Cell Biochem Biophys DOI 10.1007/s12013-015-0622-8
ORIGINAL PAPER
Interlocking Intramedullary Nails in Fracture Treatment Xiao Ouyang • Jing Rong Wang • Shi Dong Hong • Feng Xin • Lin Wang • Xiao Wei Yang • Jian Wang
Ó Springer Science+Business Media New York 2015
Abstract The aim of this study is to evaluate interlocking intramedullary nails in the treatment of fractures. We retrospectively reviewed 68 adult patients (for a total of 95 fractures) with isolated long-bone fractures who were treated with interlocking intramedullary nails between January 2010 and January 2012. The patients were followed for 18 months to observe the healing of the fracture, time, and the occurrence of complications in the shoulder, knee, and hip joint functions. After about a follow-up period of 26.2 months (range 18–39 months), all cases obtained bony union. The mean time to fracture union was 5.2 months. Cases of knees and hip joint functions of the femoral or tibial fracture and shoulder functions of the humeral fractures were observed.
X. Ouyang J. R. Wang S. D. Hong F. Xin L. Wang X. W. Yang Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou 3rd Hospital, Xuzhou, China e-mail: [email protected] J. R. Wang e-mail: [email protected] S. D. Hong e-mail: [email protected]
The interlocking intramedullary nails may be considered as an alternative method for isolated diaphyseal fractures of the extremities. The advantages of this method include small operative scars, reliable fixations, better fracture healings, and fewer complications. Keywords Interlocking intramedullary nail Extremities diaphyseal fractures Curative effect Security
Introduction With the development of biotechnology, interlocking intramedullary nails have become the golden standard in the treatment of diaphyseal fractures of the extremities. Present studies of the intramedullary nails are concentrated in certain positions, and the follow-up period is not long enough. Interlocking intramedullary nails (include gamma, reconstructive interlocking intramedullary, femoral interlocking intramedullary, retrograde interlocking intramedullary, tibial interlocking intramedullary, and humeral interlocking intramedullary nails) were used in the fracture treatment of 65 patients (a total of 95 fractures), whom were followed-up to evaluate the treatment.
F. Xin e-mail: [email protected] L. Wang e-mail: [email protected] X. W. Yang e-mail: [email protected] J. Wang (&) Hospital Administration Office, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou 3rd Hospital, No. 131 Huancheng Road, Xuzhou 221005, China e-mail: [email protected]
Clinical Materials Patients The study included 95 fractures of 68 patients (77 male, 18 female; average age: 37.8 years; range 18–79 years). These fractures include 52 cases of femoral fractures (37 fresh fractures; 15 revisions of the original internal fixation operation failed; 45 femoral shaft fractures; four femoral
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supracondylar and intercondylar fractures; one transcervical fracture; two femoral intertrochanteric fractures), 36 cases of tibial fractures (29 fresh fractures; seven revisions of the original internal fixation operation failed), seven cases of humeral fractures (five new fractures; two revisions after the original internal fixation operation fractures failed). Injury mechanisms were vehicle accidents in 69, crushing injuries in three, pathologic fracture in one, and falls in eight patients. The general characteristics of patients were open fractures in 21 including open femoral fractures in 12 and open tibial fractures in 9 and closed fracture in 74. Associated injuries: five cases associated with vulneralis shock; four cases associated with craniocerebral injury; four cases associated with abdominal injury; six cases associated with rib fractures and hemopneumothorax; one case associated with common peroneal nerve injury. Surgical Methods Interlocking intramedullary nails (include gamma, reconstructive interlocking intramedullary, femoral interlocking intramedullary, retrograde interlocking intramedullary, tibial interlocking intramedullary, and humeral interlocking intramedullary nails) were used in the fracture treatments. Brachial plexus block anesthesia and continuous epidural anesthesia was applied to the surgeries of the lower limb. After closed reduction under X-ray, a small incision was made, and the main nail was rotated into the medullary cavity to fix the fracture followed by the locator, locking the nail proximally or distally. Upon the failure of closed reduction, a limited open bone incision was allowed. Internal fixation was used by the interlocking intramedullary nail and the supplement of blood on the top of broken bone was maintained. Postoperative Management The patients received irrigations of the knees and the quadriceps after femoral fracture surgeries. The continuous non-weight-bearing movement with crutches was permitted after surgery for 2 days. Tibial fracture patients increased the weight in movement for a limited range for 4–6 weeks after surgeries. Tibial comminuted fracture patients were permitted for non-weight-bearing movement in a limited range after osteotylus formation confirmed by the X-ray. Passive irrigations of the shoulder and elbow joints was permitted in humeral fracture patients with a scarf bandage protection after surgery. Active movement of the shoulder and elbow joints was also permitted in humeral fracture patients after surgeries for 3–4 weeks. All patients underwent physiotherapy and rehabilitation training.
