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Which of the three different intramedullary nail designs is superior in the treatment of femoral shaft fractures?

Year 2023, Volume: 6 Issue: 2, 467 - 475, 27.03.2023
https://doi.org/10.32322/jhsm.1227816

Abstract

Aim: The aim of this study a retrospective comparison was the clinical and radiological results results of patients with femoral shaft fracture made oftreated with three different types of intramedullary nail (IMN).
Material and Method: The study included 54 patients operated on in our clinic because of femoral shaft fracture. The records were retrospectively examined of 18 patients applied with locked IMN (LIMN), 17 with blade expandable IMN (BEIMN), and 19 with talon distalfix IMN (TDIMN). The groups were compared statistically in respect of age, gender, BMI, affected side, operating time (mins), radiation exposure (number of shots), time to union (weeks), visual analog scale (VAS) score, soft tissue problems associated with implant irritation, amount of shortening (mm), coronal, sagittal and torsional angulation (degrees).
Results: The mean VAS score of the TDIMN group was determined to be statistically significantly higher than that of the LIMN and BEIMN groups (p=0.008, p=0.045). The operating times were similar in the BEIN and TDIMN groups (p=0.768) and significantly shorter than in the LIMN group (p<0.001). Radiation exposure was similar in the TDIMN and BEIMN groups (p=0.039), and the number of shots in the LIMN group was significantly higher than in the other two groups (p<0.001). The coronal angulation values were lower in the TDIMN group than in the BEIMN and LIMN groups (p=0.001, p=0.020). The sagittal angulation values were lower in the TDIMN group than in the BEIMN and LIMN groups (p=0.001, p<0.001). No significant difference was determined between the groups in respect of time to union, limb shortness, rotational deformity, and soft tissue problems related to implant irritation (p>0.05).
Conclusion: TDIMN is less resistant to axial loads due to its hook structure design. In fact, this is sometimes seen as a hook break. High VAS scores explain this. The sagittal and coronal angulation of the TDIMN is less, but the time to union, rotational angulation, and shortness development are similar in all three nails. This showed that all three nails did not have a significant advantage over each other in providing fracture stability.

