Validity of a Novel Digitally Enhanced Skills Training Station for Freehand Distal Interlocking.

Background and Objectives: Freehand distal interlocking of intramedullary nails is technically demanding and prone to handling issues. It requires precise placement of a screw through the nail under fluoroscopy guidance and can result in a time consuming and radiation expensive procedure. Dedicated training could help overcome these problems. The aim of this study was to assess construct and face validity of new Digitally Enhanced Hands-On Surgical Training (DEHST) concept and device for training of distal interlocking of intramedullary nails. Materials and Methods: Twenty-nine novices and twenty-four expert surgeons performed interlocking on a DEHST device. Construct validity was evaluated by comparing captured performance metrics-number of X-rays, nail hole roundness, drill tip position and drill hole accuracy-between experts and novices. Face validity was evaluated with a questionnaire concerning training potential and quality of simulated reality using a 7-point Likert scale. Results: Face validity: mean realism of the training device was rated 6.3 (range 4-7). Training potential and need for distal interlocking training were both rated with a mean of 6.5 (range 5-7), with no significant differences between experts and novices, p ≥ 0.234. All participants (100%) stated that the device is useful for procedural training of distal nail interlocking, 96% wanted to have it at their institution and 98% would recommend it to colleagues. Construct validity: total number of X-rays was significantly higher for novices (20.9 ± 6.4 versus 15.5 ± 5.3, p = 0.003). Success rate (ratio of hit and miss attempts) was significantly higher for experts (novices hit: n = 15; 55.6%; experts hit: n = 19; 83%, p = 0.040). Conclusion: The evaluated training device for distal interlocking of intramedullary nails yielded high scores in terms of training capability and realism. Furthermore, construct validity was proven by reliably discriminating between experts and novices. Participants indicate high further training potential as the device may be easily adapted to other surgical tasks

Fluoroscopic freehand and electromagnetic-guided targeting system for distal locking screws of humeral intramedullary nail

Purpose The current techniques used to lock distal screws for the nailing of long bone fractures expose the surgeons, radiologists and patients to a hearty dose of ionizing radiation. The Sureshot™ Distal Targeting System is a new technique that, with the same results, allows for shorter surgery times and, consequently, less exposure to radiation. Materials and methods The study was performed on 59 patients (34 males and 25 females) with a simple humerus fracture diagnosis, type 1.2.A according to the AO classification, who were divided into two groups. Group 1 was treated with ante-grade intramedullary nailing with distal locking screws inserted with a freehand technique. Group 2 was treated with the intramedullary nail using the Sureshot™ Distal Targeting System. Two intra-operative time parameters were evaluated in both groups: the time needed for the positioning of the distal locking screws and the time of exposure to ionizing radiations during this procedure. Results Group 2 showed a lower average distal locking time compared to group 1 (645.48″ vs. 1023.57″) and also a lower average time of exposure to ionizing radiation than in group 1 (4.35″ vs. 28.96″). Conclusion The Sureshot™ Distal Targeting System has proven to be equally effective when compared to the traditional techniques, with the added benefits of a significant reduction in both surgical time and risk factors related to the exposure to ionizing radiation for all the operating room staff and the patient

Revision total hip replacement using long curved fully hydroxyapatite-coated modular stems with distal interlocking

Successful femoral reconstruction in revision total hip replacement needs to address variable metadiaphyseal bone defects and still represents a controversial issue. We present our clinical experience with the use of two types of long revision, curved, fully hydroxyapatite (HA)-coated titanium femoral stems with distal interlocking. A group of 20 patients has been followed up clinically and radiographically for a period of 12.1 months (3-30 months). Indications included aseptic and septic loosening as well as adverse local tissue reactions (ALTR) to metal debris. The major complications in our series included postoperative instability and intraoperative periprosthetic femoral fracture. Revision curved modular fully HA-coated stems with distal interlocking provide for good primary stem stability and successful secondary osteointegration in revision total hip arthroplasty (THA) for both aseptic and septic loosening in the setting of femoral bone defects. Longer follow-up in a larger cohort of patients is needed to confirm the good and very good short-term results and assess femoral bone remodeling

Intramedullary Nailing of Periarticular Fractures

Plate fixation has historically been the preferred surgical treatment method for periarticular fractures of the lower extremity. This trend has stemmed from difficulties with fracture reduction and concerns of inadequate fixation with intramedullary implants. However, the body of literature on management of periarticular fractures of the lower extremities has expanded in recent years, indicating that intramedullary nailing of distal femur, proximal tibia, and distal tibia fractures may be the preferred method of treatment in some cases. Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications and when potential difficulties are recognized and addressed

Reinforcing the role of the conventional C-arm - a novel method for simplified distal interlocking

