Nonreamed locking intramedullary nailing for open fractures of the tibia

The use of nonreamed interlocking tibial nails in the management of open fractures of the tibial shaft has gained wide acceptance. This technique has been reported to have reproducible good results with a low incidence of complications in Type I, Type II, and Type IIIA open tibial shaft fractures. The use of nonreamed nails in Type IIIB fractures continues to be a source of controversy. The treatment of 72 open fractures of the tibial shaft with nonreamed interlocking intramedullary nailing is detailed. There were 27 Type I, 22 Type II, 11 Type IIIA, and 12 Type IIIB open tibial shaft fractures. There were three (4.2%) deep infections; one Type II, one Type IIIA, and one Type IIIB. Forty-nine fractures (68%) united by 6 months, all fractures had united by 12 months. The use of nonreamed locking intramedullary nailing in Types I, II, IIIA, and IIIB open fractures of the tibial shaft is supported.     

Nonreamed flexible locked intramedullary nailing in tibial open fractures

Thirty-nine open unstable tibial shaft fractures were treated with a nonreamed flexible locked intramedullary nail between 1992 and 1995. There were 23 Grade I, 12 Grade II, three Grade IIIA, and one Grade IIIB fractures. The average time of followup assessment was 24 months. The average time to fracture union was 24 weeks. Complications were related in most cases to fractures with highly unstable patterns and extensive soft tissue lesions. There were five (12.5%) delayed unions and one (2.5%) nonunion. Deep infections developed in three (7.7%) patients. One patient required an additional procedure to correct a varus malunion. There were no implant failures. It was concluded that nonreamed flexible locked nailing provides effective control of axial and rotational stability in unstable Grades I to IIIA open fractures with acceptable union rates and a low incidence of complications secondary to the fixation system.     

Interlocked intramedullary nailing for treatment of open femoral shaft fractures

Twenty-eight patients with open femoral shaft fractures treated by reamed intramedullary nailing were reviewed retrospectively. Nine patients had Gustilo Grade I injuries; 14, Grade II; and five, Grade IIIA. Twenty cases had static locking, two cases had dynamic locking, and six cases were not locked. Average time to union was 20 weeks. The infection and nonunion rates were 0%. The data suggest that interlocked reamed intramedullary nailing is a safe treatment option for treating open femoral shaft fractures.     

Tibial intramedullary nailing without open drilling

There are presently two competitive theories that attempt to explain the etiology of multiple sclerosis (MS). Briefly summarized, they are: 1. An infection, probably of viral type, may attack the oligodendroglia of the central nervous system; or, 2. An autoimmune process may begin with an infection of the peripheral lymphatic immune system, producing antibodies that cross the blood-brain barrier, leading to myelinoclasia. Since 1935, research has been directed toward myelin of the central nervous system and the myelin sheaths of peripheral nerve; however, dorsal root and cranial sensory ganglia (DRG) have apparently not been studied. The present hypothesis states that an infectious agent (probably viral) finds privileged sanctuary in the dorsal root and cranial sensory ganglia (DRG): thereafter periodically invading the spinal cord, brain, or peripheral nerve. Previously reported erratic spinal fluid viral titers and cultures can be explained by differences in the anatomy of the DRG in which there is a variable and limited contact of spinal fluid with sensory ganglia. Clues to this hypothesis were noted by the author during routine neurological examinations of patients with MS, in which sensory signs and symptoms were frequently encountered. This clinical observation has also been reported by others who found such symptoms in 75% of MS patients, ranking second only to incoordination.     

Vascular reaction following intramedullary nailing of the tibia in dogs

We have reinvestigated radioiodinated plasminogen as an agent for localizing preformed thrombi. Canine plasminogen was isolated from fresh plasma by the affinity chromatography technique on a lysine-sepharose 4B column and tagged with I-123 or I-131, at less than one iodine atom per molecule of enzyme, by the conventional ICI method. When injected into dogs more than 2 days after thrombus induction, radioiodinated plasminogen produced thrombus-to-blood activity ratios of 7.8 +/- 2.4. Thrombi as old as 6 days can be visualized in 80% of the cases. Both the weight of the thrombus and the thrombus-to-blood ratio are more variable for 1-day-old thrombi; this may be associated with plasminogen release accompanying thrombus retraction. The results suggest that radioiodinated plasminogen has potential as an imaging agent for pre-existing thrombi.     

