Medial migration of the helical blade with penetration into the acetabulum: a rare complication using the TFNA nail.

PURPOSE: To determine the frequency and possible reasons of medial migration with penetration into the acetabulum (MMPA) of the helical blade when using the Trochanteric Fixation Nail Advanced (TFNA) is used for treatment of pertrochanteric fractures. METHODS: All patients with pertrochanteric femoral fracture, treated by intramedullary femoral nailing with the TFNA, were retrospectively reviewed for MMPA of the helical blade. Epidemiological parameters, additional procedures, distance of medial migration, time from primary operation to revision as well as type of revision were assessed. RESULTS: 4 of 153 patients treated with the TFNA developed an MMPA of the helical blade (risk = 2.6%), with a mean medial migration of the blade of 11.6 mm (SD 8.8). The mean time from initial operation to revision surgery was 70 days (SD 30). All patients were revised by conversion to cemented total hip arthroplasty. CONCLUSION: MMPA of the helical blade is a rare but potentially hazardous complication of femoral nailing with the TFNA femoral nail, resulting in the necessity for revision surgery and total hip arthroplasty.

Clinical outcomes and tendon lengthening after arthroscopic rotator cuff repair.

BACKGROUND: There is a phenomenon in which the tendon appears to increase the length after rotator cuff repair. However, it is unclear in which cases tendon lengthening occurs and how the degree of lengthening affects the surgical outcome. This study aimed to evaluate preoperative and postoperative musculotendinous junction (MTJ) and tendon length on magnetic resonance imaging and assess the postoperative tendon lengthening and its impact on postoperative outcomes. METHODS: We reviewed 109 patients with good repair integrity after arthroscopic rotator cuff repair. Patients whose supraspinatus tendons were simply pulled out laterally without any additional procedures were included. They underwent serial magnetic resonance imaging before surgery and at 3, 6, and 24 months after surgery. The location of the MTJ in relation to the line of the glenoid fossa and the supraspinatus tendon length were measured. Clinical evaluation was conducted 2 years after surgery, including the range of shoulder motion, shoulder strength index (affected/unaffected strength), Constant score, University of California, Los Angeles score, and pain numeric rating scale. The characteristics of the preoperative tendon, change in tendon length over time, amount of the lateral shift of MTJ location and tendon length, and impact of tendon lengthening on postoperative clinical outcomes were analyzed. RESULTS: The preoperative tendon retraction significantly correlated with the MTJ location (r = -0.75; P < .0001) and preoperative tendon length (r = -0.46; P < .0001). The tendon length at 3, 6, and 24 months after surgery was significantly longer than those before surgery (26.7 ± 5.8 mm, 27.9 ± 6.6 mm, 28.5 ± 5.6 mm, and 21.5 ± 5.1 mm, respectively). From before surgery to 24 months after surgery, the MTJ location moved 8.4 ± 8.6 mm laterally and the tendon length increased 7.0 ± 6.1 mm. A significant and weak negative correlation was found between tendon lengthening and the abduction strength index (r = -0.22; P = .03); however, no significant correlation with pain, range of shoulder motion, external rotation strength index, Constant score, and University of California, Los Angeles score was found. Multiple linear regression analysis also showed that tendon lengthening was only associated with the abduction strength index (standardized coefficient = -0.20, P = .03). CONCLUSIONS: Tendon lengthening and lateral shift of MTJ location were observed after arthroscopic rotator cuff repair, and they correlated with preoperative tendon retraction. Although the amount of tendon lengthening had negative weak correlation with abduction strength index, it did not affect other postoperative outcomes.

[Complications after intramedullary stabilization of clavicle fractures]. / Komplikationen nach intramedullärer Stabilisierung von Klavikulafrakturen.

