Development and study ( clinical and bionechanical) of a new intramedullary nail for the treatment of diaphyseal humeral fractures

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. The aim of the present dissertation is the evaluation of a new nail, inspired by the writer that has been specially designed for the treatment of fractures of the humeral diaphysis. The nail is cannulated, square in shape – with concave sides – and has two different extensions that can be used with either the antegrade or the retrograde approach. Adequate rotational and axial stability is provided without the need for distal locking screws in the majority of fractures, while the need for proximal locking screws during the antegrade procedure is abolished. The nail has been tested for both its biomechanical properties and its clinical usefulness in a series of patients who had sustained fracture of the humeral diaphysis (traumatic or pathological, recent or old). The results are encouraging, as the nail was efficient both biomechanically and clinically. The patients succeeded high rates of fracture union with low complication rate and minimal morbidity regarding the functional recovery of the -ipsilateral to the fracture- shoulder and elbow joints.Ενώ η ενδομυελική ήλωση είναι η θεραπείθα εκλογής για τα κατάγματα των διαφύσεων του μηριαίου και της κνήμης, η θέση της μεθόδου στην αντιμετώπιση των διαφυσιακών καταγμάτων του βραχιονίου είναι αμφιλεγόμενη. Τα αίτια συμπεριλαμβάνουν την περίπλοκη ανατομική και τις μοναδικές εμβιομηχανικές ιδιότητες του άνω άκρου, όπως επίσης και το ότι η χειρουργική τεχνική της ενδομυελικής ήλωσης και η σχεδίαση των ήλων του βραχιονίου είχαν αντιγραφεί και χρησιμοποιηθεί στα διαφυσιακά κατάγματα του βραχιονίου. Ο στόχος της παρούσας διδακτορικής διατριβής είναι η ανάδειξη της χρησιμότητας ενός νέου ήλου, που επινοήθηκε από τον διδάκτορα, ειδικά κατασκευασμένου για την αντιμετώπιση των καταγμάτων της διάφυσης του βραχιονίου. Ο ήλος είναι αυλοφόρος, τετράπλευρος με κοίλες πλευρές, με δύο διαφορετικές προεκτάσεις που χρησιμοποιούνται ανάλογα με την χειρουργική τεχνική (ορθόδρομη ή ανάστροφη). Το σχήμα του ήλου προσφέρει επαρκή στροφική και αξονική σταθερότητα χωρίς την χρήση κοχλιών ασφάλισης, που στο βραχιόνιο έχουν αυξημένη πιθανότητα πρόκλησης προβλημάτων. Ο ήλος μελετήθηκε τόσο για τις εμβιομηχανικές του ιδιότητες όσο και για την κλινική του επάρκεια σε μία μεγάλη σειρά ασθενών, που είχαν υποστεί κάταγμα της βραχιονίου διάφυσης (τραυματικό ή παθολογικό, πρόσφατο ή και παλαιότερο). Τα αποτελέσματα της μελέτης είναι ενθαρρυντικά, καθ΄ όσον ο ήλος αξιολογήθηκε ως εμβιομηχανικά επαρκής και κλινικά αποτελεσματικός, με τους ασθενείς να παρουσιάζουν υψηλά ποσοστά πώρωσης των καταγμάτων με ταυτόχρονη ελαχιστοποίηση των επιπλοκών και των προβλημάτων αποκατάστασης της λειτουργικότητας των αρθρώσεων του ώμου και αγκώνα, σύστοιχα με το κάταγμα

Intramedullary Nailing with a Suprapatellar Approach and Condylar Bolts for the Treatment of Bicondylar Fractures of the Tibial Plateau

Background:. Bicondylar tibial plateau fractures have been treated with either plating or external fixation techniques, with conflicting results. A recently introduced technique involving the combined use of intramedullary nailing via a suprapatellar approach and condylar bolts could represent a new pathway toward better treatment of this severe injury. Methods:. The present report describes a retrospective and prospective study of all 17 patients (age range, 25 to 75 years) who were admitted under the author’s care for the treatment of a closed, bicondylar tibial plateau fracture between 2013 and 2015. All patients consented to undergo fixation of the fracture with intramedullary nailing through a suprapatellar approach and with use of condylar bolts. The reconstructed articular surface was supported with freeze-dried allograft that had been previously soaked in concentrated bone marrow. The patients were followed at regular intervals, and the results were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS). Results:. All patients were followed for at least 1 year (average and standard deviation, 25.23 ± 8.95 months; range, 12 to 46 months). All fractures united clinically and radiographically between 10 and 22 weeks (average, 15.1 ± 2.91 weeks), with no instances of neurovascular complication, infection, or implant failure. One patient underwent early revision of the fixation because of unsatisfactory reduction of the articular surface, and 1 patient had secondary fracture displacement. One condylar bolt was removed after fracture healing because of irritation at the insertion site. However, all patients regained knee motion without physiotherapy and all were fully weight-bearing by the fifth postoperative month. Conclusions:. The short and intermediate-term results associated with the use of the proposed technique appear to be satisfactory. However, the effectiveness of the technique should be reassessed with long-term studies as well as comparative studies involving other fixation techniques. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes?

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: “fixed” and “bio”, avoidance of reaming for the antegrade technique and utilization of “semi-reaming” for the retrograde technique, guidelines for reducing complications, setting the best “timing” for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures

Factors associated with surgeon recommendation for additional cast immobilization of a CT-verified nondisplaced scaphoid waist fracture

Introduction: Data from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8–12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This study aimed to investigate (1) the degree to which surgeons use fracture tenderness and radiographic appearance of union, among other factors, to decide whether or not to recommend additional cast immobilization after 8 or 12 weeks of immobilization; (2) identify surgeon factors associated with the decision to continue cast immobilization after 8 or 12 weeks. Materials and methods: In a survey-based study, 218 surgeons reviewed 16 patient scenarios of CT-confirmed nondisplaced waist fractures treated with cast immobilization for 8 or 12 weeks and recommended for or against additional cast immobilization. Clinical variables included patient sex, age, a description of radiographic fracture consolidation, fracture tenderness and duration of cast immobilization completed (8 versus 12 weeks). To assess the impact of clinical factors on recommendation to continue immobilization we calculated posterior probabilities and determined variable importance using a random forest algorithm. Multilevel logistic mixed regression analysis was used to identify surgeon characteristics associated with recommendation for additional cast immobilization. Results: Unclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons’ decision to recommend continued cast immobilization. Women surgeons (OR 2.96; 95% CI 1.28–6.81, p = 0.011), surgeons not specialized in orthopedic trauma, hand and wrist or shoulder and elbow surgery (categorized as ‘other’) (OR 2.64; 95% CI 1.31–5.33, p = 0.007) and surgeons practicing in the United States (OR 6.53, 95% CI 2.18–19.52, p = 0.01 versus Europe) were more likely to recommend continued immobilization. Conclusion: Adoption of shorter immobilization times for CT-confirmed nondisplaced scaphoid waist fractures may be hindered by surgeon attention to fracture tenderness and radiographic appearance