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CLOSED INTRAMEDULLARY
INTERLOCKING NAILING
FOR FEMORAL SHAFT FRACTUREMANAGEMENT
Dr. SARDAR SOHAIL AFSAR,
YEAR 4, POST GRADUATE TRAINEE,ORTHOPAEDIC UNIT, LRH, PESHAWAR.
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Femur Fractures
Common injury due to major violent trauma 1 femur fracture/ 10,000 people
More common in people < 25 yr or >65 yr
Femur fracture leads to reduced activity for107 days, the average length of hospital stay
is 25 days
Motor vehicle, motorcycle, auto-pedestrian,
aircraft, and gunshot wound accidents aremost frequent causes
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Anatomy Long tubular bone, anterior
bow, flair at femoral condyles
Blood supply
Metaphyseal vessels
Single nutrient artery in
diaphysis enters through thelinea aspra
Nutrient artery communicateswith medullary arteries inintramedullary canal
Medullary arteries supply 2/3 ofendosteal blood supply
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Blood Supply
Reaming destroysintramedullary endosteal bloodsupply
Periosteal blood flow increases
Medullary blood supply is
re-established over 8-12
weeks if spaces left in
canal by implant
Unreamed intramedullarynailing decreases blood flowless; restoration of endostealblood flow earlier but equal toreamed canal at 12 weeks
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Femur Fracture Classification
AO/OTA Femur Diaphysis - Bone segment 32
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Femur Fracture Management
Piriformis fossa intact,
lesser trochanter intact
Can you nail this ?
Should you nail this ?
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Femur Fracture
Management Initial traction with portable traction splint or
transosseous pin and balanced suspension
Evaluation of knee to determine pinplacement
Timing of surgery is dependent on:
Resuscitation of patient
Other injuries - abdomen, chest, brain
Isolated femur fracture
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Hare traction splint for initial reduction of
femur fractures prior to OR or skel
etal
traction
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Diaphyseal fractures are managed by
Intramedullary nailing.
Proximal or distal 1/3 fractures MAY bemanaged best with a plate or an
intramedullary nail depending on the location
and morphology of the fracture
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CLOSED INTRAMEDULLARY INTERLOCKING
NAILING
Effective method
Preferred procedure
Associated with high union rates and lowcomplication rates
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HISTORY
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Mid 1800s
Ivory pegs were
inserted into the
medullary canal for
non-union.
It had been observed
that ivory would get
reabsorbed in thehuman bone.
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1890
Gluck recorded the first description of an
interlocked intramedullary device.
The device consisted of an ivory
intramedullary nail that contained 2 holes at
the end, through which ivory interlocking pins
could be passed through.
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WORLD WAR I
Hey Groves of England reported the use of
metallic rods for the treatment of gunshot
wounds.
Very high infection rate.
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The Evolution of Kntscher Nailing
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Gerhard Kntscher 1900-1972
Gerhard Kntscher was born in Germany in
1900.
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Gerhard Kntscher - continued
His early interest inintramedullary devices resulted
from his work with the Smith-
Petersen nail.
Kntscher believed the same
basic science principles would
be able to be used for
diaphyseal fractures.
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Gerhard Kntscher - continued
During development of his marrow nail he conducted
studies on cadavers' and animals
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Gerhard Kntscher - continued
By late 1940s,
Kntscher had
designed a new nail,
the cloverleaf nail.
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Gerhard Kntscher - continued
While there was some interest in the use of
Kntschers technique in Europe during
World War II, his method was essentially
unknown in the US.
This was until it was described in an article
published in the March 12, 1945, TimeMagazine. Titled Amazing Thighbone
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Medicine: Amazing Thighbone Monday, Mar. 12, 1945
At England General Hospital in Atlantic City last week was a
wounded soldier with a strangely mended femur (thighbone).The man had been treated by the Germans, his captors.
When the broken bone failed to heal, after weeks of conventional treatment, the soldier was operated on.
