Objective To determine the efficacy and safety of external fixation versus intramedulllary nailing in the treatment of adult tibial shaft fracture. Methods We searched the specialized trials register of The Cochrane Collaboration’s Bone, Joint and Muscule Trauma Group, The Cochrane Library (CENTRAL), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006) and PUBMED (1966 to March 2006). We also handsearched some Chinese orthopedic journals. Randomized controlled trials (RCTs) and quasi-randomized trials (quasi-RCTs) comparing external fixation versus intramedullary nailing for tibial shaft fractures in adults were included. The quality of these trials was critically assessed. We used the Cochrane Collaboration’s RevMan 4.2.8 for data analyses. Result Three RCTs and two quasi-RCTs involving a total of 279 patients were included. The results of meta-analyses showed that external fixation for tibial shaft fractures in adults may increase the infection rate [RR 2.45, 95%CI (1.31,4.61), P=0.005], and the malunion rate [RR 2.85, 95%CI (1.20,6.79), P=0.02] but may reduce the duration of hospitalization [RR –5.50, 95%CI (–6.99,–4.01)]. The nonunion rate, delayed healing rate, and healing time, were comparable between external fixation and intramedulllary nailing. Conclusion The trials available for this systematic review are too few and small for reliable estimates of the relative effects of external fixation and intramedulllary nailing. Further studies are needed to determine these effects , especially for patients who have GustiloШ C fractures.
Objective To describe a surgical device for closed reduction of tibial fracture and investigate its clinical effectiveness. Methods Between June 2010 and December 2012, 24 cases of tibial fractures were treated with intramedullary nailing using a surgical device for closed reduction. There were 18 males and 6 females with an average age of 40 years (range, 20-64 years). All fractures were closed. There were 3 proximal third fractures, 12 middle third fractures, and 9 distal third fractures. According to AO classification, 12 cases were classified as type A, 8 cases as type B, and 4 cases as type C. The mean time between injury and operation was 3 days (range, 1-12 days). The intraoperative fluoroscopy frequency to confirm closed reduction and guide wire passing the fracture site, and the duration between fracture reduction and nail insertion were recorded. The injured limb alignment and fracture angular deformity were measured as described by Freedman et al. The fuction of affected limb was estimated by Johner-Wruhs criteria. Results Closed reduction was successfully performed in 24 patients. The mean fluoroscopy frequency to confirm closed reduction was 3 (range, 2-5). The fluoroscopy frequency to confirm guide wire passing the fracture site was 2. The mean duration between fracture reduction and nail insertion was 30 minutes (range, 20-42 minutes). No intraoperative or postoperative complication occurred, such as infection, vessel and nerve injuries. All incisions healed by first intention. Seventeen patients were followed up 6-16 months (mean, 10 months). Radiographic evidence showed that bridging callous was observed at 2-4 months (mean, 2.5 months). The injured limb alignment was normal on anteroposterial and lateral radiographs at 5 months postoperatively, no malalignment and obvious angular deformity was observed. The internal fixator had good position. According to Johner-Wruhs criteria for evaluation of the affected limb function, the results were excellent in 12 cases and good in 5 cases with an excellent and good rate of 100%. Conclusion The surgical device for closed reduction of tibial fracture is simple and easy to use, and has good effectiveness combined with intramedullary nailing.