References

  • Rosa N, Marta M, Vaz M, et al. Recent developments on intramedullary nailing: a biomechanical perspective. Ann N Y Acad Sci 2017; 1408: 20-31.
  • Wood GW. Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci 2006; 11: 657-69.
  • Sipahioglu S, Zehir S, Sarikaya B, Isikan UE. Comparision of the expandable nail with locked nail in the treatment of closed diaphyseal fractures of femur. Niger J Clin Pract 2017; 20: 792-8.
  • Pourmokhtari, M. Principles of fixation with ınterlocking nailing. Iranian Journal of Orthopaedic Surgery Summer 2018; 16: 265-72.
  • Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg 2007; 15: 97-106.
  • Basaran T, Calbiyik M, Basaran PÖ, Hassa, E, Ipek D. Blade expandable intramedullary nails for fixation of tibial shaft fractures. Acta Orthop Belg 2019; 85: 472-6.
  • Çamurcu Y, Sofu H, Issın A, Koçkara N, Genç E, Çetinkaya M. Is talon tibial intramedullary nailing clinically superior compared to conventional locked nailing? Jt Dis Relat Surg 2017; 28: 152-7.
  • Bekmezci T, Baca E, Kaynak H, Kocabaş R, Tonbul M, Yalaman O. Early results of treatment with expandable intramedullary nails in femur shaft fractures. Acta Orthop Traumatol Turc 2006;40: 1-5.
  • Whelan DB, Bhandari M, Stephen D, et al. Development of the radiographic unionscore for tibial fractures for the assessmentof tibial fracture healing after intramedullary fixation. J Trauma 2010; 68: 629-32.
  • Litrenta J, Tornetta P, Mehta S, et al. Determination of radiographic healing: an assessment of consistency using RUST and modified RUST in metadiaphyseal fractures. J Orthop Trauma 2015; 29: 516-20.
  • Samiezadeh S, Avval PT, Fawaz Z, Bougherara H. Biomechanical assessment of composite versus metallic intramedullary nailing system in femoral shaft fractures: a finite element study. Clin Biomech 2014; 29: 803-10.
  • Clatworthy MG, Clark DI, Gray DH, Hardy AE. Reamed versus unreamed femoral nails. a randomised prospective trial. J Bone Joint Surg Br 1998; 80: 485-9.
  • Rosa N, Marta M, Vaz M, et al. Intramedullary nailing biomechanics: evolution and challenges. Proc Inst Mech Eng H 2019; 233: 295-308.
  • Letechipia J, Alessi A, Rodrı´guez G, Asbun J. Design and preliminary testing of an active intramedullary nail. Clin Transl Invest 2014; 66: 70-8.
  • Ligier JN. Biomechanics of FIN. In Flexible Intramedullary Nailing in Children: The Nancy University Manual. P. Lascombes, Ed. Berlin: Springer-Verlag; 2009; 19-24.
  • Rosa N, Simoes R, Magalh˜aes FD, Marques AT. From mechanical stimulus to bone formation: a review. Med Eng Phys 2015; 37: 719-28.
  • Wu KJ, Li SH, Yeh KT, et al. The risk factors of nonunion after intramedullary nailing fixation of femur shaft fracture in middle age patients. Medicine 2019; 98: e16559.
  • Yapici F, Gur V, Onac O, et al. For intramedullary nailing of femoral shaft fractures, talon fixation is helpful to cope with the troublesome distal locking, but conventional distal locking with screws offers a more stable construct: Talon femoral nail versus conventional femoral nail. Ulus Travma Acil Cerrahi Derg 2022; 28: 513-22.
  • Rühm W, Laurier D, Wakeford R. Cancer risk following low doses of ionising radiation–Current epidemiological evidence and implications for radiological protection. Muta Res Genet Toxicol Environ Mutagen 2022; 873: 503436.
  • Robatjazi M, Dareyni A, Baghani HR, Hosseinzade M, Akbarzadeh R, Mehrpoyan M. Investigation of radiation dose around C-arm fluoroscopy and relevant cancer risk to operating room staff. Radiat Environ Biophys 2022; 61:301-7.
  • Chou LB, Cox CA, Tung JJ, Harris AH, Brooks-Terrell D, Sieh W. Prevalence of cancer in female orthopaedic surgeons in the United States. J Bone Joint Surg Am 2010; 92:240-4.
  • Barry TP. Radiation exposure to an orthopedic surgeon. Clin Orthop Relat Res 1984; 182:160-4.
  • Daryoush JR, Lancaster AJ, Frandsen JJ, Gililland JM. Occupational Hazards to the Joint Replacement Surgeon: Radiation Exposure. J Arthroplasty 2022; 37:1464-9.
  • Tandale SR, Gavali Y, Naik S, et al. Radiation exposure among anesthetist, orthopedic surgeon, and scrub nurse in orthopedic operation theater complex. Med J DY Patil Vidyapeeth 2022; 15: 857-61.
  • González-Cisneros AC, Briceño-González AM. Exposure of radioactive emanations, during surgery in orthopedics and traumatology. Orthotips AMOT 2022; 18: 25-8.
  • Hadelsberg UP, Harel R. Hazards of ionizing radiation and its impact on spine surgery. World Neurosurg 2016; 92: 353-9.
  • Moreschini O, Petrucci V, Cannata, R. Insertion of distal locking screws of tibial intramedullary nails: a comparison between the free-hand technique and the SURESHOT™ Distal Targeting System. Injury 2014; 45: 405-7.