<p>Abstract</p> <p>Background</p> <p>The common practice for insertion of distal locking screws of intramedullary nails is a freehand technique under fluoroscopic control. The process is technically demanding, time-consuming and afflicted to considerable radiation exposure of the patient and the surgical personnel. A new concept is introduced utilizing information from within conventional radiographic images to help accurately guide the surgeon to place the interlocking bolt into the interlocking hole. The newly developed technique was compared to conventional freehand in an operating room (OR) like setting on human cadaveric lower legs in terms of operating time and radiation exposure.</p> <p>Methods</p> <p>The proposed concept (guided freehand), generally based on the freehand gold standard, additionally guides the surgeon by means of visible landmarks projected into the C-arm image. A computer program plans the correct drilling trajectory by processing the lens-shaped hole projections of the interlocking holes from a single image. Holes can be drilled by visually aligning the drill to the planned trajectory. Besides a conventional C-arm, no additional tracking or navigation equipment is required.</p> <p>Ten fresh frozen human below-knee specimens were instrumented with an Expert Tibial Nail (Synthes GmbH, Switzerland). The implants were distally locked by performing the newly proposed technique as well as the conventional freehand technique on each specimen. An orthopedic resident surgeon inserted four distal screws per procedure. Operating time, number of images and radiation time were recorded and statistically compared between interlocking techniques using non-parametric tests.</p> <p>Results</p> <p>A 58% reduction in number of taken images per screw was found for the guided freehand technique (7.4 ± 3.4) (mean ± SD) compared to the freehand technique (17.6 ± 10.3) (<it>p </it>< 0.001). Total radiation time (all 4 screws) was 55% lower for the guided freehand technique compared to conventional freehand (<it>p </it>= 0.001). Operating time per screw (from first shot to screw tightened) was on average 22% reduced by guided freehand (<it>p </it>= 0.018).</p> <p>Conclusions</p> <p>In an experimental setting, the newly developed guided freehand technique for distal interlocking has proven to markedly reduce radiation exposure when compared to the conventional freehand technique. The method utilizes established clinical workflows and does not require cost intensive add-on devices or extensive training. The underlying principle carries potential to assist implant positioning in numerous other applications within orthopedics and trauma from screw insertions to placement of plates, nails or prostheses.</p

Short cephalomedullary nail toggle: a closer examination

Objectives: In patients with wide femoral canals, an undersized short nail may not provide adequate stability, leading to toggling of the nail around the distal interlocking screw and subsequent loss of reduction. The purpose of this study was to identify risk factors associated with nail toggle and to examine whether increased nail toggle is associated with increased varus collapse. Design: Retrospective cohort study. Setting: Level 1 and level 3 trauma center. Patients/Participants: Seventy-one patients with intertrochanteric femur fractures treated with short cephalomedullary nails (CMN) from October 2013 to December 2017. Intervention: Short CMN. Main Outcome Measurements: Nail toggle and varus collapse were measured on intraoperative and final follow-up radiographs. Risk factors for nail toggle including demographics, fracture classification, quality of reduction, Dorr type, nail/canal diameter ratio, lag screw engaging the lateral cortex, and tip-apex distance (TAD) were recorded. Results: On multivariate regression analysis, shorter TAD (P = .005) and smaller nail/canal ratio (P \u3c .001) were associated with increased nail toggle. Seven patients (10%) sustained nail toggle \u3e4 degrees. They had a smaller nail/canal ratio (0.54 vs 0.74, P \u3c .001), more commonly Dorr C (57% vs 14%, P = .025), lower incidence of lag screw engaging the lateral cortex (29% vs 73%, P = .026), shorter TAD (13.4 mm vs 18.5 mm, P = .042), and greater varus collapse (6.2 degrees vs 1.3 degrees, P \u3c .001) compared to patients with nail toggle \u3c 4 degrees. Conclusions: Lower percentage nail fill of the canal and shorter TAD are risk factors for increased nail toggle in short CMNs. Increased nail toggle is associated with increased varus collapse

Is a Magnetic-Manual Targeting Device an Appealing Alternative for Distal Locking of Tibial Intramedullary Nails?

Background: In order to enable a radiation-free, accurate and simple positioning of distal locking screws, a combined magnetic and manual targeting system has been developed by Sanatmetal®. Where a low-frequency magnetic field is initially used to detect the position of the first drill hole and three more holes can be found with a mechanical template. Objectives: Our cadaver study was performed to evaluate the accuracy and efficiency of this device. Materials and Methods: In two runs, 30 probands (group 1: 10 students; group 2: 10 residents; group 3: 10 attendings), none of who being familiar with the device, tested the radiation-free system using 60 intact cadaver tibias. Each proband performed the surgical procedure twice in succession. Results: Referring to the first attempts, 9.6, 7.2 and 7.1 minutes were the time periods required to insert the four distal screws and the relevant values for the second attempts were 8.6, 6.3 and 6.2 minutes; in both cases revealing a significant difference between group 1 and 2 and group 1 and 3. Furthermore, the mean values within each group indicated a significant decrease of the test duration. Out of the 240 drillings, only one failure (group 1) occurred, representing an accuracy of 99.58 %. Of the probands, 90 % rated the targeting device better than the free-hand technique and 77 % at least attested a high user-friendliness. Conclusions: Due to our satisfactory test results, the brief training, the steep learning curve and the radiation-free technique the new device has to be considered an appealing alternative for distal locking

Recommendation of use of checklists in tibial intramedullary nail removal : Retrospective study of mechanical complications related to nail removal

