Limitations in Use of Elastic Stable Intramedullary Nailing (ESIN) in Children with Disorders of Bone Mineralization.

BACKGROUND: Elastic intramedullary nails (ESIN) have been the treatment of choice in many long bone fractures in children for more than 20 years. The introduction of ESIN has drastically reduced tissue traumatization during fracture fixation procedures and decreased the risk of growth cartilage damage, as well as allowing for preservation of the natural biology of closed fracture healing. The objective of the present report is to draw attention to a small group of patients with bone mineralization disorders, who consequently demonstrate decreased mechanical resistance of the skeletal system, in whom indications for using ESIN fixation are limited. MATERIAL AND METHODS: The study group consisted of 6 patients who met the criteria for using ESIN fixation, but did not demonstrate a satisfactory outcome. The inclusion criteria included age below 18 years, appropriate ESIN nail insertion technique with correct calculation of nail diameter (2/5 of the medullary canal diameter), body mass < 50 kg and achieving appropriate prebending that is the prerequisite of three-point intramedullary support. The patients' medical records and radiographs were analyzed and they were invited for clinical and radiological follow-up examinations. RESULTS: All six patients demonstrated a gradually increasing bending deformity of the long bone axis. Additionally, in three patients, there was intrusion of terminal parts of the nails into the bone. In one patient with bone fibrous dysplasia, the proximal epiphysis was perforated by the flattened ends of the nails. In all patients, the removal of the ESIN fixation was followed by single or double-level corrective osteotomies and Rush pin fixation. CONCLUSION: In cases of long bone fractures in children with metabolic bone disorders in whom the bone structure is weakened and the bones themselves are easily deformed, more rigid intramedullary fixation with Rush or Fassier-Duval type nails as primary osteosynthesis should be considered.

Finite element analysis of two cephalomedullary nails in treatment of elderly reverse obliquity intertrochanteric fractures: zimmer natural nail and proximal femoral nail antirotation-ΙΙ.

BACKGROUND: More elderly patients are suffering from intertrochanteric fractures. However, the choice of internal fixation is still controversial, especially in the treatment of unstable intertrochanteric fracture; thus, previous implants continue to be improved, and new ones are being developed. The purpose of our study was to compare the biomechanical advantages between the zimmer natural nail (ZNN) and proximal femoral nail antirotation-II (PFNA-II) in the treatment of elderly reverse obliquity intertrochanteric fractures. METHODS: A three-dimensional finite element was applied for reverse obliquity intertrochanteric fracture models (AO31-A3.1) fixed with the ZNN or PFNA-II. The distribution, peak value and position of the von Mises stress and the displacement were the criteria for comparison between the two groups. RESULTS: The stresses of the internal fixation and femur in the ZNN model were smaller than those in the PFNA-II model, and the peak values of the two groups were 364.8 MPa and 171.8 MPa (ZNN) and 832.3 MPa and 1795.0 MPa (PFNA-II). The maximum amount of displacement of the two groups was similar, and their locations were the same, i.e., in the femoral head vertex (3.768 mm in the ZNN model and 3.713 mm in the PFNA-II model). CONCLUSIONS: The displacement in the two models was similar, but the stresses in the implant and bone were reduced with the ZNN. Therefore, the ZNN implant may provide biomechanical advantages over PFNA-II in reverse obliquity intertrochanteric fractures, as shown through the finite element analysis. These findings from our study may provide a reference for the perioperative selection of internal fixations.

Risk factor analysis for delayed union after subtrochanteric femur fracture: quality of reduction and valgization are the key to success.