  • Zhu Y, Chang H, Yu Y, Chen W, Liu S, Zhang Y. Meta-analysis suggests that the electromagnetic technique is better than the free-hand method for the distal locking during intramedullary nailing procedures. Int Orthop 2017; 41:1041-8.
  • Bekmezci T, Baca E, Kocabas R, Kaynak H, Tonbul, M. Early results of treatment with expandable intramedullary nails in tibia shaft fractures. Acta Orthop Traumatol Turc 2005; 39:421-4.
  • Magee LC, Karkenny AJ, Nguyen JC, et al. Does surgical experience decrease radiation exposure in the operating room? J Pediatr Orthop 2021; 41: 389-94.
  • Xu W, Christopher AN, Hu S, Steinberg DR, Bozentka DJ, Lin IC. Investigating patient-level radiation exposure in hand and wrist fracture surgery. Ann Plast Surg 2022; 88: 309-13.
  • Steiner M, Claes L, Ignatius A, Simon U, Wehner T. Disadvantages of interfragmentary shear on fracture healing-mechanical insights through numerical simulation. J Orthop Res 2014; 32: 865-72.
  • Penzkofer R, Maier M, Nolte A, et al. Influence of intramedullary nail diameter and locking mode on the stability of tibial shaft fracture fixation. Arch Orthop Trauma Surg 2009; 129: 525-31.
  • Jaarsma RL, Van Kampen A. Rotational malalignment after fractures of the femur. J Bone Joint Surg Br 2004; 86: 1100-4.
  • Brouwer KJ, Molenaar JC, van Linge B. Rotational deformities after femoral shaft fractures in childhood: a retrospective study 27-32 years after the accident. Acta Orthop Scand 1981; 52: 81-9.
  • Bråten M, Terjesen T, Rossvoll I. Femoral anteversion in normal adults: ultrasound measurements in 50 men and 50 women. Acta Orthop Scand 1992; 63: 29-32.
  • Schmitz N, Gehweiler D, Wähnert D, et al. Influence of the Reamer-Irrigator-Aspirator diameter on femoral bone strength and amount of harvested bone graft–a biomechanical cadaveric study. Injury 2020; 51: 2846-50.
  • Sennerich T, Sutter P, Ritter G, Zapf S. Computerized tomography follow-up of the antetorsion angle after femoral shaft fractures in the adult. Der Unfallchirurg 1992; 95: 301-5.
  • Strecker W, Franzreb M, Pfeiffer T, Pokar S, Wikström M, Kinzl L. Computerized tomography measurement of torsion angle of the lower extremities. Der Unfallchirurg 1994; 97: 609-13.
  • Wissing H, Spira, G. Determination of rotational defects of the femur by computer tomographic determination of the antetorsion angle of the femoral neck. Unfallchirurgie 1986; 12: 1-11.
  • Ivanov D, Barabash A, Barabash Y. Expandable intramedullary nail: review of biomechanical studies. Russian Open Medical Journal 2016; 5: e0206.
  • Özkaya M, Demir T. Numerical evaluation of the mechanical properties of a novel expandable intramedullary nailing: A new alternative to standard interlocking nailing. Injury 2021; 52: 3239-52.
  • Plenert T, Garlichs G, Nolte I, et al. Biomechanical comparison of a new expandable intramedullary nail and conventional intramedullary nails for femoral osteosynthesis in dogs. PLoS ONE 2020; 15: e0231823.
  • Akar B, Balioğlu MB. Clinical results of closed intramedullary nailing in femoral diaphysis fractures. Ann Clin Anal Med 2022: 1-5.
  • Jiang M, Li C, Yi C, Tang S. Early intramedullary nailing of femoral shaft fracture on outcomes in patients with severe chest injury. A meta analysis. Sci Rep 2016; 6: 30566
  • Brumback RJ, Virkus WW. Intramedullary nailing of the femur: reamed versus nonreamed. J Am Acad Orthop Surg 2000; 8: 83-90.
  • Vicenti G, Bizzoca D, Carrozzo M, et al. The ideal timing for nail dynamization in femoral shaft delayed union and non-union. Int Orthop 2019; 43: 217-22.
  • Angadi DS, Stepherd DET, Vadivelu R. Rigid intramedullary nail fixation of femoral fracturesin adolescents: what evidence in is available? J Orthopaed Traumatol 2014; 15: 147-53.
  • Gabarre S, Alberada J, Gracia L, Puertolas S, Ibarz E, Herrera A. Influenza of gap size, screw configuration, and nail materials in the stability of anterograde reamed intramedullary nail in femoral transverse fractures. Injury 2017; 48: 40-6.
  • Hamahashi K, Uchiyama Y, Kobayashi Y, Ebihara G, Ukai T, Watanabe M. Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments: a retrospective analysis of risk factors for delayed union. Trauma Surg Acute Care Open 2019; 4: e-000203.
  • Ricci WM, Bellabarba C, Lewis R, et al. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma 2001; 15: 90-5
  • Guerado E, Bertrand ML. Malalignment in intramedullary nailing. How to achieve and to maintain correct reduction? Injury 2017; 48: 30-4.
  • Rothberg DL, Holt DC, Horwitz DS, Kubiak EN. Tibial nailing with the knee semi-extended: review of techni ques and indications: AAOS exhibit selection. JBJS 2013; 95: e116.
Year 2023, Volume: 6 Issue: 2, 467 - 475, 27.03.2023
https://doi.org/10.32322/jhsm.1227816