123
Results Out-patient follow-up was performed to observe fracture healing. After an average of 26.2 months (range 18–39 months) follow-up period, all cases got bony union and the mean time to fracture union was 5.2 months (Figs. 1, 2, 3, 4). One tibial fracture was delayed union and healed by dynamic compression; two cases of nonunion (a tibial and a femoral fracture) were subsequently healed by replacing the interlocking intramedullary nail and bone grafting. The incision infection (one tibial and one femoral fracture) was observed in two patients. There was no impact on fracture healing. One implant case was healed after replacement of interlocking intramedullary nail. Proximal or distal implant disruptions and deformity were not observed in two fractures in the union process. One femoral fracture was uncovered in the surgery and healed after additional internal fixation. Favorable activities of the knees and hip joints occurred after surgery of the femoral or tibial fracture, whereas favorable activities of shoulders were observed after humeral fracture surgery. All patients had no complications in the follow-up period.
Discussion Advantages of Interlocking Intramedullary Nails in Fracture Treatment (1) The fixation with interlocking intramedullary nails was firmer than with eccentric fixation, avoiding periosteal
Fig. 1 X-ray before surgery: femoral comminuted fracture
Cell Biochem Biophys Fig. 2 X-ray showed good contraposition after femoral fracture fixation with interlocking intramedullary nail for 2 weeks
Fig. 4 X-ray showed interlocking intramedullary nail removed after 24 months
Fig. 3 X-ray showed femoral fracture union after surgery for 12 months
grafting technique with interlocking intramedullary nails promoted better fracture union [3]. (4) By making only one small incision, the main nail is rotated into the medullary cavity via the cancellous bone screw thread at both ends, thus reducing the need for excessive reaming [4]. (5) Fracture surgeries with interlocking intramedullary nails are simple to operate, have satisfactory treatment, and are developed in all hospital levels. Ninety-five cases of fractures including femoral, tibial, and humeral fractures were well healed and had favorable recovery of joint functions. Compared with the plate fixation surgeries, we used the interlocking intramedullary nails and limited incisions in the femoral, tibial, and humeral fractures which had smaller incisions, simpler surgeries, and is widely used in China. Indications of Interlocking Intramedullary Nails in Fracture Treatment
necrosis, and a lack of blood supplementation. The interlocking intramedullary nail maintains the physiological and mechanical bone structures by rotation and shortening. (2) Interlocking intramedullary nails are static, providing firmer fixation and quick functional motion, protecting the joints from ankylosis, especially for complicate fractures [1, 2]. (3) The interlocking intramedullary nail fixation and limited incision were observed in the surgeries. There was less damage in blood supplement, thus reducing the osteogenic effect by interlocking intramedullary nails. Internal bone
The interlocking intramedullary nail can be widely used in the treatment of fractures. (1) Closed fractures. Interlocking intramedullary nails are applied in several types and sections of the femoral fractures, such as fractures of the femoral shaft, femoral supracondylar, intercondylar, transcervical, femoral intertrochanteric, and tibial fracture. Proximal and distal fractures of the tibia are contraindicated due to the special positions. (2) Open fractures. Current studies show open fractures that were not the contraindication of interlocking intramedullary nail treatment [5]. (3) Serious and complicated fractures. Forty-four floating knees of 22 patients, femoral distal intertrochanteric line fracture associated with being ipsilateral more than 1/3 lower fractures of
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Options of Interlocking Intramedullary Nail Technology
and multisegmental fractures, resetting fracture pieces via the incision. Furthermore, the auxiliary fixation by steel wire and screw (Fig. 2) was applied as necessary, so as to be anatomic and near anatomic reduction, providing a better internal environment of the fracture union. The treatment of long-bone fractures with interlocking intramedullary nails and the limited open reduction avoids the blindness of closed nailing reduction and reduces the additional injury. According to the surgical condition, closed reductions with interlocking intramedullary nails for fracture fixation should be applied when the orthopedic table and C-arm X-ray machine were used, whereas limited incisions with interlocking intramedullary nails for fracture fixation should be used without the above instruments in the primary hospitals.