BACKGROUND: Subtrochanteric femur fractures (SFF) are uncommon, but have a high complication rate concerning non-union and mechanical complications. There is ongoing discussion about risk factors for delayed fracture healing after SFF. The purpose of this study was to evaluate potential risk factors for delayed fracture healing after SFF. METHODS: This retrospective radio-morphometric case control study compares 61 patients after SFF in two groups (uncomplicated healing within 6 months postoperatively vs. delayed union) concerning radiographical properties. The patients were analyzed concerning the following parameter: Quality of the reduction according to Baumgaertner, CCD-angle, Tip-Apex Distance, leg-length shortening and fracture healing according to the RUSH Score. RESULTS: The mean RUSH-Score at 6 months postoperatively was 21.32(±4.57). At that point of time, only 29/61 fractures were radiographically fully consolidated (timely fracture healing) and 32 patients were rated as delayed union. The total revision rate was 9/61 (14.7%), whereof four patients required revision for symptomatic non-union of the SFF. The results of the radio-morphometric measurement showed a significant difference between both groups concerning the degree of reduction measured according to Baumgaertner (p = 0.022). The postoperative ipsilateral CCD-angle was different between the two groups (p = 0.019). After 12 months postoperatively, 48/61 (78.6%) of fractures were rated healed without any further intervention. CONCLUSIONS: Delayed union after SFF occurs frequently. In our patient population, the quality of reduction and the postoperative CCD-angle were the key factors to avoid delayed union. LEVEL OF EVIDENCE: Level III, Therapeutic study. TRIAL REGISTRATION: Clinical Trial Registry University of Regensburg Z-2018-1074-1. Registered 04. Aug 2018. https://studienanmeldung.zks-regensburg.de.

Comparison of curettage and bone grafting combined with elastic intramedullary nailing vs curettage and bone grafting in the treatment of long bone cysts in children.

To compare the efficacy of curettage and bone grafting combined with elastic intramedullary nailing (EIN) vs curettage and bone grafting in the treatment of long bone cysts in children and to clarify the necessity of using EIN in the treatment of bone cysts.Sixty-two patients were involved in this study from Jan. 2009 to Sept. 2017 (43 males, 19 females; 27 humeri, 35 femurs); the patients were assigned to an EIN group, comprising 30 patients who underwent curettage and bone grafting combined with EIN, or to a non-elastic intramedullary nailing (NEIN) group, comprising 32 patients who underwent curettage and bone grafting alone. The prognosis of the 2 groups was assessed with reference to the standard of Capanna.No statistically significant differences in sex, age, location, activity, pathological fracture, cyst volume, operative time and intraoperative blood loss were found between the 2 groups (P > .05). The effective rate was 90.0% in the EIN group and 68.8% in the NEIN group, and the difference was statistically significant (P < .05).Compared to simple curettage and bone grafting, curettage and bone grafting combined with EIN treatment can significantly improve the prognosis of children with bone cysts. It is recommended that EIN be added to bone cyst curettage and bone grafting.

Greater rate of cephalic screw mobilisation following proximal femoral nailing in hip fractures with a tip-apex distance (TAD) and a calcar referenced TAD greater than 25 mm.

BACKGROUND: To ascertain whether the tip-apex distance (TAD), calcar referenced TAD (CalTAD), and the sum of both (TADcalTAD) are predictive measurements of mobilisation of the cephalic screw in patients with trochanteric hip fractures. METHODS: Between 2014 and 2015, 68 patients (mean age 86 years, 45 females, 23 males) with a trochanteric hip fracture underwent intramedullary nailing. The TAD and CalTAD were measured, and for each parameter, we calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: There is evidence of a statistically significant association between a TAD and CalTAD greater than 25 mm and a TADcalTAD greater than 50 mm and mobilisation of the cephalic screw. All measurements have similar sensitivity, but the TAD presents the highest specificity (p < 0.01). CONCLUSION: To avoid the risk of mobilisation of the cephalic screw and possible subsequent failure of the construct, surgeons should strive for a TAD and CalTAD less than 25 mm and a TADcalTAD less than 50 mm when using intramedullary fixation.

[Evolution and principles of intramedullary locked nailing]. / Entwicklung und Prinzipien der Verriegelungsmarknagelung.