He was mystified to find that his only new wound was a 2-inch incision above the hipbone.
Two days later, the German surgeons told him to move his
leg; a few days after that, they told him to walk.
He did and he has walked ever since.
.
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After his exchange, U.S. Army doctors X-rayed thesoldier's leg.
They were amazed at what they saw: a half-inch metal rodof some kind had been rammed down the thighbonethrough the marrow for three-quarters of the bone's length,thus supplying a permanent, internal splint.
Mechanically, the surgeons agree, there is no reason sucha splint should not work if the lower end of the rod werefirmly wedged in hard tissue.
But in the past, use of internal splints has been restrictedto slim wire to align broken bones in fingers, toes andarms. In such cases, outside splinting is also used and themended bones are not required to withstand any end-to-end pressure.
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They call the rod technique "a daring operation"
and wonder how their German colleagues insert
it without dangerously cutting down blood supplyand without introducing infection.
Surgeons at the hospital cautiously say they"have no opinion one way or another about this
case."
But they add that they are not quite satisfied withthe way the bone is mending around the metal
crutch, possibly because of impaired circulation.
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1950s
Two important techniques were developed.
1. Intramedullary reamers
2. Interlocking Screws
Both techniques improved stability.
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1950s Intramedullary reamers
Flexible reamers were
developed by
Kntscher.
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1960s Intramedullary nailingwent on hiatus in the
1960s. Due to
increased enthusiasm
for compression plating
of long bone fractures.
Developments still
continued with the
cephalomedullary
nails.
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1960s continued
The development of radiological image
intensification,
allowed surgeons to
readopt closed nailingtechniques. With
lower risks to surgeon
and patient.
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1970s and 1980s
The exuberance that accompanied the
advent of compression plating for tibias and
femurs in the 1960s quickly diminished in the
1970s.
Thus renewed interest in refining closed
nailing techniques appeared.
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1990s and the 21st Century
Introduction of new titanium nails,
cephalomedullary devices such as the GSH
(Green- Seligson-Henry) nail.
Slotted cloverleaf designs were being
replaced by non-slotted designs. Which
provided greater torsional rigidity.
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Future
Two areas of future research.
1. Biomaterials
Biodegradable polymers
Shape memory alloy
2. Biological
1. Bone morphogenic protein-2 and -7
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PRESENT PRACTICE
CLOSED ANTEGRADE INTRAMEDULLARY
INTERLOCKING NAILING
GOLD STANDART
FOR FEMORAL SHAFT FRACTURE
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Multiple choices
Antegrade vs retrograde
Via piriformis fossa vs trochanteric
Supine position or lateral position
With or without traction
Reamed or unreamed
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Several factors
Fracture characteristic
Associated musculoskeletal and/or visceral
injuries
Body habitus
Associated local soft tissue injury
Technical familiarity
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INSERTION PORTAL
ANTEGRADE NAILING Piriformis starting point
Trochanteric starting point
RETROGRADE NAILING
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Antegrade nailing
Piriformis starting point Healing rates as high as
99% and low complication
rates
Colinear trajectory with
long axis of femoral shaft
Reduces the risk ofiatrogenic fracture
communition and varus
malalignment
Relative technical difficulty
esp. obese patients Also sensitive to
anteroposterior translation-
--hoop stresses
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}
Guide pin
Degree of overlap indicates
posterior position in piriformis fossa
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Early antegrade nails designed for this
starting point
Based upon anatomy of proximal femur,posterior piriformis fossa is in line with
proximal femoral canal
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Subcutaneous location of greater trochantertechnically
easier
Risk of varus malalignment and iatrogenic fracture
comminution
Medially directed insertion angle---iatrogenic
comminution
So starting point not too lateral is crucial to avoid this
Nail rotation by 900---- modification
Implants specifically built--- proximal lateral bend
This all has lead to reduced complication rates withresults similar to those seen with piriformis nailing
Trochanteric starting point
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TROCHANTERIC ENTRY
Guide pin
Need lateral image to judge anterior-
posterior position
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Retrograde nailing
RELATIVE INDICATIONS
Ipsilateral Fractures Femoral Neck
Intertrochanteric
Acetabular
Tibia Patella
Bilateral Femurs
Polytrauma
Obesity
Pregnancy Distal Fractures
Retrograde nailing hasadv. of
improved fracturealignment of distalshaft fractures
decreased operatingroom time
decreased bloodloss
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RETROGRADE ENTRY
PCL
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RETROGRADE NAILING Continued
Alternative
Insertion site in intracondylar notch at the apex of
blumensaat line--- 1cm anterior to posterior
cruciate ligament origin
Distal end of nail must be buried beneath
subchordral bone to avoid injury to patella with the
knee in flexion
At least two distal interlocks to minimize risk of
secondary telescoping of nail into knee joint
Retrograde nailing using modern techniques i.e.