Objective To compare the outcomes between intramedullary nail change and augmentation plating with a retained intramedullary nail for aseptic nonunion of femoral shaft fractures after femoral nailing, and to analyze the cause so as to guide the clinical application. Methods Between June 2001 and June 2011, 28 patients with aseptic nonunion of femoral shaft fractures after femoral nailing were treated with intramedullary nail change (11 patients, group A) and augmentation plating with a retained intramedullary nail (17 patients, group B), and the clinical data were analyzed retrospectively. There was no significant difference in age, gender, smoking, location of fracture, Association for the Study of Internal Fixation (AO/ASIF) classification, type of injury, associated injury, type of nonunion, and time of nonunion between 2 groups (P gt; 0.05). The patients were followed up by imaging and the clinical function at regular intervals to observe the callus growth and the recovery condition of the affected limb function, and clinical curative effectiveness was evaluated by Tohner-Wrnch standard. Results The operation time, intraoperative bleeding volume, and intraoperative erythrocyte-transported volume in group A were significantly higher than those in group B (P lt; 0.05). There was no significant difference in postoperative drainage volume and hospitalization days between 2 groups (P gt; 0.05). All the incisions healed by first intention, and no nerve and blood vessel injury occurred. All patients were followed up 18.6 months on average (range, 12-36 months). All cases obtained bone union, and time of clinical and radiological bone healing in group B was significantly shorter than those in group A (P lt; 0.05). During follow-up, no following complication occurred: deep incision infection, injuries of blood vessels and nerves, loosening and breakage of internal fixation, loss of reduction, angulated and rotational malunion. According to Tohner-Wrnch standard at last follow-up, the results were excellent in 6 cases, good in 3 cases, and poor in 2 cases, with an excellent and good rate of 81.8% in group A; the results were excellent in 12 cases, good in 5 cases, with an excellent and good rate of 100% in group B; and difference was significant between 2 groups (Z= — 2.623, P=0.021). Conclusion Augmentation plating with a retained intramedullary nail is an ideal treatment for aseptic nonunion of femoral shaft fractures after femoral nailing and can achieve satisfactory clinical outcomes because it has simpler operation, shorter operation time, less blood loss, and less trauma than intramedullary nail change.
Objective To discuss the effectiveness of antibiotic-impregnated cement temporary spacer for osteomyel itis and nonunion of bone caused by intramedullary fixation. Methods Between June 2002 and May 2006, 12 patients with chronic osteomyel itis and nonunion of bone caused by intramedullary nail ing were treated, including 8 males and 4 females with an average age of 40.2 years (range, 26-53 years). The fracture locations included tibia in 7 cases and femur in 5cases. Infection occurred within 2 weeks after intramedullary fixation in 7 cases and within 3 months in 5 cases. The mean time from infection to admission was 5 months (range, 1-24 months). The results of bacteria culture were positive in 10 cases and negative in 2 cases. White blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were higher than normal values. An antibiotic-impregnated cement temporary spacer was inserted after removal of biomembrane and internal fixator, thorough debridement and irrigation. After osteomyel itis was controlled by antibiotic therapy postoperatively, two-stage bone transplantation and internal fixation were performed after 3 to 6 months. Results All wounds healed by first intention without early compl ication. All cases were followed up 24 to 48 months (mean, 34 months). WBC count, ESR, and CRP were normal at 3 months postoperatively. The X-ray films showed the fracture heal ing at 10-14 weeks after operation (mean, 12 weeks). Expect one patient had knee range of motion of 90°, the lower l imb function of the others returned to normal. No infection recurred during follow-up. Conclusion Antibiotic-impregnated cement temporary spacer could control osteomyelitis and nonunion of bone caused by intramedullary nail ing, and two-stage bone transplantation and internal fixation after osteomyelitis is an effictive and ideal way to treat osteomyelitis and nonunion of bone caused by intramedullary nail ing.
【Abstract】 Objective To explore the biomechanical properties of a new intramedullary controlled dynamicnail ing (ICDN). Methods Ten pairs of specimens of adult femurs, with the age of 18 to 55 years, were divided into twogroups (groups A1 and B2, n=10). The length of the specimens was (438 ± 10) mm , and the external diameter was (26.4 ± 1.5) mm. The specimens of the two groups were osteotomized transversely after the biomechanical test. ICDNs and GK nails were randomly implanted into the femurs, respectively (groups A2 and B2). Torsional, bending and axial compressive tests were made in each group, and the effect of dynamic compression between the fracture fragments was tested. Results The resistance to compression of groups A1, B1, A2 and B2 were (0.19 ± 0.18) × 106, (0.22 ± 0.12) × 106, (1.67 ± 0.68) × 106 and (0.86 ± 0.32) × 106 N/mm, respectively. There was statistically significant difference between groups A2 and B2 (P lt; 0.01). The bending stiffnesses of coronal section of groups A1, B1, A2 and B2 were (0.94 ± 0.25) × 103, (1.10 ± 0.21) × 103, (0.70 ± 0.22) × 103, (0.64 ± 0.21) × 103 N/mm, respectively. The bending stiffness of sagittal plane of groups A1, B1, A2 and B2 were (1.06 ± 0.26) × 103, (0.96 ± 0.25) × 103, (0.67 ± 0.25) × 103, (0.61 ± 0.18) × 103 N/mm, respectively. There were no statistically significant differences between groups A1 and B1 or between groups A2 and B2 (P gt; 0.05). When the torque was 5 Nm, the torsional stiffness of groups A1, B1, A2 and B2 were (4.00 ± 2.54), (4.76 ± 1.93), (0.50 ± 0.63), (0.35 ± 0.31) Nm/°, respectively. When the torque was8 Nm, the torsional stiffness of groups A1, B1, A2 and B2 were (4.30 ± 3.27), (3.94 ± 2.01), (0.42 ± 0.52), (0.36 ± 0.18) Nm/°, respectively. There were statistically significant differences between groups A1 and A2 or between groups B1 and B2 (P lt; 0.05), and no statistically significant difference between between groups A2 and B2 (P gt; 0.05). The average maximal pressure generated between the fracture fragments which were fixed with ICDN was 21.6 N, and the pressure between the fracture fragments which were fixed with GK nail ing could not be tested. Conclusion The design of ICDN conforms to the special anatomical structure of the femur. ICDN could provide a completely different structure, a different fixation principal and a more balancedfixation than GK nail. ICDN incorporates the flexible and rigid fixation, which is l ikely to be the trend of the fracture fixation.