The Choice Between Static and Dynamic Fixation
Complications and the Prevention
The traditional views showed that static fixations by interlocking intramedullary nails were applied with comminuted fractures. Comminuted fractures are associated with a bone defect, whereas dynamic fixations were used with proximal or distal fractures and delayed unions [11, 12]. Interlocking intramedullary nails revealed an antishortening function by static fixation and used biologics in fracture stress dynamic fixation, promoting fracture healing. We changed the models of static fixation and dynamic fixation. The static fixation was permitted in our study. The dynamic fixation was applied to the patients of delayed fracture unions via removing proximal or distal nails. Tiny activities were allowed in the dynamic fixation. Moreover, as a kind of elastic fixation, the dynamic fixation provided the ideal mechanical environment of bone tissue differentiation and complete regeneration.
Although various factors were involved in fracture healing, the primary reason should attribute to the separation of the fractured end. Tibial delayed union in one patient was completely healed by subsequent dynamic processing [16, 17]. Two cases of nonunion (one tibial fracture and one femoral fractures) were subsequently treated by replacing the interlocking intramedullary nail and bone grafting. Previous studies showed that anterior knee pain, shoulder stiffness, and shoulder pain occurred after the treatment with interlocking intramedullary nails of tibial, femoral, and humeral fracture, but did not effect fracture recovery. Anterior knee pain, shoulder stiffness, and shoulder pain were not found in our patients. We should pay attention to the protection of the soft tissue. Moreover, strengthening exercises and physical rehabilitations should be applied after operations. The occurrence of postoperative infection in open fractures is correlated with the degree of injury, contaminated levels, and the treatment of the soft tissue [18]. Only two patients with open fractures had superficial infections, which were resolved with antibiotics. Wang et al. indicated that antibiotics and fracture stableness should be permitted in postoperative infection, instead of removing or replacing the nails [19]. Additionally, the germi culture, drug sensitivity test, and sensitive antibiotics were allowed upon infection. Incision and drainage were allowed with the abscess. Removing the nails and external fixators should be applied when the infection is not under control [20]. One fracture that occurred during the surgery was completely healed by adding another internal fixation. One case of implant disruption was healed after replacement of interlocking intramedullary nail. Proximal or distal implant disruptions and deformity were not observed in two fractures in the fracture union process. Tao Zhang et al. indicated that the reason for nail disruptions was mainly due to the premature weight-bearing [21]. Increased
tibia and fibula, but not the intra-articular fractures such as intercondylar fractures or tibial plateau fractures, were treated with interlocking intramedullary nails. Good treatment outcomes were observed [6–8]. (4) Internal fixation failure of long-bone fractures. Twenty-four revisions of the original internal fixation failure were treated with interlocking intramedullary nails [6, 11]. (5) Pathologic fractures [9, 10]. The interlocking intramedullary nail is the best choice for pathologic fracture treatment. One pathological fracture caused by bone metastatic focus was treated with the interlocking intramedullary nail after debridement and filled with cement.