Background: The removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication. Methods: This is a retrospective seven-year (2010-2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital's orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed. Results: A total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail's distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula. Conclusion: Nail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. latrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws. (C) 2018 Elsevier Ltd. All rights reserved.Peer reviewe

Accurate Determination of the Sites of the Distal Hole of the Humeral Interlocking Intramedullary Nail Using Monofilament Solid Core Optical Fiber

This prospective study was conducted in order to evaluate the results of using the monofilament solid core optical fiber for the accurate determination of the site of the distal hole of the humeral interlocking intramedullary nail. Seven patients with fresh humeral fractures treated with humeral interlocking intramedullary nailing from April 2005 to May 2007 were evaluated. The minimum follow-up period was 12 months. We analyzed type of humeral fracture, time of technique, length of the incision, and Radiation exposure. All cases were treated with one distal locking screw during interlocking intramedullary nailing. The technique is based on the semitransparency of the bone tissue. The system is composed of 2 parts: light source and monofilament solid core optical fiber. Description of the technique:- After reduction of the fracture and assembly of the nail, a mechanical measure is taken to determine the expected site of the distal locking holes of the interlocking nail and site of skin incision, then a longitudinal skin incision is made and the soft tissue is dissected until the bone is reached, then the optical fiber is introduced until its tip reaches the distal hole and adjusted to concentrate the light on the nail hole. At this time an illuminated ellipse appears on the anterior cortex of the bone. The drill bit is adjusted to the center of this ellipse then the drilling is started. After piercing of the nearby cortex a 3.5 mm suction handle is introduced in the bone hole to suck the blood then physical and mechanical checks are done after which the far cortex is drilled. The results show that the site of the distal hole of the humeral interlocking intramedullary nail could be detected successfully in all cases with no radiation exposure. As a conclusion; we can say that Monofilament solid core optical fiber can be used successfully for the accurate determination of the site of the distal hole of the humeral interlocking intramedullary nail. For satisfactory results, accurate technique and experience of the operator were required

Prijelomi dijafize humerusa: liječenje antegradnim usidrenim endomedularnim čavlom s primjenom neutralizacijskih vijaka kroz frakturnu pukotinu

The aim of this study was to compare union time between two different nail designs for the treatment of humeral shaft fracture, i.e. antegrade interlocking intramedullary nail with and without additional interlocking neutralization screws. The retrospective study included 51 patients treated with antegrade humeral intramedullary nailing between January 2015 and December 2017. The inclusion criteria of the study were proximal and middle third humeral shaft fractures. Fifty-one patients met the inclusion criteria; 23 patients were treated with antegrade intramedullary nail with additional interlocking neutralization screws through fracture site (group A) and 28 patients were treated with antegrade intramedullary nail without additional interlocking neutralization screws (group B). Medical documentation and radiographic images taken preoperatively and postoperatively were reviewed. Radiological union was defined as cortical bridging of at least three of four cortices in two-plane radiographs, with disappearance of the fracture gap. There were no significant differences in union time between the groups (p>0.05). To our knowledge, this is the first report of antegrade interlocking humeral nailing with additional interlocking neutralization screws through fracture site. Hypothetical advantages of fracture gap reduction by additional interlocking neutralization screws to promote union were not confirmed by this first clinical trial.Cilj ovoga istraživanja bio je usporediti vrijeme cijeljenja prijeloma dijafize humerusa pri liječenju s dva različita dizajna intramedularnog čavla: antegradni ukotvljeni intramedularni čavao s dodatnim ukotvljenim neutralizacijskim vijcima i bez njih. Retrospektivna studija obuhvatila je 51 bolesnika liječenog antegradnim humeralnim intramedularnim čavlima između siječnja 2015. i prosinca 2017. godine. Kriteriji uključenja u studiju bili su prijelomi proksimalne i srednje trećine dijafize humerusa. Pedeset i jedan bolesnik je ispunio kriterije uključenja: 23 bolesnika su liječena antegradnim intramedularnim čavlom s dodatnim ukotvljenim neutralizacijskim vijcima kroz mjesto prijeloma (skupina A), a 28 bolesnika je liječeno antegradnim intramedularnim čavlom bez dodatnih ukotvljenih neutralizacijskih vijaka (skupina B). Analizirana je medicinska dokumentacija i radiološke slike učinjene prije i poslije operacije. Radiološko cijeljenje prijeloma definirano je kao kortikalno premošćivanje najmanje tri od četiri korteksa u dvoprofilnim radiografima, s nestankom frakturne pukotine. Nije bilo značajne razlike u vremenu cijeljenja prijeloma između skupina (p>0,05). Prema našim spoznajama, ovo je prva studija o liječenju prijeloma humerusa antegradnim intramedularnim čavlom s dodatnim ukotvljenim neutralizacijskim vijcima kroz mjesto prijeloma. Hipotetsku prednost redukcije prijelomne pukotine s dodatnim ukotvljenim neutralizacijskim vijcima u svrhu poticanja cijeljenja nije potvrdila ova prva klinička studija