following interlocking intramedullary nailing is related to fracture site, fracture reduction and nail diameter. The choice of reamed nails or unreamed nails depends on the fracture site and reduction degree.
Collapse
|
18
|
Brinker MR, O'Connor DP. Management of Aseptic Tibial and Femoral Diaphyseal Nonunions Without Bony Defects. Orthop Clin North Am 2016; 47:67-75. [PMID: 26614922 DOI: 10.1016/j.ocl.2015.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
An evidence-based description of aseptic tibial and femoral diaphyseal nonunions without segmental defects is based on a systematic search of MEDLINE. Aseptic nonunion of the femoral or tibial diaphysis without segmental defects and with an in situ nail, treated with reamed exchange nailing or augmentative plating and bone grafting, has consistently high union rates. Aseptic nonunion without segmental defects and with in situ plate and screw fixation is best managed with revision plate and screw fixation and autogenous bone graft. Various techniques and methods of biological stimulation have relatively high union rates.
Collapse
Affiliation(s)
- Mark R Brinker
- Fondren Orthopedic Group LLP, Texas Orthopedic Hospital, 7401 South Main Street, Houston, TX 77030, USA; Department of Orthopaedic Surgery, The University of Texas Medical School at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | - Daniel P O'Connor
- Department of Health and Human Performance, University of Houston, 3855 Holman GAR104, Houston, TX 77204-6015, USA.
| |
Collapse
|
19
|
Westhauser F, Zimmermann G, Moghaddam S, Bruckner T, Schmidmaier G, Biglari B, Moghaddam A. Reaming in treatment of non-unions in long bones: cytokine expression course as a tool for evaluation of non-union therapy. Arch Orthop Trauma Surg 2015; 135:1107-16. [PMID: 26085339 DOI: 10.1007/s00402-015-2253-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Indexed: 11/29/2022]
Abstract
UNLABELLED The analysis of peripheral serum cytokine expression patterns has been shown to be a possible method for demonstrating changes in bone metabolism. The aim of this study is to evaluate the effectiveness of this method within the treatment of long bone non-union with intramedullary reaming, a well-established non-union treatment concept. MATERIALS AND METHODS Three groups were added to this study: group one (G1) suffered from long bone non-unions, treated successfully with intramedullary reaming; group two (G2) consisted of long bone fractures with proper fracture healing; and group three (G3) included long bone fractures resulting in non-unions. We took blood samples on day 2, and after week 1, 4, 6, month 3 and 6 after initial treatment. Clinical and radiological follow-up were provided for 6 months. We measured transforming growth factor ß-1 (TGFß-1), platelet-derived growth factor (PDGF-AB), and insulin like growth factor-1 (IGF-1) at all-time points. RESULTS TGF-ß1 levels in G1 and G2 increased from day 2 to 6 weeks after surgery. In general, G1 and G2 showed parallel TGF-ß1 expression patterns, and G3 had a significant peak during first week compared to G1 (p = 0.023). PDGF peaked in G3 during first week after treatment, whereas G1 had its maximum after 4 weeks and G2 after 6 weeks. We were able to detect a significantly lower PDGF concentration at 3 months in G1 compared to G3 (p = 0.029). IGF-1 showed a peak concentration in G1 during the first 4 weeks. Afterwards, concentration levels in both G1 and G2 were higher. CONCLUSIONS Our study was able to show that the cytokine expression pattern in physiological bone healing is similar to that in successful non-union treatment with intramedullary reaming. Our results show that the effect of non-union therapy could be observed objectively by measuring cytokine expression patterns in peripheral blood even in a small group of patients.
Collapse
Affiliation(s)
- Fabian Westhauser
- Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, HTRG-Heidelberg Trauma Research Group, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
OBJECTIVES The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion. DESIGN Retrospective cohort. SETTING Tertiary referral center. PATIENTS Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral and 4 segmental) who presented with an intramedullary nail on an average of 16 months after the initial treatment were presented in this study. INTERVENTION Insertion of an exchange nail of at least >2-mm diameter than the prior nail using a different manufacturer's nail, static interlocking, partial fibulectomy in a select group of patients, and correction of underlying metabolic and endocrine abnormalities. MAIN OUTCOME MEASUREMENTS Union rate, time to union. RESULTS Forty-five of 46 tibial nonunion sites (98%) healed at an average of 4.8 months. CONCLUSIONS Patient selection criteria and a systematic approach to exchange nailing for tibial nonunion is highly successful. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
21
|
Gao KD, Huang JH, Tao J, Li F, Gao W, Li HQ, Wang QG. Management of femoral diaphyseal nonunion after nailing with augmentative locked plating and bone graft. Orthop Surg 2012; 3:83-7. [PMID: 22009591 DOI: 10.1111/j.1757-7861.2011.00124.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Exchange nailing (EN) for aseptic femoral shaft nonunion is currently a standard orthopaedic treatment modality. However, according to recent studies there is occasionally a high failure rate when EN is used. In the present study, augmentative locked plating and bone graft was used as an alternative method for treating such cases. The purpose of this study was to report the treatment outcomes of selected femoral diaphyseal nonunions that had initially been treated by nailing. METHODS Thirteen patients with femoral diaphyseal nonunions underwent revision surgery with locked plate and bone graft. The inclusion criteria were: (a) nonisthmic nonunion; (b) atrophic/oligotrophic nonunion. All patients were managed by augmentative locked plating and bone graft. RESULTS All patients were followed up for a mean of 1.2 years (range, 1-2 years). After revision surgery all nonunions achieved bony union, the average union time being 7.5 months (range, 6-12 months). No major complications were observed in this case series. CONCLUSION Augmentative locked plating is an effective and simple technique for treatment of femoral diaphyseal nonunion after nailing in selected cases.
Collapse
Affiliation(s)
- Kan-da Gao
- Department of Orthopaedics, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China.
| | | | | | | | | | | | | |
Collapse
|