The Option Between Closed Reduction and Open Reduction Closed and open nailing reduction were alternatively applied in interlocking intramedullary nail surgeries. Compared with that in the open reduction, orthopedic table, select process instruments, and radiographic image enhancement are necessary for the closed reduction. Moreover, the surgeries with the closed reduction had less hemorrhage, lower infection rate, and higher healing rate than that in surgeries with the open reduction [13–15]. We tried to improve the technique of the interlocking intramedullary nail by applying a limited incision in 23 fractures. We used limited incision and interlocked intramedullary nails for internal fixation without C-arm X-ray machine, special surgical instruments, orthopedic table or repeated closed manipulative reduction. Limited open reduction was used for severe comminuted fractures
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weight-bearing after porosis was the key measure to prevent nail disruptions.
Conclusion In conclusion, using the interlocking intramedullary nails in the treatment of long-bone fractures appears to have many benefits, such as the reliable fixation, smaller incisions, fewer complications, and favorable outcome. Additionally, functional results are promising in the treatment of fractures.
References 1. Ouyang, X., Wang, J., Wang, P., et al. (2006). Treatment of the floating knee with interlocking intramedullary nail and limited open reduction. Journal of Practical Orthopedics, 12, 9–12. 2. Sun, L., Liu, X., Wang, X., et al. (2005). The treatment of extremity fractures using the interlocking nail. Chinese Journal of Orthopedics, 25, 129–135. 3. Li, H., Yao, S., Zhao, C., et al. (2005). The study of reamed versus unreamed femoral intramedullary nailing for femoral shaft fracture. Chinese Journal of Bone and Joint Injury, 20, 104–106. 4. Wang, J., Yu, G., Wang, S., et al. (2004). Cause analysis and handling of the postoperative complications of the tubular bone fractures of lower extremities treated with intramedullary interlocking nails. Chinese Journal of Bone and Joint Injury, 19, 164–166. 5. Zhang, T., Pang, G., Wang, J., et al. (2005). Complication prevention in the treatment of femoral shaft fracture with interlocking intramedullary nail. Chinese Journal of Bone and Joint Injury, 20, 289–291. 6. Reid, J. S. (2003). Fractures of the proximal humerus. Current Opinion in Orthopaedics, 14, 269–280. 7. Visser, C. P., Coene, L. N., Brand, R., et al. (2001). Nerve lesions in proximal humeral fractures. Shoulder Elbow Surgery, 10, 421–427.
8. Neer, C. S. (1955). Articular replacement for the humeral head. Bone Joint Surgery (Am), 37, 215–228. 9. Demirhan, M., Kilicoglu, O., Ahinel, L., et al. (2003). Prognostic factors in prosthetic replacement for acute proximal humerus fractures. Journal of Orthopaedics Trauma, 17, 181–188. 10. Neer, C. S. (1970). Displaced proximal humera1 fractures treatment of three-part and four-part displacement. Journal Bone Joint Surgery (Am), 52, 1090–1103. 11. Boileau, P., Trojani, C., & Walch, G. (2001). Shoulder arthroplasty for the treatment of the secuelae of fractures of the proxi mal humerus. Shoulder Elbow Surgery, 10(4), 299. 12. Urner, N. M., Van de Leemput, A. J., Draaisma, J., et al. (2008). Validity of the visual analogue scale as an instrument to measure self-efficacy in resuscitation skills. Medical Education, 42(5), 503. 13. Vallier, H. A., Cureton, B., Patterson, A., & Brendan, M. (2012). Factors influencing functional outcomes after distal tibia shaft fractures. Journal of Orthopaedic Trauma, 26(3), 178–183. 