BACKGROUND: Operative treatment of clavicle fractures by intramedullary nailing with titanium elastic nailing (TEN) has been established as an alternative to plate osteosynthesis for many years. The main complication after TEN osteosynthesis is nail migration. The goal of this study was evaluation of predictors for medial nail migration and comparison with plate osteosynthesis. MATERIAL AND METHODS: A retrospective analysis of electronic patient charts, surgical protocols and radiographs of all operatively treated clavicle shaft fractures between 2010-2014 (n = 141) was performed. When evaluating the patient charts and the surgical protocols special attention was paid to the fracture type, the duration of the operation, the need for an open reduction and the onset of complications as well as the duration until implant removal. Radiographs were analyzed concerning the implant location and an implant migration. RESULTS: Surgery time (39 vs. 83 min) as well as the time to implant removal (226 vs. 495 days) were significantly reduced (p = 0.00), while complication (39% vs. 21.4%) as well as reoperation rates (15% vs. 7.1%; p = 0.033) were increased in TEN compared to plate osteosynthesis. The main complication was medial nail migration. The following predictors regarding medial migration could be identified: open or closed reduction (p = 0.021), multifragmentary fractures (p = 0.049), oblique fractures (p = 0.08) and TEN thickness (33% at 2 mm, 0% at 3 mm). DISCUSSION: Advantages of TEN are a shorter surgery time as well as a shorter duration until implant removal. The TEN osteosynthesis led to a significantly increased complication rate, with nail migration representing the major reason. When predictors for medial TEN migration are considered, type B and C fractures can also be sufficiently treated by a large diameter TEN.

Cephalomedullary Nail Lag Screw Migration Following Open Reduction and Internal Fixation of an Intertrochanteric Femur Fracture in a Patient With Body Mass Index of 63.

Hip fractures are prevalent among the elderly population and are correlated with notable morbidity and mortality. Treatment with intramedullary nails has risen in popularity with good results, however complications can occur. We report on a 62-year-old female with a body mass index of 63 kg/m2 who presents with cephalomedullary nail lag screw migration following an open reduction and internal fixation of an intertrochanteric fracture, which was subsequently converted to a hip hemiarthroplasty after hardware failure of her cephalomedullary nail. Proper radiographic follow-up is essential for catching the complication early and preventing further injury. Hemiarthroplasty is an appropriate next step when facing this complication.

Intrapelvic migration of the lag screw in intramedullary nailing after intertrochanteric fracture fixation: A case report.

The expected number of hip fractures worldwide will rise from 1.7 million in 1990, to 6.3 million in 2050. In parallel, surgical complications are expected to increase. We describe a rare complication of intrapelvic migration of the lag screw from trochanteric nail in a 90-year-old woman.

Intramedullary nailing confers an increased risk of medial migration compared to dynamic hip screw fixation in unstable intertrochanteric hip fractures.

INTRODUCTION: Medial migration of the femoral neck element (FNE) superomedially against gravity with respect to the intramedullary component of the cephalomedullary nail is a complication increasingly recognized to cause femoral head cut-out in intramedullary nailing of pertrochanteric hip fractures. Although cut-outs are common to both intra- and extramedullary fixation, especially in unstable pertrochanteric hip fractures, FNE medial migration in sliding hip screws continues to remain sparse despite increased awareness of the phenomenon. This study aims to investigate whether intramedullary nailing is biomechanically predisposed to FNE medial migration compared to extramedullary fixation with sliding hip screws to account for the discrepancy in reported FNE medial migration rates. MATERIALS AND METHODS: Twelve fourth-generation synthetic femurs (Sawbones) with unstable intertrochanteric fractures were divided into 2 groups (n=6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA, Synthes) (n=6) in the first group, and the Dynamic Hip Screw (DHS, Synthes) (n=6) in the second group. Both groups were subjected to bidirectional cyclic loading (600N compression loading, 120N tensile loading) at 2 Hz for 5000 cycles. The medial migration distance (MMD) was recorded at the end of the testing cycles. RESULTS: The mean MMD in the PFNA group was 4.56mm (SD 0.69mm) with consistent reproduction of medial migration across all constructs tested. This was significantly more compared to the MMD of 1.17mm (SD 0.69mm) in the DHS group (p<0.001). CONCLUSION: Intramedullary nailing of unstable intertrochanteric hip fractures is inherently predisposed to FNE medial migration making it more susceptible to consequent cut-out compared to fixation with the DHS.

Scanning Electron Microscopy Study of Retrieved Implants Suggests a Ratcheting Mechanism Behind Medial Migration in Cephalomedullary Nailing of Hip Fractures.