Abstract

References

  • Rosa N, Marta M, Vaz M, et al. Recent developments on intramedullary nailing: a biomechanical perspective. Ann N Y Acad Sci 2017; 1408: 20-31.
  • Wood GW. Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci 2006; 11: 657-69.
  • Sipahioglu S, Zehir S, Sarikaya B, Isikan UE. Comparision of the expandable nail with locked nail in the treatment of closed diaphyseal fractures of femur. Niger J Clin Pract 2017; 20: 792-8.
  • Pourmokhtari, M. Principles of fixation with ınterlocking nailing. Iranian Journal of Orthopaedic Surgery Summer 2018; 16: 265-72.
  • Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg 2007; 15: 97-106.
  • Basaran T, Calbiyik M, Basaran PÖ, Hassa, E, Ipek D. Blade expandable intramedullary nails for fixation of tibial shaft fractures. Acta Orthop Belg 2019; 85: 472-6.
  • Çamurcu Y, Sofu H, Issın A, Koçkara N, Genç E, Çetinkaya M. Is talon tibial intramedullary nailing clinically superior compared to conventional locked nailing? Jt Dis Relat Surg 2017; 28: 152-7.
  • Bekmezci T, Baca E, Kaynak H, Kocabaş R, Tonbul M, Yalaman O. Early results of treatment with expandable intramedullary nails in femur shaft fractures. Acta Orthop Traumatol Turc 2006;40: 1-5.
  • Whelan DB, Bhandari M, Stephen D, et al. Development of the radiographic unionscore for tibial fractures for the assessmentof tibial fracture healing after intramedullary fixation. J Trauma 2010; 68: 629-32.
  • Litrenta J, Tornetta P, Mehta S, et al. Determination of radiographic healing: an assessment of consistency using RUST and modified RUST in metadiaphyseal fractures. J Orthop Trauma 2015; 29: 516-20.
  • Samiezadeh S, Avval PT, Fawaz Z, Bougherara H. Biomechanical assessment of composite versus metallic intramedullary nailing system in femoral shaft fractures: a finite element study. Clin Biomech 2014; 29: 803-10.
  • Clatworthy MG, Clark DI, Gray DH, Hardy AE. Reamed versus unreamed femoral nails. a randomised prospective trial. J Bone Joint Surg Br 1998; 80: 485-9.
  • Rosa N, Marta M, Vaz M, et al. Intramedullary nailing biomechanics: evolution and challenges. Proc Inst Mech Eng H 2019; 233: 295-308.
  • Letechipia J, Alessi A, Rodrı´guez G, Asbun J. Design and preliminary testing of an active intramedullary nail. Clin Transl Invest 2014; 66: 70-8.
  • Ligier JN. Biomechanics of FIN. In Flexible Intramedullary Nailing in Children: The Nancy University Manual. P. Lascombes, Ed. Berlin: Springer-Verlag; 2009; 19-24.
  • Rosa N, Simoes R, Magalh˜aes FD, Marques AT. From mechanical stimulus to bone formation: a review. Med Eng Phys 2015; 37: 719-28.
  • Wu KJ, Li SH, Yeh KT, et al. The risk factors of nonunion after intramedullary nailing fixation of femur shaft fracture in middle age patients. Medicine 2019; 98: e16559.
  • Yapici F, Gur V, Onac O, et al. For intramedullary nailing of femoral shaft fractures, talon fixation is helpful to cope with the troublesome distal locking, but conventional distal locking with screws offers a more stable construct: Talon femoral nail versus conventional femoral nail. Ulus Travma Acil Cerrahi Derg 2022; 28: 513-22.
  • Rühm W, Laurier D, Wakeford R. Cancer risk following low doses of ionising radiation–Current epidemiological evidence and implications for radiological protection. Muta Res Genet Toxicol Environ Mutagen 2022; 873: 503436.