reaming, snug fitting nails, interlocking screws
union rates similar to that of antegrade nailing
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CONCERNS REGARDING RETROGRADE
Cartilage Injury?
Patello -femoral jointmechanics
Nonunion and implantfailure with migration intoknee
Intraarticular infection
Nail removal
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PATIENT POSITION
Position--- supine
Skin traction with foot
secured in boot
Non injured leg----hemilithotomy position
Lateral decubitus ---
improved ease ofaccess to piriformis
fossa
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BILATERAL FEMUR FRACTURES
FREE LEG POSITION
Supine
Shortest set up time
Easy Starting portal
Ideal for Polytrauma +/-
Bilateral
**Need Extra Help***
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REAMING
Persistent subject of debate
Systemic effects of reaming on multitraumapatient esp. with pulmonary injury
Degree of fat embolization almost similar with reamed or unreamed nails
Disrupted endosteal blood supplyreconstitutes rapidly
Use nail 1 to 1.5 mm smaller then largestreamer used
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REAMING Continued
Avoid thermal necrosis and fat embolization Use of modern fluted reamer designs
Sharp reamers
Slower reamers produce less heat but more emboli
then faster reaming
Reaming has
Beneficial effects on union rates Deposition of local bone graft
Beneficial inflammatory response
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REAMING Continued
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NAIL INSERTION
RETROGRADE
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SPECIAL SITUATION
Multitrauma patient
Open fractures
Vascular and neurological injury
Obese
Ipsilateral proximal femur and femoral shaft
fractures
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Multiple trauma
Timing and safety of reaming
Additional trauma of IM nail--- Borderline stable
patient to decompensation cuz
Release of inflammatory mediators
Hypothermia
Effects of reaming
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Damage control orthopaedics
Provisional surgical
stabilization to minimizesurgical time, blood loss and
additional trauma
Usually with monolateral
external fixator
Converted to IM nailing
Retrograde unreamed nailing
with or without proximal
interlocking--- alternative to
external fixator
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Open fractures
Much less common then tibia
Significant soft tissue trauma
Timing of initial debridment does not significantly
affect infection risk Severity of open injury most significant factor
Wounds should be extended
Nonviable soft tissues and bone should be debrided
with serial debridment at 24 to 48 hoursrecommended
Immediate IM nailing---- all but most severe cases
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Provision external fixator
useful Converted to IM nailing
Intravenous antibiotics
Gun shots causingfemoral fractures withentry and exit wound canbe treated as closefractures
Extensive wounds ----treated as open fractures
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Vascular and neurological injuries Rare and associated with penetrating trauma
Algorithm for management
Bony stabilization
Neurovascular repair with attention to obtain proper length Usually external fixator
Converted to IM nailing in 2 weeks
Another option is retrograde IM nailing with interlocking
deferred until vascular repair
Reduces ischemic time and need for fasciotomy
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Obese patient
Starting point in antegrade nailing is problem
Retrograde nailing --- good results
Reduces surgery time and radiation exposure
Antegrade
Better results with trochanter insertion point rather then
piriformis in obese patients esp. with new implants i.e.