【Abstract】 Objective To discuss the techniques and advantages of closed reduction and intramedullary nail ing intreating femoral shaft fracture without cannulated femoral reamer. Methods From January 2006 to June 2007, 24 cases offemoral shaft fracture were treated with closed reduction and intramedullary nail ing. Among them, there were 14 males and 10 females, with the average age of 38.3 years (ranging from 18 years to 63 years), with 7 left legs and 17 right legs. The average course of the disease was 7.6 days (ranging from 3 days to 20 days). According to the AO typing, there were 5 cases of type A, 6 of type B, 7 of type C1, 2 of type C2 and 4 of type C3. Closed reduction was achieved with manipulation and reaming of femoral canal was instructed by fluoroscopy. Results The operation time lasted from 100 minutes to 170 minutes, with the average time of 128.3 minutes. One patient was given a transfusion of 400 mL, and others were not. Twenty cases were followed up with the average time of 13.1 months (ranging from 6 months to 24 months). A mild to large amount of bony callus was showed on X-ray films 6 to 12 weeks postoperatively. Walking without crutches began at the average week of 22.2 (ranging from 15 to 30) postoperatively. Range of motion of the knee was 0° to 145.5°. No infection or break of the internal fixator occurred. Myositis ossificans with pain and insufficient flexion of hip (120°) happened in 1 case and the pain disappeared after non-steroid anti-inflammatory drugs were taken. Nonsymptomatic myositis ossificans occurred in 2 cases and no treatment was needed. Conclusion Closed reductionand intramedullary nail ing can help to protect the blood supply of fracture fragments and provide central fixation. The operation process will be more compl icated if cannulated femoral reamer is not available.
Objective To study the effect of internal fixation with absorbable intramedullary nail on the treatment of phalange fractures in replantation of severed finger. Methods From September 2001 to October 2003, 28 cases with industrial severed finger (21 males and 7 females, with the age of 18-35 years) were replanted within 1-6 hours. The severed locations were index fingers in 11 cases, middle fingers in 8 cases, ring fingers in 6 cases, little fingers in 3 cases. All cases of phalange fractures were fixed by absorbable intramedullary nails of poly-DL-lactic acid(PDLLA) that combined with chitosan. Out of the 28 cases, 15 cases were with proximal phalange, 11 cases were with middle phalange, 2 cases were with distal phalange. The bone marrow cavity of the phalanges were dilated, then the intramedullary nail was inserted with suitable diameter and length to fix the fracture. Postoperatively resin bandage was applied for 3-4 weeks.Results All the 28 patients survived the performance and postoperative follow-up ranged from 3 to 10 months(4 months in average). Rejection was observed in one case 3 weeks after operation, bone unions were obtained in other cases. According to the Chinese Medical Association’s evaluation standard for replantation of amputated finger, 18 fingers resulted in excellence, 9 fingers in good function and 1 with unsatisfactory function. The excellent and good rate was 96.4%. Conclusion Internal fixation with absorbable intramedullary nail of PDLLA combined with chitosan proves to be effective in the replantation of severed finger.