14. Kitaoka, H. B., Alexander, I. J., Adelaar, R., et al. (1994). Clinical systems for the ankle-hindfoot, midfoot, hallux and lesser toes. Foot Ankle, 15(7), 349–353. 15. Zhang, Z. (2005). 24 cases analysis of distal tibial 1/3 fracture with Locking intramedullary nail in treatment. Journal of Ningxia Medical College, 27(4), 317–318. 16. Leliveld, M. S., & Verhofstad, M. H. (2012). Injury to the infrapatellar branch of the saphenous nerve a possible cause for anterior knee pain after tibial nailing. Injury, 43(6), 779–783. 17. Wang, Y., Tang, P., Cai, X., et al. (2009). Campbell’s Operative Orthopaedics (10th ed., pp. 2557–2559). Beijing: People’s Medical Publishing House. 18. Werner, A., Bohm, D., Ilg, A., et al. (2002). KaPandji intramedullary wire osteosynthesis in proximal humeral fractures. Un fallehirurg, 105(4), 332–337. 19. Otoole, R. V., Gobezie, R., Hwang, R., et al. (2006). Low complication rate of LISS for femur fractures adjacent to stable hip or hip arthroplasty. Clinical Orthopaedics, 450, 203–210. 20. Ito, K., Hungerbuhler, R., Wahl, D., et al. (2001). Improvedintramedullary nail interlocking in osteoporotic bone. Jounal of Orthopaedic Trauma, 3, 192–196. 21. Haentjens, P., Casteleyn, P. P., DeBoek, H., et al. (1989). Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar arthroplasty compared with internal fixation. Bone Joint Surgery, 71, 1214–1225.
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ORIGINAL PAPER
Interlocking Intramedullary Nails in Fracture Treatment Xiao Ouyang • Jing Rong Wang • Shi Dong Hong • Feng Xin • Lin Wang • Xiao Wei Yang • Jian Wang
Ó Springer Science+Business Media New York 2015
Abstract The aim of this study is to evaluate interlocking intramedullary nails in the treatment of fractures. We retrospectively reviewed 68 adult patients (for a total of 95 fractures) with isolated long-bone fractures who were treated with interlocking intramedullary nails between January 2010 and January 2012. The patients were followed for 18 months to observe the healing of the fracture, time, and the occurrence of complications in the shoulder, knee, and hip joint functions. After about a follow-up period of 26.2 months (range 18–39 months), all cases obtained bony union. The mean time to fracture union was 5.2 months. Cases of knees and hip joint functions of the femoral or tibial fracture and shoulder functions of the humeral fractures were observed.
X. Ouyang J. R. Wang S. D. Hong F. Xin L. Wang X. W. Yang Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou 3rd Hospital, Xuzhou, China e-mail: [email protected] J. R. Wang e-mail: [email protected] S. D. Hong e-mail: [email protected]
The interlocking intramedullary nails may be considered as an alternative method for isolated diaphyseal fractures of the extremities. The advantages of this method include small operative scars, reliable fixations, better fracture healings, and fewer complications. Keywords Interlocking intramedullary nail Extremities diaphyseal fractures Curative effect Security
Introduction With the development of biotechnology, interlocking intramedullary nails have become the golden standard in the treatment of diaphyseal fractures of the extremities. Present studies of the intramedullary nails are concentrated in certain positions, and the follow-up period is not long enough. Interlocking intramedullary nails (include gamma, reconstructive interlocking intramedullary, femoral interlocking intramedullary, retrograde interlocking intramedullary, tibial interlocking intramedullary, and humeral interlocking intramedullary nails) were used in the fracture treatment of 65 patients (a total of 95 fractures), whom were followed-up to evaluate the treatment.