Retrograde intramedullary nailing of femoral diaphyseal fractures

OBJECTIVES: To prospectively evaluate the results of retrograde intramedullary nailing of femoral shaft fractures. DESIGN: Prospective, consecutive series. PATIENTS AND SETTING: All patients with a femoral shaft fracture admitted at an urban Level 1 trauma center from December 1995 to December 1996 were treated with a retrograde femoral intramedullary nail. INTERVENTION: Retrograde femoral intramedullary nailing was performed on a radiolucent operating room table. Through a three-centimeter medial parapatellar incision, a reamed ten-millimeter retrograde nail was inserted. METHODS: From the time of injury until union, the following parameters were assessed: operative time, blood loss, extent of comminution, open grade, associated injuries, Injury Severity Score, body mass index, time to union, secondary procedures, range of motion in the knee. and complications. RESULTS: Fifty-seven patients with sixty-one fractures were available for follow-up, which averaged 43.1 weeks. Fifty-two percent of fractures demonstrated Winquist Type 3 or 4 comminution. Twenty-six percent of the fractures were open. Fifty-two fractures healed after the initial nailing, five of seven dynamized nails healed, and one patient with bone loss requiring bone graft united yielding a final union rate of 95 percent. Of the three nonunions (5 percent), two healed with exchange nailing and one remains asymptomatic at seventy-one weeks. One patient developed a late septic knee that resolved with treatment. Excellent range of motion in the knee was obtained by those patients who did not have other ipsilateral limb injuries. CONCLUSIONS: This consecutive series had a 95 percent union rate after nailing and dynamization as necessary. No knee problems were associated with the retrograde femoral intramedullary nailing technique. The one septic knee raises concerns about the use of retrograde nailing in severe open femoral shaft fractures. Retrograde femoral nailing should be given serious consideration as an alternative to antegrade femoral nailing.     

Retrograde intramedullary nailing of supracondylar femoral fractures

As an alternative to standard AO/Association for the Study of Internal Fixation plate and screw techniques, retrograde intramedullary locked nailing of supracondylar and intracondylar (AO/Association for the Study of Internal Fixation Type 33) fractures is reviewed. This includes a historic review, the technique for knee arthrotomy, fracture reduction and nail insertion, and the reported clinical and biomechanical results. The retrograde intramedullary locked nail is a viable alternative for the treatment of AO/Association for the Study of Internal Fixation Type 33-A and some C supracondylar femoral fractures and should be part of the internal fixation armamentarium, however, it does not replace the standard biologic plate and screw techniques for most fractures.     

Interlocking nailing for fractures of the femur and tibia

In 132 patients, fractures of the lower limb (71 femoral and 61 tibial fractures) were treated using interlocking nailing (ILN) according to Grosse and Kempf during the period 1986-1989. Of these, 118 were followed up for a median of 19 months (range 9-32 months). Inpatient stay averaged 9 days regardless of the fracture. Consolidation was achieved in approximately 3 or 4 months from the operation in tibial and femoral fractures, respectively. Tibial fractures were technically more demanding than femoral ones, and their average operating time was significantly longer (73 min versus 51 min). Only one patient had a malunion in malrotation. The most serious complication was in a closed upper tibial fracture with traumatic rupture of the popliteal artery. Although the nailing was technically successful, an above-knee amputation had to be carried out. In only one case did the nail fail, and tibial plating had to be performed. Given the present degree of expertise, ILN for fractures of the long bones of the lower limb is a safe and relatively easy procedure to perform.     