Key factors for successful osteosynthetic fracture stabilization are anatomical fracture reduction, restoration of axis and torsion alignment as well as tissue-preserving operative techniques. In long bone fractures, the use of intramedullary long bridging nailing offers ideal conditions for bone healing, as axial and rotational stability is provided by canal-filling nails and locking screws. In addition, the tissue in the fracture region is protected as the intramedullary nail insertion is distant from the fracture. The indication spectrum for modern intramedullary locked nailing includes diaphyseal fractures of long bones, metaphyseal fractures and reconstructions, as well as treatment of nonunion, osteotomy and arthrodesis of the lower extremities. Continuous improvements in nail design and instrumentation as well as the introduction of anatomical reconstruction nails will optimize the spectrum and effectiveness of intramedullary osteosynthesis even further.

No association between surgical delay and mortality following distal femoral fractures. A study from the danish fracture database collaborators.

BACKGROUND: The purpose of this study was to investigate whether surgical delay or the educational level of surgeon is associated with early mortality in patients with distal femoral fractures. METHODS: 392 consecutive patients aged ≥50 years registered in the Danish Fracture Database for surgery of a non-pathological, closed, low-energy distal femoral fracture (AO33A-C) were included. Data included age, gender, American Society of Anaesthesiologists (ASA) score, type of fracture, educational level of surgeon and surgical delay. Educational level of surgeon was defined as "attending or above as surgeon", "attending or above as supervisor" or "below attending alone". Surgical delay was defined as hours (h) from radiological diagnostics until onset of surgery. Mortality data was provided by The Civil Registration System. Mortality rates were calculated using multiple logistical regression analysis. RESULTS: Mean age was 76 years (range 50-101), 79% of patients were female and 65% had an extra articular fracture (AO33A). 8% were operated within 12h, 33% within 24h, 67% within 48h and 83% within 72h. Educational level of surgeon was "attending or above as surgeon" in 56% of all cases and "attending or above as supervisor" in 33%. Mortality was 7.1% at day 30 and 12.5% at day 90. The logistical regression analysis did not demonstrate any association between surgical delay or educational level of surgeon and mortality. Increasing age, male gender and ASA score >2 significantly increased both 30-day and 90-day mortality. CONCLUSION: No association between surgical delay or educational level of surgeon and mortality was found. These findings do not support the development of guidelines for decreasing surgical delay in this population.

Numerical Optimization of the Position in Femoral Head of Proximal Locking Screws of Proximal Femoral Nail System; Biomechanical Study.

BACKGROUND: Proximal femoral fracture rates are increasing due to osteoporosis and traffic accidents. Proximal femoral nails are routinely used in the treatment of these fractures in the proximal femur. AIMS: To compare various combinations and to determine the ideal proximal lag screw position in pertrochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen classification 31-A1) of the femur by using optimized finite element analysis. STUDY DESIGN: Biomechanical study. METHODS: Computed tomography images of patients' right femurs were processed with Mimics. Afterwards a solid femur model was created with SolidWorks 2015 and transferred to ANSYS Workbench 16.0 for response surface optimization analysis which was carried out according to anterior-posterior (-10°0) and posterior-anterior directions of the femur neck significantly increased these stresses. The most suitable position of the proximal lag screw was confirmed as the middle of the femoral neck by using optimized finite element analysis.

Evaluation of malrotation following intramedullary nailing in a femoral shaft fracture model: Can a 3D c-arm improve accuracy?

INTRODUCTION: Difficulty determining anatomic rotation following intramedullary (IM) nailing of the femur continues to be problematic for surgeons. Clinical exam and fluoroscopic imaging of the hip and knee have been used to estimate femoral version, but are inaccurate. We hypothesize that 3D c-arm imaging can be used to accurately measure femoral version following IM nailing of femur fractures to prevent rotational malreduction. METHODS: A midshaft osteotomy was created in a femur Sawbone to simulate a transverse diaphyseal fracture. An intramedullary (IM) nail was inserted into the Sawbone femur without locking screws or cephalomedullary fixation. A goniometer was used to simulate four femoral version situations after IM nailing: 20° retroversion, 0° version, 15° anteversion, and 30° anteversion. In each simulated position, 3D c-arm imaging and, for comparison purposes, perfect lateral radiographs of the knee and hip were performed. The femoral version of each simulated 3D and fluoroscopic case was measured and the results were tabulated. RESULTS: The measured version from the 3D c-arm images was 22.25° retroversion, 0.66° anteversion, 19.53° anteversion, and 25.15° anteversion for the simulated cases of 20° retroversion, 0° version, 15° anteversion, and 30° anteversion, respectively. The lateral fluoroscopic views were measured to be 9.66° retroversion, 12.12° anteversion, 20.91° anteversion, and 18.77° anteversion for the simulated cases, respectively. CONCLUSION: This study demonstrates the utility of a novel intraoperative method to evaluate femur rotational malreduction following IM nailing. The use of 3D c-arm imaging to measure femoral version offers accuracy and reproducibility.