F. Xin e-mail: [email protected] L. Wang e-mail: [email protected] X. W. Yang e-mail: [email protected] J. Wang (&) Hospital Administration Office, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou 3rd Hospital, No. 131 Huancheng Road, Xuzhou 221005, China e-mail: [email protected]
Clinical Materials Patients The study included 95 fractures of 68 patients (77 male, 18 female; average age: 37.8 years; range 18–79 years). These fractures include 52 cases of femoral fractures (37 fresh fractures; 15 revisions of the original internal fixation operation failed; 45 femoral shaft fractures; four femoral
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supracondylar and intercondylar fractures; one transcervical fracture; two femoral intertrochanteric fractures), 36 cases of tibial fractures (29 fresh fractures; seven revisions of the original internal fixation operation failed), seven cases of humeral fractures (five new fractures; two revisions after the original internal fixation operation fractures failed). Injury mechanisms were vehicle accidents in 69, crushing injuries in three, pathologic fracture in one, and falls in eight patients. The general characteristics of patients were open fractures in 21 including open femoral fractures in 12 and open tibial fractures in 9 and closed fracture in 74. Associated injuries: five cases associated with vulneralis shock; four cases associated with craniocerebral injury; four cases associated with abdominal injury; six cases associated with rib fractures and hemopneumothorax; one case associated with common peroneal nerve injury. Surgical Methods Interlocking intramedullary nails (include gamma, reconstructive interlocking intramedullary, femoral interlocking intramedullary, retrograde interlocking intramedullary, tibial interlocking intramedullary, and humeral interlocking intramedullary nails) were used in the fracture treatments. Brachial plexus block anesthesia and continuous epidural anesthesia was applied to the surgeries of the lower limb. After closed reduction under X-ray, a small incision was made, and the main nail was rotated into the medullary cavity to fix the fracture followed by the locator, locking the nail proximally or distally. Upon the failure of closed reduction, a limited open bone incision was allowed. Internal fixation was used by the interlocking intramedullary nail and the supplement of blood on the top of broken bone was maintained. Postoperative Management The patients received irrigations of the knees and the quadriceps after femoral fracture surgeries. The continuous non-weight-bearing movement with crutches was permitted after surgery for 2 days. Tibial fracture patients increased the weight in movement for a limited range for 4–6 weeks after surgeries. Tibial comminuted fracture patients were permitted for non-weight-bearing movement in a limited range after osteotylus formation confirmed by the X-ray. Passive irrigations of the shoulder and elbow joints was permitted in humeral fracture patients with a scarf bandage protection after surgery. Active movement of the shoulder and elbow joints was also permitted in humeral fracture patients after surgeries for 3–4 weeks. All patients underwent physiotherapy and rehabilitation training.
123
Results Out-patient follow-up was performed to observe fracture healing. After an average of 26.2 months (range 18–39 months) follow-up period, all cases got bony union and the mean time to fracture union was 5.2 months (Figs. 1, 2, 3, 4). One tibial fracture was delayed union and healed by dynamic compression; two cases of nonunion (a tibial and a femoral fracture) were subsequently healed by replacing the interlocking intramedullary nail and bone grafting. The incision infection (one tibial and one femoral fracture) was observed in two patients. There was no impact on fracture healing. One implant case was healed after replacement of interlocking intramedullary nail. Proximal or distal implant disruptions and deformity were not observed in two fractures in the union process. One femoral fracture was uncovered in the surgery and healed after additional internal fixation. Favorable activities of the knees and hip joints occurred after surgery of the femoral or tibial fracture, whereas favorable activities of shoulders were observed after humeral fracture surgery. All patients had no complications in the follow-up period.