  • Robatjazi M, Dareyni A, Baghani HR, Hosseinzade M, Akbarzadeh R, Mehrpoyan M. Investigation of radiation dose around C-arm fluoroscopy and relevant cancer risk to operating room staff. Radiat Environ Biophys 2022; 61:301-7.
  • Chou LB, Cox CA, Tung JJ, Harris AH, Brooks-Terrell D, Sieh W. Prevalence of cancer in female orthopaedic surgeons in the United States. J Bone Joint Surg Am 2010; 92:240-4.
  • Barry TP. Radiation exposure to an orthopedic surgeon. Clin Orthop Relat Res 1984; 182:160-4.
  • Daryoush JR, Lancaster AJ, Frandsen JJ, Gililland JM. Occupational Hazards to the Joint Replacement Surgeon: Radiation Exposure. J Arthroplasty 2022; 37:1464-9.
  • Tandale SR, Gavali Y, Naik S, et al. Radiation exposure among anesthetist, orthopedic surgeon, and scrub nurse in orthopedic operation theater complex. Med J DY Patil Vidyapeeth 2022; 15: 857-61.
  • González-Cisneros AC, Briceño-González AM. Exposure of radioactive emanations, during surgery in orthopedics and traumatology. Orthotips AMOT 2022; 18: 25-8.
  • Hadelsberg UP, Harel R. Hazards of ionizing radiation and its impact on spine surgery. World Neurosurg 2016; 92: 353-9.
  • Moreschini O, Petrucci V, Cannata, R. Insertion of distal locking screws of tibial intramedullary nails: a comparison between the free-hand technique and the SURESHOT™ Distal Targeting System. Injury 2014; 45: 405-7.
  • Zhu Y, Chang H, Yu Y, Chen W, Liu S, Zhang Y. Meta-analysis suggests that the electromagnetic technique is better than the free-hand method for the distal locking during intramedullary nailing procedures. Int Orthop 2017; 41:1041-8.
  • Bekmezci T, Baca E, Kocabas R, Kaynak H, Tonbul, M. Early results of treatment with expandable intramedullary nails in tibia shaft fractures. Acta Orthop Traumatol Turc 2005; 39:421-4.
  • Magee LC, Karkenny AJ, Nguyen JC, et al. Does surgical experience decrease radiation exposure in the operating room? J Pediatr Orthop 2021; 41: 389-94.
  • Xu W, Christopher AN, Hu S, Steinberg DR, Bozentka DJ, Lin IC. Investigating patient-level radiation exposure in hand and wrist fracture surgery. Ann Plast Surg 2022; 88: 309-13.
  • Steiner M, Claes L, Ignatius A, Simon U, Wehner T. Disadvantages of interfragmentary shear on fracture healing-mechanical insights through numerical simulation. J Orthop Res 2014; 32: 865-72.
  • Penzkofer R, Maier M, Nolte A, et al. Influence of intramedullary nail diameter and locking mode on the stability of tibial shaft fracture fixation. Arch Orthop Trauma Surg 2009; 129: 525-31.
  • Jaarsma RL, Van Kampen A. Rotational malalignment after fractures of the femur. J Bone Joint Surg Br 2004; 86: 1100-4.
  • Brouwer KJ, Molenaar JC, van Linge B. Rotational deformities after femoral shaft fractures in childhood: a retrospective study 27-32 years after the accident. Acta Orthop Scand 1981; 52: 81-9.
  • Bråten M, Terjesen T, Rossvoll I. Femoral anteversion in normal adults: ultrasound measurements in 50 men and 50 women. Acta Orthop Scand 1992; 63: 29-32.
  • Schmitz N, Gehweiler D, Wähnert D, et al. Influence of the Reamer-Irrigator-Aspirator diameter on femoral bone strength and amount of harvested bone graft–a biomechanical cadaveric study. Injury 2020; 51: 2846-50.
  • Sennerich T, Sutter P, Ritter G, Zapf S. Computerized tomography follow-up of the antetorsion angle after femoral shaft fractures in the adult. Der Unfallchirurg 1992; 95: 301-5.