Antegrade versus retrograde nailing techniques and trochanteric versus piriformis intramedullary nailing entry points for femoral shaft fractures: a systematic review and meta-analysis.

BACKGROUND: There are several different techniques commonly used to perform intramedullary (IM) nailing of the femur to fix femoral fractures. We sought to identify significant differences in outcomes of studies comparing 1) trochanteric and piriformis entry and 2) antegrade and retrograde entry in IM nailing of the femur. METHODS: We searched MEDLINE, Cochrane and Embase databases and the Orthopaedic Trauma Association and American Academy of Orthopaedic Surgeons websites for comparative studies published from inception to November 2015. Criteria used to select articles for detailed review included use of antegrade and retrograde entry point or use of trochanteric and piriformis entry point for IM nailing of the femur in adult patients. Functional and technical outcomes were extracted from accepted studies. RESULTS: We identified 483 potential studies, of which 52 were eligible. Of these, we included 13 publications and 2 abstracts (2 level I, 7 level II and 6 level III studies). Trochanteric entry significantly reduced operative duration by 14 min compared with piriformis entry (p = 0.030). Retrograde nailing had a greater risk of postoperative knee pain than antegrade nailing (p = 0.05). On the other hand, antegrade nailing had significantly more postoperative hip pain (p = 0.003) and heterotopic ossification (p < 0.001) than retrograde nailing. No significant differences in functional outcomes were observed. CONCLUSION: Although some significant differences were found, the varying quality of studies made recommendation difficult. Our meta-analysis did not confirm superiority of either antegrade over retrograde or trochanteric over piriformis entry for IM nailing of the femur. LEVEL OF EVIDENCE: Level III therapeutic.

CONTEXTE: Plusieurs techniques différentes sont couramment utilisées pour l'enclouage intramédullaire (IM) du fémur afin d'immobiliser les fractures fémorales. Nous avons voulu dégager les différences significatives sur le plan des résultats d'études ayant comparé 1) l'entrée par le trochanter et par la fossette piriforme et 2) l'entrée par voies antérograde et rétrograde pour l'enclouage IM du fémur. MÉTHODES: Nous avons interrogé les bases de données MEDLINE, Cochrane et EMBASE et les sites Web de l'Orthopaedic Trauma Association et de l'American Academy of Orthopaedic Surgeons pour recenser les études comparatives publiées depuis leur création et jusqu'en novembre 2015. Les critères utilisés pour la sélection des articles en vue d'un examen détaillé incluaient l'utilisation de points d'entrée antérograde et rétrograde ou du trochanter et de la fossette piriforme pour l'enclouage IM du fémur chez des patients adultes. Les résultats fonctionnels et techniques ont été dégagés des études retenues. RÉSULTATS: Nous avons recensé 483 études potentielles, dont 52 se sont révélées admissibles. Parmi elles, nous avons inclus 13 publications et 2 résumés (2 études de niveau I, 7 de niveau II et 6 de niveau III). Le point d'entrée par le trochanter a significativement réduit la durée des interventions, soit de 14 min, comparativement à l'entrée par la fossette piriforme (p = 0,030). L'enclouage rétrograde a comporté un risque plus élevé de douleur postopératoire au genou comparativement à l'enclouage antérograde (p = 0,05). Par ailleurs, l'enclouage antérograde a donné lieu à significativement plus de douleur à la hanche (p = 0,003) et d'ossification hétérotopique (p < 0,001) postopératoires comparativement à l'enclouage rétrograde. Aucune différence significative n'a été observée sur le plan des résultats fonctionnels. CONCLUSION: Même si nous avons noté quelques différences significatives, la qualité variable des études nous empêche de formuler des recommandations. Notre métaanalyse n'a pas confirmé la supériorité du point d'entrée antérograde plutôt que rétrograde ou par le trochanter plutôt que par la fossette piriforme pour l'enclouage IM du fémur. NIVEAU DE PREUVE: Niveau III thérapeutique.