ObjectiveTo design an auto-compressive and anti-circumrotate intramedullary nail( ACACIN) and to evaluate the preliminary clinical efficacy on fixing adult femur fracture. Methods From January 1998 to June 2001, 23 patientswith femur fracture were stabilized with auto-compressive and anti-circumrotateintramedullary nail. 2-4 elastic blocks were installed into the proximal and distal different distance of quincunx nail to defend circumrotate and axis compress. Results Fracture healing were obtained in all 23 patients treated with auto-compresseiveand anti-circumrotate intramedullary nail, the time of fracture healing was 6-13 weeks in 21 cases and 15-22 weeks in 2 cases of old fracture. There was no complication related to infection, nail break, abnormal union and joint ankylosis. The results were excellent in 19 cases, good in 3 cases, and moderate in 1 case according Kolmert’s criterion for function ; the effective rate was 95.7%. Conclusion Auto-compressive and anti-circumrotate intramedullary nail has a suitable radian for adult femur, can afford stable fixation, anti-circumrotate andaxis compress.
Objective To compare the efficacy of plating versus intramedullary nailing in the treatment of adult humeral shaft fracture. Methods We identified eligible studies in PubMed (1950 to September 2007), MEDLINE (1950 to September 2007), OVID CINAHL (1950 to September 2007), OVID EBM (3rd Quarter 2007), CBMdisk (1978 to June 2007) and CNKI (1981 to June 2007). We also handsearched several Chinese orthopedic journals. Data were extracted and evaluated by two reviewers independently. Randomized controlled trials (RCTs) comparing plating versus intramedullary nailing for humeral shaft fracture in adults were included and the quality of these trials was critically assessed. Data analyses were conducted with Stata 10.0. Results Six RCTs involving 425 patients were included, among which the statistical heterogeneity was not significant (Pgt;0.1). Cumulative meta-analyses showed that intramedullary nailing might increase the re-operation rate in studies conducted before the year of 2000 (OR=0.39, 95%CI 0.17 to 0.90, P=0.03), but the difference was not significant in studies conducted after 2000 (OR=0.54, 95%CI 0.27 to 1.08, P=0.08). Intramedullary nailing might increase the incidence of shoulder impingement compared with plating (OR=0.13, 95%CI 0.03 to 0.65, P=0.01). The rates of non-union, deep infection, iatrogenic radial nerve injury and internal fixation failure were similar between plating and intramedullary nailing. Meta-analyses were not conducted for union time, operation time and bleeding (transfusion) volume, because the relevant data were not available from the included trials. Conclusion Intramedullary nailing may increase the incidence of shoulder impingement. The rates of re-operation, non-union, deep infection, iatrogenic radial nerve injury and internal fixation failure are similar between plating and intramedullary nailing. Further well-designed and large-scale randomized controlled trials are required to determine the effects of plating and intramedullary nailing on these outcomes.
Objective To determine the efficacy and complication rate of intramedullary nailing versus compression plate in the treatment of adult humeral shaft fracture. Methods We searched the specialized trials register of The Cochrane Collaboration’s Bone, Joint and Muscle Trauma Group, The Cochrane Library (including CENTRAL), MEDLINE (1966 to 2006), EMbase (1980 to 2006), PubMed (1966 to 2006), NRR (http://www.update-software.com/National/), CCT (http://www.controlled-trials.com) and CBMdisc (1979 to July 2006). We also handsearched some Chinese orthopedic journals. Data were extracted and evaluated by two reviewers independently. Randomize controlled trials comparing intramedullary nailing versus compression plate for humeral shaft fracture in adults were included and the quality of these trials was critically assessed. Data analyses were done using The Cochrane Collaboration’s RevMan 4.2.8. Results Three randomize controlled trials involving 215 patients were included. The meta-analysis showed that intramedullary nailing may increase the re-operation rate (OR=2.68, 95%CI 1.19 to 6.04, P=0.02), pain in the shoulder (OR=13.02, 95%CI 2.23 to 75.95, P=0.004), and the rate of decreased range of motion of the shoulder (OR=18.60, 95%CI 1.01 to 341.83, P=0.05). The rates of no union, infection and iatrogenic radial nerve injury were comparable between intramedullary nailing and compression plate. Meta-analysis was not conducted for the time of union, because the relevant data were not available for the included trials. Conclusions Further well-designed and large-scale randomize controlled trials are required to determine the effects of intramedullary nailing and compression plate on these outcomes, because the trials available for this systematic review are too few and too small.