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Are inflatable nails an alternative to interlocked nails in tibial fractures?

ABSTRACT: Recently developed inflatable nails avoid reaming and interlocking screws in tibial fractures and reflect a new principle for stabilization of long bone fractures. We asked if the bending stiffness, rotational rigidity, or play (looseness of rotation) differed between an inflatable versus large-diameter reamed interlocked nails, and whether the maximal torque to failure of the two bone-implant constructs differed. In a cadaveric model, we compared the biomechanical properties with those of an interlocked nail in eight pairs of fractured tibial bones. Bending stiffness, rotational rigidity, play (looseness in rotation), and torsional strength within 20 degrees rotation were investigated using a biaxial servohydraulic testing system. For all biomechanical variables, we found a large interindividual variance between the pairs attributable to bone quality (osteoporosis) for both fixation methods. The inflatable nail had a higher bending stiffness, with a mean difference of 58 N/mm, and a lower torsional strength, with a mean difference of 13.5 Nm, compared with the locked nail. During torsional testing we noted slippage between the inflatable nail and bone. We observed no differences in play or rotational rigidity. Given the lower torsional strength we recommend caution with weightbearing until there are signs of fracture consolidation.

SUBMITTER: Blomquist J

PROVIDER: S-EPMC2311493 | biostudies-other | 2008 May

REPOSITORIES: biostudies-other

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Project description:BackgroundSurgeons agree on the benefits of operative treatment of tibial fractures - the most common of long bone fractures - with an intramedullary rod or nail. Rates of re-operation remain high - between 23% and 60% in prior trials - and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better.Methods/designThe objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0-3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes.DiscussionThe primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following re-operations: bone grafts, implant exchanges, and dynamizations, in patients with fracture gaps less than 1 cm post intramedullary nail insertion. Infections and fasciotomies were considered events irrespective of the fracture gap. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. S.P.R.I.N.T is the largest collaborative trial evaluating alternative orthopaedic surgical interventions in patients with tibial shaft fractures. The methodological rigor will set new benchmarks for future trials in the field and its results will have important impact on patient care. The S.P.R.I.N.T trial was registered [ID NCT00038129] and received research ethics approval (REB#99-077).

Project description:ObjectivesThis study was performed to determine (1) the incidence of humeral shaft fractures within the Medicare noncancer population, (2) the trends in utilization of humeral shaft fixation techniques by plate-and-screw devices and intramedullary nails, (3) differences in procedure times, and (4) the outcomes of individuals as measured by rate of secondary operations and 1-year mortality.Design/settingRetrospective comparative cohort analysis. A cancer-free Medicare part B claims sample derived from a 5% sample from the years 1993 to 2007 was analyzed.Patients/interventionOur cohorts were generated by diagnostic and procedural codes for humeral shaft fractures.Main outcome measurementThe incidence of humeral shaft fracture and trend in operative fixation were evaluated for all years of data. Surgical times were assessed by anesthesia Current Procedural Terminology codes. Outcomes and complications were assessed by Current Procedural Terminology codes. The proportion of individuals experiencing complications and 1-year mortality were compared by proportion hazards.ResultsWe identified 1385 claims for humeral shaft fractures over 15 years, with an adjusted rate of between 12.0 and 23.4 fractures per 100,000 beneficiaries. We identified 511 individuals who received surgical treatment for humeral shaft fractures, 451 of whom had complete 1-year follow-up data. Nail fixation was more prevalent than plate fixation most years and had shorter anesthesia time by 27.1 minutes (P < 0.0001). There were no significant differences in the complication rates between the 2 groups as measured by incidence of secondary operations and 1-year mortality.ConclusionsIntramedullary nails are used for the majority of operative humeral shaft fractures among Medicare beneficiaries. Nailing has a shorter mean operative time. The 2 surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality.Level of evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Project description:PurposeTo examine the condition and triggers of stress fractures of the lateral tibial plateau (LTP) similar to type III lateral hinge fractures (LHFs) after open wedge high tibial osteotomy (OWHTO).MethodsOWHTO was performed in 118 knees. They were examined for LHFs by computed tomography (CT). Patients were divided into the stress fracture group (Group SF) if they showed fracture lines on CT performed after starting weight-bearing walking and the normal group (Group N) for others.ResultsThe mean age was significantly older in Group SF (P = 0.022). Preoperatively, Group SF showed a significantly higher tibio-femoral angle (TFA, P = 0.014). No significant differences were observed in TFA and weight-bearing line ratio after surgery. Correction angle was significantly higher in the SF group. And all of the SF were more than 13 degrees. There was no significant difference in LHF incidence between groups, whereas stress fracture incidence differed significantly for each type of LHF (chi-squared test, P = 0.0001): 14.6% of type I cases, 100% of type II cases, 0% of type III cases, and 6.1% of those without LHF.DiscussionThe load on the LTP is assumed to act as a shearing force in type II fractures, which may contribute greatly to stress fractures. In type III, stress fractures may not occur because of the load dispersed at the fracture part. The stress fracture site is similar to type III LHF, and this kind of fracture is thought to be a delayed type III because it occurs after patients start weight-bearing walking. Moreover, they are observed in type I cases with a stable hinge and in 6% of cases without LHF. This study showed that high varus knees corrected with a large correction angle may develop stress fractures. OWHTO requires attention to stress fractures of the LTP, which can be regarded as delayed type III, in those developing LHFs postoperatively or having a high varus knee preoperatively.ConclusionThese results indicated the possibility of stress fracture in LTP during weight-bearing exercise after OWHTO, which was regarded as a delayed type III fracture. The results showed that Correction angle was more than 13 degrees, and lateral hinge fracture type II of the Takeuchi classification was an inducement of this stress fracture.Level of evidenceLevel IV.

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Are inflatable nails an alternative to interlocked nails in tibial fractures?

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