Intramedullary Nailing System in Unstable Both Bone Diaphyseal Fractures in Children.

Background Forearm fractures in pediatric population is usually managed conservatively. Unstable fractures need operative intervention like closed or open intramedullary nailing or open reduction and internal fixation with plates and screws. However, there is no consensus regarding the method of treatment according to age group. Objective To standardize the use of elastic nailing system as effective form of treatment in terms of function, cost and lower complications as compared to widely used titanium nails in developed countries.Method Sixty eight pediatric patients with both bone forearm diaphyseal fractures were managed with closed reduction and intramedullary fixation with rush nail or k-wire and followed at least for 6 months for evaluation of radiological and functional outcome. Result Patients were divided into two age groups, Group A for age of 5 to 9 years (26 patients) and Group B for age of 10-15 years (42 patients). The mean time for union for Group A patient was 7.31 weeks which was significantly lower than that of Group B patients of 9.33 weeks (p-value < 0.05). All the patients in Group A had excellent outcome and 36 (85.7%) patients had excellent outcome and 6 (14.3%) had good outcome in Group B. 5 out of 68 cases (7.35 %) had minor complications (2 in Group A and 3 in Group B). The mean time for implant removal was 17.9 weeks in Group A and 22.9 in Group B. Conclusion Intramedullary fixation for unstable diaphyseal both bone fractures of forearm is safe and cost effective method of treatment with good to excellent functional outcome with union time being significantly lower in younger age group.

Retrograde tibial nailing: a minimally invasive and biomechanically superior alternative to angle-stable plate osteosynthesis in distal tibia fractures.

BACKGROUND: Currently, antegrade intramedullary nailing and minimally invasive plate osteosynthesis (MIPO) represent the main surgical alternatives in distal tibial fractures. However, neither choice is optimal for all bony and soft tissue injuries. The Retrograde Tibial Nail (RTN) is a small-caliber prototype implant, which is introduced through a 2-cm-long incision at the tip of the medial malleolus with stab incisions sufficient for interlocking. During this project, we investigated the feasibility of retrograde tibial nailing in a cadaver model and conducted biomechanical testing. METHODS: Anatomical implantations of the RTN were carried out in AO/OTA 43 A1-3 fracture types in three cadaveric lower limbs. Biomechanical testing was conducted in an AO/OTA 43 A3 fracture model for extra-axial compression, torsion, and destructive extra-axial compression. Sixteen composite tibiae were used to compare the RTN against an angle-stable plate osteosynthesis (Medial Distal Tibial Plate, Synthes®). Statistical analysis was performed by Student's t test. RESULTS: Retrograde intramedullary nailing is feasible in simple fracture types by closed manual reduction and percutaneous reduction forceps, while in highly comminuted fractures, the use of a large distractor can aid the reduction. Biomechanical testing shows a statistically superior stability (p < 0.001) of the RTN during non-destructive axial loading and torsion. Destructive extra-axial compression testing resulted in failure of all plate constructs, while all RTN specimens survived the maximal load of 1,200 N. CONCLUSIONS: The prototype retrograde tibial nail meets the requirements of maximum soft tissue protection by a minimally invasive surgical approach with the ability of secure fracture fixation by multiple locking options. Retrograde tibial nailing with the RTN is a promising concept in the treatment of distal tibia fractures.

Comparing femoral version after intramedullary nailing performed by trauma-trained and non-trauma trained surgeons: is there a difference?