Discussion Advantages of Interlocking Intramedullary Nails in Fracture Treatment (1) The fixation with interlocking intramedullary nails was firmer than with eccentric fixation, avoiding periosteal
Fig. 1 X-ray before surgery: femoral comminuted fracture
Cell Biochem Biophys Fig. 2 X-ray showed good contraposition after femoral fracture fixation with interlocking intramedullary nail for 2 weeks
Fig. 4 X-ray showed interlocking intramedullary nail removed after 24 months
Fig. 3 X-ray showed femoral fracture union after surgery for 12 months
grafting technique with interlocking intramedullary nails promoted better fracture union [3]. (4) By making only one small incision, the main nail is rotated into the medullary cavity via the cancellous bone screw thread at both ends, thus reducing the need for excessive reaming [4]. (5) Fracture surgeries with interlocking intramedullary nails are simple to operate, have satisfactory treatment, and are developed in all hospital levels. Ninety-five cases of fractures including femoral, tibial, and humeral fractures were well healed and had favorable recovery of joint functions. Compared with the plate fixation surgeries, we used the interlocking intramedullary nails and limited incisions in the femoral, tibial, and humeral fractures which had smaller incisions, simpler surgeries, and is widely used in China. Indications of Interlocking Intramedullary Nails in Fracture Treatment
necrosis, and a lack of blood supplementation. The interlocking intramedullary nail maintains the physiological and mechanical bone structures by rotation and shortening. (2) Interlocking intramedullary nails are static, providing firmer fixation and quick functional motion, protecting the joints from ankylosis, especially for complicate fractures [1, 2]. (3) The interlocking intramedullary nail fixation and limited incision were observed in the surgeries. There was less damage in blood supplement, thus reducing the osteogenic effect by interlocking intramedullary nails. Internal bone
The interlocking intramedullary nail can be widely used in the treatment of fractures. (1) Closed fractures. Interlocking intramedullary nails are applied in several types and sections of the femoral fractures, such as fractures of the femoral shaft, femoral supracondylar, intercondylar, transcervical, femoral intertrochanteric, and tibial fracture. Proximal and distal fractures of the tibia are contraindicated due to the special positions. (2) Open fractures. Current studies show open fractures that were not the contraindication of interlocking intramedullary nail treatment [5]. (3) Serious and complicated fractures. Forty-four floating knees of 22 patients, femoral distal intertrochanteric line fracture associated with being ipsilateral more than 1/3 lower fractures of
123
Cell Biochem Biophys
Options of Interlocking Intramedullary Nail Technology
and multisegmental fractures, resetting fracture pieces via the incision. Furthermore, the auxiliary fixation by steel wire and screw (Fig. 2) was applied as necessary, so as to be anatomic and near anatomic reduction, providing a better internal environment of the fracture union. The treatment of long-bone fractures with interlocking intramedullary nails and the limited open reduction avoids the blindness of closed nailing reduction and reduces the additional injury. According to the surgical condition, closed reductions with interlocking intramedullary nails for fracture fixation should be applied when the orthopedic table and C-arm X-ray machine were used, whereas limited incisions with interlocking intramedullary nails for fracture fixation should be used without the above instruments in the primary hospitals.
The Choice Between Static and Dynamic Fixation
Complications and the Prevention
The traditional views showed that static fixations by interlocking intramedullary nails were applied with comminuted fractures. Comminuted fractures are associated with a bone defect, whereas dynamic fixations were used with proximal or distal fractures and delayed unions [11, 12]. Interlocking intramedullary nails revealed an antishortening function by static fixation and used biologics in fracture stress dynamic fixation, promoting fracture healing. We changed the models of static fixation and dynamic fixation. The static fixation was permitted in our study. The dynamic fixation was applied to the patients of delayed fracture unions via removing proximal or distal nails. Tiny activities were allowed in the dynamic fixation. Moreover, as a kind of elastic fixation, the dynamic fixation provided the ideal mechanical environment of bone tissue differentiation and complete regeneration.