prox. Lateral bend
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Ipsilateral proximal femur and femoral shaft
fracture SOF fracture with NOF or intertrochanteric
fracture--- challenging injuries
In up to 9% of all SOF fractures
Easily missed Do hip and knee radiology to all SOF fractures
Variety of fixation techniques Separate implants
Single IM device i.e. recon nail
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COMPLICATIONS OF FEMORAL
NAILING
Malunion
Nonunion
Leg length discrepancy
Infection
Other potential complications
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Malunion( angular and rotational) Angular malunion most common in prox. (30%)
and distal (10%) fractures Blocking screws can be used
Interference fit
Diaphyseal angular malunion----in elderly patients
with capacious canals Rotational malunion --- remain concern
Alignment of anterior superior iliac spine, thepatella and the second toe
Both legs should be examined for rotationalsymmetry
CT is more accurate
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Nonunion
Less then 10%
Deep infection should beconsidered
Treatment
Dynamization
Exchange nail Plate fixation with bone
grafting
Fractures with bony
defects, atrophic
characteristics or faileddynamization
Reaming with exchange
nail or open graft and
repair
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Leg length discrepancy
Obtaining equal lengths after nailing in
comminuted fractures---- challenge(43% length
discrepancy rates) Length should be compared immediately after
nailing
Post operative clinical examination or CT
scanogram to define discrepancies
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Infection
Ranges from 1% to 3.8%
Early (
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Nail is removed
Canal reamed for debridment purpose
Nonviable bone resected Intravenous and potentially local antibiotics for at
least 6 weeks
Definitive reconst. delayed until the infection is
controlled Monitoring
Close clinical observation
Complete blood count
Erythrocyte sedimentation rate
C-reactive protein levels
Host factors
Smoking and malnutrition should be addressed
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Still concern for infection--- frozen tissue sections
intraoperatively
Other potential complications
Heterotropic bone at site of antegrade nail
insertion
Neurovascular injury
Prominent hardware
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FUNCTIONAL OUTCOME
May have functional residual deficit
Reduced strength of hip abductors and
extensors
Altered gait patterns
Needs prolonged muscle strengthening
exercises
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SUMMARY
Effective method
High union and low complication rates
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Descriptive study
On 68 patients in orthopaedic unit of ladyreading hospital, Peshawar
From march 2002 to march 2004
Patient age more then 15 years of each genderwith fracture shaft of femur due to high velocity
gunshot injuries were included
Patients with intertrochanteric, supracondylar
fractures were excluded and also who failed tofollow up
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All patients treated with either close or open
interlocking nailing
Out come was measured as poor, good and
excellent
Follow up for 18 months and in some cases
for up to 30 months
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64(94.12%) male and 4(5.88%) female
64(94.12%) had close interlocking nailing while4(5.88%) had open interlocking nailing
58(85.29%) had static and 10(14.71%) had dynamic
interlocking nailing
5(7.35%) had knee flexion contracture
2(2.94%) had limb shortening of < 2cm
4(5.88%) had non union
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Excellent in 42(61.76%)
Good in 18(26.4%)
Poor in 8(11.77%)
CONCLUSION
So interlocking nailing is best option for treatment
of fracture shaft of femur caused by high velocitygunshots
ON GOING RESEARCH PROJECTS
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ON GOING RESEARCH PROJECTS
ON INTERLOCKING NAIL
SIGN NAIL OPEN INTERLOCKING NAIL
WITH OUT USE OF IMAGE INTENSIFIER
COMPLICATIONS OF CLOSE ANTEGRADE
INTRAMEDULLARY INTERLOCKING
NAILING IN FEMORAL SHAFT FRACTURE
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THANK YOU