INTRODUCTION: As with some procedures, trauma fellowship training and greater surgeon experience may result in better outcomes following intramedullary nailing (IMN) of diaphyseal femur fractures. However, surgeons with such training and experience may not always be available to all patients. The purpose of this study is to determine whether trauma training affects the post-operative difference in femoral version (DFV) following IMN. MATERIALS AND METHODS: Between 2000 and 2009, 417 consecutive patients with diaphyseal femur fractures (AO/OTA 32A-C) were treated via IMN. Inclusion criteria for this study included complete baseline and demographic documentation as well as pre-operative films for fracture classification and post-operative CT scanogram (per institutional protocol) for version and length measurement of both the nailed and uninjured femurs. Exclusion criteria included bilateral injuries, multiple ipsilateral lower extremity fractures, previous injury, and previous deformity. Of the initial 417 subjects, 355 patients met our inclusion criteria. Other data included in our analysis were age, sex, injury mechanism, open vs. closed fracture, daytime vs. nighttime surgery, mechanism of injury, and AO and Winquist classifications. Post-operative femoral version of both lower extremities was measured on CT scanogram by an orthopaedic trauma fellowship trained surgeon. Standard univariate and multivariate analyses were performed to determine statistically significant risk factors for malrotation between the two cohorts. RESULTS: Overall, 80.3% (288/355) of all fractures were fixed by trauma-trained surgeons. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. This difference was not statistically significant when accounting for other factors in a multivariate model (p>0.05). The same statistical trend was true when analyzing outcomes of only the more severe Winquist type III and IV fractures. Additionally, surgeon experience was not significantly predictive of post-operative version for either trauma or non-trauma surgeons (p>0.05 for both). CONCLUSIONS: Post-operative version or percentage of DFV >15° did not significantly differ following IMN of diaphyseal femur fractures between surgeons with and without trauma fellowship training. However, prospective data that removes the inherent bias that the more complex cases are left for the traumatologists are required before a definitive comparison is made.

Preventing eccentric reaming of the trochanter during trochanteric nailing.

The lateralizing vector of a flexible guide wire can result in eccentric lateral reaming of the proximal femur during intramedullary nailing procedures. This effect is especially true with peritrochanteric fractures that have a fracture line exit near the entry point, and in obese patients. We present one method of maintaining a co-axial position of the guide wire and reamer assembly to help direct the portal of reaming in a more anatomic position. Use of a concave shaped retractor such as an Appendiceal or Richardson helps to "capture" the reamer shaft and control where proximal reaming occurs. We have found this method to be easy to use and effective when indicated.

Techniques for intramedullary nailing of proximal tibia fractures.

Despite poor early results with intramedullary nailing of extra-articular proximal tibia fractures, improvements in surgical technique and implant design modifications have resulted in more acceptable outcomes. However, prevention of the commonly encountered apex anterior and/or valgus deformities remains a challenge when treating these injuries. It is necessary for the surgeon to recognize this and know how to neutralize these forces. Surgeons should be comfortable using a variety of the reduction techniques presented to minimize fracture malalignment.

[Trochanteric fractures - implants]. / Trochanterické zlomeniny - implantáty.

The current market offers a wide range of extra- and intramedullary implants. Their selection should be based on a careful consideration of their design, biomechanical properties and last but not least the quality of the instrumentation set. Mainly this may substantially influence a smooth course of the operation.

[Nailing of pertrochanteric fractures - operative technique]. / Hrebování pertrochanterických zlomenin - operacní technika.

Nailing of pertrochanteric fractures is indicated when DHS is associated with high rate of complications. Thus in unstable comminuted fractures, mainly with posterolateral defect and instability, with Adam´s arch defect and medial instability and in cases when fracture line extends into the subtrochanteric region. The increase in number of nailed pertrochanteric fractures has both its rational and irrational reasons; irrational, as until now there is no clear evidence, that nailing is a faster, safer and easier procedure with a lower rate of complications compared with DHS, a rational, as a proven increase in number of unstable and comminuted fractures has to be reflected in treatment changes. Thus, with respecting the operative techniques principles, intramedullary nailing provides evident biomechanical advantages with the possibility of full weight-bearing and a very low rate of complications.

