cpc presentation on iln

8/8/2019 Cpc Presentation on Iln

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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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During development of his marrow nail he conducted

studies on cadavers' and animals


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By late 1940s,

Kntscher had

designed a new nail,

the cloverleaf nail.


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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

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