Double level fractures of the femur treated with closed intramedullary nailing

Breast cancer patients receiving tamoxifen (Tam) are at an increased risk for developing endometrial carcinomas, possibly due to the partial estrogenic effect of Tam on endometrial cells. Progestational therapy has not routinely been included in Tam regimens. It was our aim to determine the presence of estrogen receptors (ERs) and progesterone receptors (PRs) in normal and abnormal endometria from postmenopausal women with breast cancer who were treated with Tam. Standard immunohistochemical staining of ERs and PRs was performed on paraffin sections from formalin-fixed uterine curettings or hysterectomy specimens from 40 patients who had received 20-40 mg of Tam daily for a minimum of 3 months. For comparison, normal endometria from 20 women who had not received Tam (11 premenopausal, 9 postmenopausal) were also studied for ER and PR expression. Staining was evaluated using semiquantitative immunoreactivity scores (IRS) ranging from 0 (negative) to 12 (strongly positive). In the group of patients receiving Tam, ERs and PRs were detected in the nuclei of glandular cells in 24/24 cases of endometrial atrophy (ER/PR-IRS, 2-12), in 8/8 endometrial polyps (ER-IRS, 6-12; PR-IRS, 4-12), in 4/4 adenomatous endometrial hyperplasias (ER-IRS, 3-8; PR-IRS, 1-12), and in 4/4 well-differentiated endometrioid adenocarcinomas (ER-IRS, 2-12; PR-IRS, 6-8). Of the 11 endometria from premenopausal patients who had not received Tam, 8 were ER+/PR+ (ER-IRS, 1-12; PR-IRS, 1-12), 1 was ER+/PR- (ER-IRS, 3; PR-IRS, 0), 1 was ER-/PR+ (ER-IRS, 0; PR-IRS, 2), and 1 was ER-/PR- (ER/PR-IRS, 0). Among 9 atrophic endometria from women not treated with Tam, 6 were ER+/PR+ (ER-IRS, 4-12; PR-IRS, 3-6), 1 was ER+/PR- (ER-IRS, 4; PR-IRS, 0), and 2 were ER-/PR- (ER/PR-IRS, 0). The consistent finding of ER and PR expression in endometria from postmenopausal women receiving Tam further supports the suspected estrogenic effect exerted by Tam on endometrial cells. Progestational therapy could be beneficial in the prevention of Tam-induced abnormal endometrial proliferations.     

Fractures of the femoral shaft: a prospective study of closed intramedullary nailing, modified open intramedullary nailing, and cast-bracing

One hundred twelve consecutive fractures of the femoral diaphysis were treated in a prospective study at Grady Memorial Hospital, a designated trauma center, during the three-year period 1978 through 1980. Fifty of these were treated by closed intramedullary nailing; all united. Of the rest, 20 were treated by modified open intramedullary nailing, and 42 by cast-bracing. Closed intramedullary nailing offered a significant reduction in hospitalization and healing times compared to the other two methods; however, the high cost of equipment, along with the added cost of reoperation to remove the nail, rendered cast-bracing economically superior. Fractures treated by modified open intramedullary nailing developed no infections, but these patients lost significantly more blood during operation than those treated by closed nailing. Because of the decreased hospitalization and healing times, we prefer the closed intramedullary nailing technic for use in selected femoral fractures treated during the acute phase by an experienced surgical team.     

Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus

In previous experiments using the fat substitute sucrose polyester (SPE, or olestra), no compensatory response was observed on day 2 after experimental manipulations, which reduced the percentage of energy from fat to approximately equal to 30% from 40% on day 1. In the present study a more severe manipulation was made; the amount of energy from fat was reduced from 32% to 20% to determine whether such a reduction would provoke any physiologic or behavioral response. Subjects came to the unit for two, 2-d test sessions. Intake on day 1 was fixed: subjects were given meals containing either control fat (11319 kJ, 32% of energy as fat) or SPE (9561 kJ, 20% of energy as fat). On day 2, intake was ad libitum. On day 1 subjects rated themselves as more hungry while consuming the fat-substituted meals than when consuming the control meals and they disclosed greater hunger in the end-of-day questionnaires. The effect of the manipulation was carried over into day 2. By the end of day 2, subjects had compensated for 74% of the energy (fat) deficit caused by the previous day's manipulation. These results differ from those obtained when fat was reduced from 40% to 30% of energy; this more severe reduction reveals that a reduction in fat of this size can lead to a biobehavioral response. Together, these data suggest that people could change their diet to meet dietary guidelines; however, if a more severe reduction is attempted, adherence may be made more difficult by the strength of the compensatory response.     