  • Strecker W, Franzreb M, Pfeiffer T, Pokar S, Wikström M, Kinzl L. Computerized tomography measurement of torsion angle of the lower extremities. Der Unfallchirurg 1994; 97: 609-13.
  • Wissing H, Spira, G. Determination of rotational defects of the femur by computer tomographic determination of the antetorsion angle of the femoral neck. Unfallchirurgie 1986; 12: 1-11.
  • Ivanov D, Barabash A, Barabash Y. Expandable intramedullary nail: review of biomechanical studies. Russian Open Medical Journal 2016; 5: e0206.
  • Özkaya M, Demir T. Numerical evaluation of the mechanical properties of a novel expandable intramedullary nailing: A new alternative to standard interlocking nailing. Injury 2021; 52: 3239-52.
  • Plenert T, Garlichs G, Nolte I, et al. Biomechanical comparison of a new expandable intramedullary nail and conventional intramedullary nails for femoral osteosynthesis in dogs. PLoS ONE 2020; 15: e0231823.
  • Akar B, Balioğlu MB. Clinical results of closed intramedullary nailing in femoral diaphysis fractures. Ann Clin Anal Med 2022: 1-5.
  • Jiang M, Li C, Yi C, Tang S. Early intramedullary nailing of femoral shaft fracture on outcomes in patients with severe chest injury. A meta analysis. Sci Rep 2016; 6: 30566
  • Brumback RJ, Virkus WW. Intramedullary nailing of the femur: reamed versus nonreamed. J Am Acad Orthop Surg 2000; 8: 83-90.
  • Vicenti G, Bizzoca D, Carrozzo M, et al. The ideal timing for nail dynamization in femoral shaft delayed union and non-union. Int Orthop 2019; 43: 217-22.
  • Angadi DS, Stepherd DET, Vadivelu R. Rigid intramedullary nail fixation of femoral fracturesin adolescents: what evidence in is available? J Orthopaed Traumatol 2014; 15: 147-53.
  • Gabarre S, Alberada J, Gracia L, Puertolas S, Ibarz E, Herrera A. Influenza of gap size, screw configuration, and nail materials in the stability of anterograde reamed intramedullary nail in femoral transverse fractures. Injury 2017; 48: 40-6.
  • Hamahashi K, Uchiyama Y, Kobayashi Y, Ebihara G, Ukai T, Watanabe M. Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments: a retrospective analysis of risk factors for delayed union. Trauma Surg Acute Care Open 2019; 4: e-000203.
  • Ricci WM, Bellabarba C, Lewis R, et al. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma 2001; 15: 90-5
  • Guerado E, Bertrand ML. Malalignment in intramedullary nailing. How to achieve and to maintain correct reduction? Injury 2017; 48: 30-4.
  • Rothberg DL, Holt DC, Horwitz DS, Kubiak EN. Tibial nailing with the knee semi-extended: review of techni ques and indications: AAOS exhibit selection. JBJS 2013; 95: e116.
There are 53 citations in total.

Details

Primary Language English
Subjects Health Care Administration
Journal Section Original Article
Authors

Taner Alıç 0000-0003-3848-8577

Cemal Güler 0000-0001-6831-563X

Murat Çalbıyık 0000-0001-5654-9500

Ercan Hassa 0000-0002-0298-7545

Publication Date March 27, 2023
Published in Issue Year 2023 Volume: 6 Issue: 2

Cite

AMA Alıç T, Güler C, Çalbıyık M, Hassa E. Which of the three different intramedullary nail designs is superior in the treatment of femoral shaft fractures?. J Health Sci Med / JHSM. March 2023;6(2):467-475. doi:10.32322/jhsm.1227816

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