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

PURPOSE: To systematically evaluate the clinical efficacy of reamed and nonreamed intramedullary nailing in treatment of closed tibial fractures with Cochrane systematic review methods. METHODS: According to the Cochrane systematic review methods, literatures were retrieved from Cochrane library, PubMed, EMbase and other database. Randomized controlled trials (RCTs) and quasi-randomized controlled clinical trials about reamed and nonreamed intramedullary nailing in the treatment of closed tibial fractures were collected and RevMan 5.0 was chosen for meta-analysis. RESULTS: A total of seven studies were included in this meta-analysis. Reamed intramedullary nailing was better than nonreamed intramedullary nailing in nonunion rate [P = 0.02, RR = 0.46, 95% CI: (0.24, 0.91)] and implant failure rate [P <0.0001, RR = 0.36, 95% CI: (0.22, 0.57)]. No statistically significant difference was observed in malunion rate, compartment syndrome rate, postoperative infection [P = 0.18, RR = 0.50, 95% CI: (0.18, 1.383); P = 0 43, RR = 0.77, 95% CI: (0.40, 1.48); P = 0.27, RR = 0.38, 95% CI: (0.01, 7.87)]. CONCLUSION: Compared with the nonreamed intramedullary nailing, reamed intramedullary nailing can lead to better outcome in the treatment of closed tibial fractures.

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

PURPOSE: To systematically evaluate the clinical efficacy of reamed and nonreamed intramedullary nailing in treatment of closed tibial fractures with Cochrane systematic review methods. METHODS: According to the Cochrane systematic review methods, literatures were retrieved from Cochrane library, PubMed, EMbase and other database. Randomized controlled trials (RCTs) and quasi-randomized controlled clinical trials about reamed and nonreamed intramedullary nailing in the treatment of closed tibial fractures were collected and RevMan 5.0 was chosen for meta-analysis. RESULTS: A total of seven studies were included in this meta-analysis. Reamed intramedullary nailing was better than nonreamed intramedullary nailing in nonunion rate [P = 0.02, RR = 0.46, 95% CI: (0.24, 0.91)] and implant failure rate [P <0.0001, RR = 0.36, 95% CI: (0.22, 0.57)]. No statistically significant difference was observed in malunion rate, compartment syndrome rate, postoperative infection [P = 0.18, RR = 0.50, 95% CI: (0.18, 1.383); P = 0 43, RR = 0.77, 95% CI: (0.40, 1.48); P = 0.27, RR = 0.38, 95% CI: (0.01, 7.87)]. CONCLUSION: Compared with the nonreamed intramedullary nailing, reamed intramedullary nailing can lead to better outcome in the treatment of closed tibial fractures.

Are we prepared for orthopedic trauma surgery outside normal working hours? A retrospective analysis.

BACKGROUND: This retrospective analysis was done to determine whether there is a change in outcomes of trauma patients undergoing intramedullary nailing (IMN) for femur and tibia fracture as an emergency versus elective procedure. METHODS: Data were collected for all patients admitted to male orthopedic wards between 1 January 2004 and 30 June 2009 with femur and tibia fractures that required IMN. The data collected included surgery undertaken on as emergency or elective procedure, duration of surgery, complications encountered, and union status of fracture. RESULTS: There were 431 fractures of the tibia, fibula and femur. Operating time for femur fracture as an emergency procedure was significantly greater than for elective surgery (191±79 versus 155±65 minutes; p≤0.001, confidence interval [CI] -19.54). For tibia fracture, operating times were 167.1±62 versus 69.2±35 minutes (p<0.001, CI <-85.4). Complications of infection, secondary surgery and of union were more common in emergency procedures than elective surgeries. CONCLUSION: This study shows that complications are higher in emergency surgery than elective surgery due to the increase in the duration of surgery. This is attributed to the non-availability of dedicated trained orthopedic nursing staff and theater during emergency procedures. We believe that it is time to develop dedicated orthopedic trauma theaters in hospitals that treat emergency fracture fixations.