Gait study in evaluation of results in intramedullary nailing for femoral shaft fractures

The present preliminary investigation conducted on six adult males whose femur shaft fractures had been fixed internally by means of Hansen-Street intermedullary nails indicated that our gait study technic helps confirm the clinical findings in such cases. Five patients, although their fractures had united and they had resumed their usual activities, were not deemed quite normal as yet and the causes for their gait abnormality were identified in the clinical examination. The gait study technic thus provided fairly accurate quantitative support of the clinical findings.     

A comparison of the relative costs of cast treatment and intramedullary nailing for tibial diaphyseal fractures in the UK

A retrospective study was undertaken to compare the costs of treating tibial diaphyseal fractures non-operatively in a cast or operatively with locked intramedullary nailing. In total 39 patients with isolated closed or grade I open, two-part, displaced tibial diaphyseal fractures were studied. Of these, 18 were treated by manipulation under anaesthesia and cast immobilization, and 21 by closed, reamed, locked intramedullary nailing. A detailed analysis of the cost of treatment of each patient was performed and analysed in terms of the in-hospital costs and the overall costs, taking into account time off work. The mean hospital costs were 2226 pounds for plaster treatment and 3727 pounds for intramedullary nailing (significantly different, p < 0.05). The mean time off work was 9 weeks longer in the plaster group and when the cost of lost production through time off work was added to the hospital costs, the overall costs of plaster treatment and intramedullary nailing were 6810 Pounds and 6592 Pounds (difference not significant). This study suggests that the cost to the hospital of treating these fractures is less with plaster treatment but that the overall cost to the community is no different.     

Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures

From 04/91 to 06/96 sixty-nine open fractures of the tibia were primarily treated on the day of the accident with unreamed nailing (UTN, Synthese). The distributions of fracture type according to the AO classification and of soft tissue injury according to Gustilo were as follows: fracture type: A: 28%, B: 52%, C: 20%; soft tissue injury: I: 30%, II: 28%, IIIA: 12%, IIIB: 12%, IIIC: 6%. Of the 65 fractures assessed 46 (71%) healed within 18 weeks without secondary intervention. There was delayed healing in three fractures requiring secondary conversion to reamed nailing. Eight fractures (12%) developed pseudarthrosis of which five (8%) healed uneventfully. Deep infections was manifest in four fractures (6%). Three of these infections developed after secondary intervention to treat pseudarthrosis. Seven of the eight pseudarthroses and three of the four infections healed eventually. Revision procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing or infection (10 reamed nailing procedures, three cancellous bone grafts, and one of each of the following: sequestrectomy, fibular osteotomy, plate fixation, external fixator, monorail procedure). The results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.     

Pudendal nerve palsy after femoral intramedullary nailing

BACKGROUND: Recent results suggest decreased interferon gamma (IFN-gamma) but high interleukin 4 (IL-4) production in patients with atopic dermatitis (AD). Because the relative activities of IL-4 and IFN-gamma seem to regulate the amplitude of the IgE response we suggested a role for IFN-gamma in the treatment of AD. OBJECTIVE: The purpose of this study was to assess the efficacy of systemic IFN-gamma treatment in patients with severe AD. METHODS: Patients with severe AD (n = 14) were treated with recombinant IFN-gamma for 6 weeks. During the study only basic local therapy with steroid-free hydrophilic or emollient ointments was allowed. RESULTS: Eight patients (57%) showed marked clinical improvement during systemic IFN-gamma therapy. Four of these patients showed continuous improvement 3 months after treatment was discontinued. Mean total and antigen-specific serum IgE concentrations were not statistically different during and after treatment, whereas mean spontaneous IgE production in vitro was significantly lower after 6 weeks of IFN-gamma therapy. CONCLUSION: Our results suggest that IFN-gamma treatment may represent a novel therapeutic approach in patients with severe AD.