INTRODUCTION: Medial migration is the paradoxical migration of the femoral neck element (FNE) superomedially against gravity with respect to the intramedullary component of the cephalomedullary device, increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. We postulate that the peculiar anti-gravity movement of the FNE in the medial migration phenomenon stems from a ratcheting mechanism at the intramedullary nail-FNE interface, which should inadvertently produce unique wear patterns on the FNE that can be seen with high-powered microscopy. By examining the wear patterns on retrieved implants from patients with medial migration, our study aims to draw clinical correlations to the ratcheting mechanism hypothesis. MATERIAL AND METHODS: Four FNEs were retrieved from revision surgeries of four patients with prior intramedullary nail fixation of their pertrochanteric hip fractures complicated by femoral head perforation. The FNEs were divided into two groups based on whether or not there was radiographic evidence of medial migration prior to the revisions. Wear patterns on the FNEs were then assessed using both scanning electron microscopy and light microscopy. RESULTS: Repetitive, linearly-arranged, regularly-spaced, unique transverse scratch marks were found only in the group with medial migration, corresponding to the specific segment of the FNE that passed through the intramedullary component of the PFNA during medial migration. These scratch marks were absent in the group without medial migration. CONCLUSION: Our findings are in support of a ratcheting mechanism behind the medial migration phenomenon with repetitive toggling at the intramedullary nail-FNE interface and progressive propagation of the FNE against gravity.

Medial migration of the tympanostomy tube: what is the optimal management option?

The tympanostomy tube insertion is the gold standard of treatment for secretory otitis media. Complications are associated with this surgery in 17% of cases. One of the rare but real complications is the medial migration of the tympanostomy tube. To our knowledge, this is the 14th case reported in childhood. Considering this rarity, there is no consensus for the management of this phenomenon. Some authors propose a surgical removal, while others prefer to observe whether the patient is asymptomatic. We reported a case of migration of the tympanostomy tube and described the detailed clinical features and management options. This case report and mini-review will broaden readers the knowledge of medial migration of the tympanostomy tube and may guide the relative treatment of this complication in the future.

Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model.

OBJECTIVES: The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling. METHODS: A total of 18 synthetic femurs (Sawbones, Vashon Island, Washington) with comminuted pertrochanteric fractures were divided into three groups (n = 6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA) implant (Synthes, Oberdorf, Switzerland; n = 6). Group 1 was subjected to unidirectional compression loading (600 N), with an elastomer (70A durometer) replacing loose fracture fragments to simulate surrounding soft-tissue tensioning. Group 2 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading), also with the elastomer replacing loose fracture fragments. Group 3 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading) without the elastomer. All constructs were tested at 2 Hz for 5000 cycles or until cut-out occurred. The medial migration distance (MMD) was recorded at the end of the testing cycles. RESULTS: The MMDs for Groups 1, 2, and 3 were 1.02 mm, 6.27 mm, and 5.44 mm respectively, with reliable reproduction of medial migration seen in all groups. Bidirectional loading groups showed significantly higher MMDs compared with the unidirectional loading group (p < 0.01). CONCLUSION: Our results demonstrate significant contributions of bidirectional cyclic loading to the medial migration phenomenon in cephalomedullary nail fixation of pertrochanteric hip fractures.Cite this article: G. W. Law, Y. R. Wong, A. K-S. Yew, A. C. T. Choh, J. S. B. Koh, T. S. Howe. Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model. Bone Joint Res 2019;8:313-322. DOI: 10.1302/2046-3758.87.BJR-2018-0271.R1.

What to do with medialized tympanostomy tubes? A survey of pediatric otolaryngologists.