Although various factors were involved in fracture healing, the primary reason should attribute to the separation of the fractured end. Tibial delayed union in one patient was completely healed by subsequent dynamic processing [16, 17]. Two cases of nonunion (one tibial fracture and one femoral fractures) were subsequently treated by replacing the interlocking intramedullary nail and bone grafting. Previous studies showed that anterior knee pain, shoulder stiffness, and shoulder pain occurred after the treatment with interlocking intramedullary nails of tibial, femoral, and humeral fracture, but did not effect fracture recovery. Anterior knee pain, shoulder stiffness, and shoulder pain were not found in our patients. We should pay attention to the protection of the soft tissue. Moreover, strengthening exercises and physical rehabilitations should be applied after operations. The occurrence of postoperative infection in open fractures is correlated with the degree of injury, contaminated levels, and the treatment of the soft tissue [18]. Only two patients with open fractures had superficial infections, which were resolved with antibiotics. Wang et al. indicated that antibiotics and fracture stableness should be permitted in postoperative infection, instead of removing or replacing the nails [19]. Additionally, the germi culture, drug sensitivity test, and sensitive antibiotics were allowed upon infection. Incision and drainage were allowed with the abscess. Removing the nails and external fixators should be applied when the infection is not under control [20]. One fracture that occurred during the surgery was completely healed by adding another internal fixation. One case of implant disruption was healed after replacement of interlocking intramedullary nail. Proximal or distal implant disruptions and deformity were not observed in two fractures in the fracture union process. Tao Zhang et al. indicated that the reason for nail disruptions was mainly due to the premature weight-bearing [21]. Increased
tibia and fibula, but not the intra-articular fractures such as intercondylar fractures or tibial plateau fractures, were treated with interlocking intramedullary nails. Good treatment outcomes were observed [6–8]. (4) Internal fixation failure of long-bone fractures. Twenty-four revisions of the original internal fixation failure were treated with interlocking intramedullary nails [6, 11]. (5) Pathologic fractures [9, 10]. The interlocking intramedullary nail is the best choice for pathologic fracture treatment. One pathological fracture caused by bone metastatic focus was treated with the interlocking intramedullary nail after debridement and filled with cement.
The Option Between Closed Reduction and Open Reduction Closed and open nailing reduction were alternatively applied in interlocking intramedullary nail surgeries. Compared with that in the open reduction, orthopedic table, select process instruments, and radiographic image enhancement are necessary for the closed reduction. Moreover, the surgeries with the closed reduction had less hemorrhage, lower infection rate, and higher healing rate than that in surgeries with the open reduction [13–15]. We tried to improve the technique of the interlocking intramedullary nail by applying a limited incision in 23 fractures. We used limited incision and interlocked intramedullary nails for internal fixation without C-arm X-ray machine, special surgical instruments, orthopedic table or repeated closed manipulative reduction. Limited open reduction was used for severe comminuted fractures
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weight-bearing after porosis was the key measure to prevent nail disruptions.
Conclusion In conclusion, using the interlocking intramedullary nails in the treatment of long-bone fractures appears to have many benefits, such as the reliable fixation, smaller incisions, fewer complications, and favorable outcome. Additionally, functional results are promising in the treatment of fractures.
References 1. Ouyang, X., Wang, J., Wang, P., et al. (2006). Treatment of the floating knee with interlocking intramedullary nail and limited open reduction. Journal of Practical Orthopedics, 12, 9–12. 2. Sun, L., Liu, X., Wang, X., et al. (2005). The treatment of extremity fractures using the interlocking nail. Chinese Journal of Orthopedics, 25, 129–135. 3. Li, H., Yao, S., Zhao, C., et al. (2005). The study of reamed versus unreamed femoral intramedullary nailing for femoral shaft fracture. Chinese Journal of Bone and Joint Injury, 20, 104–106. 4. Wang, J., Yu, G., Wang, S., et al. (2004). Cause analysis and handling of the postoperative complications of the tubular bone fractures of lower extremities treated with intramedullary interlocking nails. Chinese Journal of Bone and Joint Injury, 19, 164–166. 5. Zhang, T., Pang, G., Wang, J., et al. (2005). Complication prevention in the treatment of femoral shaft fracture with interlocking intramedullary nail. Chinese Journal of Bone and Joint Injury, 20, 289–291. 6. Reid, J. S. (2003). Fractures of the proximal humerus. Current Opinion in Orthopaedics, 14, 269–280. 7. Visser, C. P., Coene, L. N., Brand, R., et al. (2001). Nerve lesions in proximal humeral fractures. Shoulder Elbow Surgery, 10, 421–427.
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