INTRODUCTION: Tympanostomy tube placement is the most common surgical procedure performed in children. Medial migration of a tympanostomy tube is a rare occurrence where the tube migrates into the middle ear cavity as opposed to its normal extrusion into the external auditory canal. Whether medialized tympanostomy tubes should be surgically removed in asymptomatic patients is controversial. The objective of this study was to determine experience and management approach of medialized tympanostomy tubes among pediatric otolaryngologists. METHODS: A 12-question cross-section survey was designed and distributed to the American Society of Pediatric Otolaryngology (ASPO) members. The survey study was granted McGill University institutional review board and ASPO research committee approval. The survey data were filtered and cross-tabulated. Descriptive statistics were generated. RESULTS: 128 pediatric otolaryngologists completed the 12-question survey. The majority of respondents had experienced at least one case of medialized tympanostomy tube (90.6%). The majority of patients (82.0%) were asymptomatic. 74 out of 128 respondents (57.8%) indicated that they would not remove a medialized tube in an asymptomatic patient. However, 7.0% of those respondents clarified that they would proceed to surgical removal if the patient were undergoing general anesthesia for another surgery. 30.5% of respondents indicated that they would surgically remove the tube even if the patient were asymptomatic. 6.3% of respondents indicated that opted management in children would be based on a shared decision with parents. Most respondents (80.5%) did not experience complications with surgical removal nor with elected observation. CONCLUSION: There is no consensus among pediatric otolaryngologists regarding the necessity of surgically removing a medialized tympanostomy tube in asymptomatic patients. The survey suggests that both options are acceptable. If observation is chosen, it is important that parents are well informed of the potential long-term sequelae of a medialized tube and advised to consult if symptoms occur.

To remove or not to remove: Review of cases of medial migration of tympanostomy tubes.

OBJECTIVE: Few cases of medial migration of tympanostomy tubes have been reported and its optimal management has not been well delineated especially in asymptomatic patients. The aim of this review is to present all cases of medialized tympanostomy tubes reported in the literature in order to provide the most beneficial management option. METHODS: Eligible articles were identified through a comprehensive search in Cochrane, Embase and Medline electronic databases. Two reviewers independently screened the data sources, using pre-defined inclusion criteria to generate a list of eligible articles. Data extracted included patient demographics, diagnosis, type of tube, timing of migration, presenting symptoms, examination outcomes, treatment and follow up. RESULTS: 10 articles were chosen for data extraction from which 29 patients presenting with medial migration of tympanostomy tube were identified. CONCLUSION: The low complications associated with removing a medialized tube and the risk of leaving foreign objects in the middle ear cleft make myringotomy for removal of the tube a practical and safe management option for medialized tubes even in asymptomatic patients.

Scanning Electron Microscopy Study of Retrieved Implants Suggests a Ratcheting Mechanism Behind Medial Migration in Cephalomedullary Nailing of Hip Fractures

@#Introduction:Medial migration is the paradoxical migration of the femoral neck element (FNE) superomedially against gravity with respect to the intramedullary component of the cephalomedullary device, increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. We postulate that the peculiar antigravity movement of the FNE in the medial migration phenomenon stems from a ratcheting mechanism at the intramedullary nail-FNE interface, which should inadvertently produce unique wear patterns on the FNE that can be seen with high-powered microscopy. By examining the wear patterns on retrieved implants from patients with medial migration, our study aims to draw clinical correlations to the ratcheting mechanism hypothesis. Material and methods: Four FNEs were retrieved from revision surgeries of four patients with prior intramedullary nail fixation of their pertrochanteric hip fractures complicated by femoral head perforation. The FNEs were divided into two groups based on whether or not there was radiographic evidence of medial migration prior to the revisions. Wear patterns on the FNEs were then assessed using both scanning electron microscopy and light microscopy. Results: Repetitive, linearly-arranged, regularly-spaced, unique transverse scratch marks were found only in the group with medial migration, corresponding to the specific segment of the FNE that passed through the intramedullary component of the PFNA during medial migration. These scratch marks were absent in the group without medial migration. Conclusion: Our findings are in support of a ratcheting mechanism behind the medial migration phenomenon with repetitive toggling at the intramedullary nail-FNE interface and progressive propagation of the FNE against gravity.

Medial migration of lag screw after gamma nailing.

Fractures of the proximal femur are common in the elderly population. Intramedullary nailing has become the standard treatment for intertrochanteric fractures although several extramedullary implants (e.g. dynamic hip screw (DHS), blade plate, locking compression plate (LCP), etc.) exist. However, despite this being a very common operation in traumatology, there are numerous associated complications. We report the rare complication of the migration of the medial lag screw into the pelvis at five and a half weeks postoperatively. The implant was removed and replaced by a total hip arthroplasty with simultaneous grafting of the acetabular defect and strapping of the greater trochanter. The evolution was favourable. We also present a review of the literature and analyze our case.