Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery

Purpose: Failure to adequately recruit patients in orthopaedic trials has often led to early stopping and publication of research findings from smaller sample sizes than originally planned. The purpose of this study is to demonstrate the effect of sample size in a large, clinical trial by using SPRINT trial data to evaluate the results that would have been reported if the trial were stopped at various enrollments. Method: The SPRINT trial evaluated reamed vs. unreamed nailing in 1226 tibia fractures. We analyzed the re-operation rates after various increments in sample size and compared the early results that would have been reported at smaller enrollments with those seen in the final, adequately powered study. Results: In the final analysis of 1226 patients, there was a significant reduction in the risk of re-operation with reamed nails for closed fractures (35% reduction; p=0.02) and a trend towards an increased risk of re-operation for open fractures (23% increase; p=0.26). In stark contradiction, the results for the first 50 patients enrolled in the trial revealed a substantial increased risk for reamed nails in closed fractures (risk increase: 165%). It was not until enrollment reached 800 patients that the results reflected the final findings of an advantage for reamed nails. In open fractures, the trend favoring unreamed nails was not seen until 200 patients had been enrolled. Conclusion: Our findings suggest that stopping the SPRINT trial early would have led to misleading estimates of the treatment effect between reamed and unreamed nails

In order to define the operative indications, we compared the post-operative complications, time of consolidation, incidence of compartment syndrome, and fat embolism in centro medullary nails made from two different metals. This study includes approximately 234 centro medullary nails (TARGON System) used for treatment of diaphysal fractures of the leg or femur after a skiing injury. Steel nails were used before 1998 and titanium nails after 1998. The time of consolidation was the same for steel nails and titanium reamed nails. We remain faithful to limited reaming which avoids destruction of bone, and cortical and exothermic damage, but enables easier insertion of the titanium nail for leg fractures and bone grafts in sitù. The incidence of compartment syndrome with use of a titanium nail is reduced threefold. Regarding femoral fracture, the insertion of the nail without wire is more complicated and the operative stage is extended by 25%. The time of consolidation is the same for titanium or steel nails, and there were no failures with either type. However, we advise using titanium reamed nails for leg fractures and steel reamed nails for femoral fractures. If there is a suspicion of fat embolism, it is better to use femoral titanium nails

Aims: Neutrophil (PMN) dysfunction is implicated in both acute respiratory distress syndrome (ARDS) and sepsis. We aimed to determine the PMN response following isolated long-bone/pelvic fracture by investigating temporal changes in PMN migration and surface receptor expression (CXCR1, PECAM- 1, & CD18/ CD11b) following injury. Methods: Of the 20 patients consented to enter the study, 14 underwent reamed nailing/ORIF within 24 hours, and 6 were treated with an Ex-Fix or conservatively. 11 normal volunteers (NLV) were used as controls. Blood samples were obtained within 2 hours of admission, at 24 hours, at day 3 and day 5. PMN were isolated and the number of PMN migrating across porous collagen IV coated tissue culture inserts, in response to IL-8 were quantitated by myeloperoxidase activity. PMN surface receptor expression was assessed by whole blood FACScan analysis. Results: Signiþcantly greater numbers of fracture patient PMN migrated on admission as compared with NLV. In the Ex-Fix group the numbers migrating declined steadily and showed a hypo-response on day 5. In the reamed nailing group there was a further elevation in the PMN numbers migrating post-operatively. CXCR1 & CD18 expression was signiþcantly increased on admission. PECAM-1 was signiþcantly down-regulated on admission. Conclusions: Following isolated long-bone/pelvic fracture PMN are primed for increased migration in response to IL-8. This is associated with up-regulation of CXCR1 and CD18, and down-regulation of PECAM-1. Treatment by reamed nailing and ORIF confers a Ç second hit È manifest as a further increase in IL-8 mediated PMN migration

Introduction: Road side accidents resulting in polytrauma with an associated fracture of femur is a common pattern of injury in asian countries. We hypothesised that the use of unreamed nailing in the management of such fractures has better outcome than reamed nailing. Material and Methods: We retrospectively reviewed 116 cases of polytrauma with associated fracture of shaft of femur admitted in our tertiary teaching hospital in North India bewteen Jan 1996 to Dec 2001. The patients were initially resuscitated according to the advanced trauma life support protocol. They were randomally managed by interlocking nail using reamed (n=48) and unreamed (n=68) technique after being haemodynamically stabilized. Five intraoperative parameters were recorded – the surgical time, fluoroscopy time, the intraoperative blood loss, intraoperative oxygen saturation, and any intraoperative complications. The patients were assessed postoperatively for ninety six hours for features of adult respiratory distress syndrome. All patients were clinically and radiologically assessed at 6 weekly intervals till union. The follow-up reassessments were performed by a single surgeon (AG). Results: There were 80 males, 30 females (6 were bilateral), with an average age of 26 years (range 19 to 64 years). The fractures were closed in 74 and open in 42 (Gustillo Grade 1;n=28, Grade 2;n=9, Grade 3;n=5). 48 were managed by reamed interlock nailing (Group 1) and 68 by unreamed interlock nailing (Group 2). 58 patients had an associated blunt trauma chest, 36 had blunt trauma abdomen, 18 had an associated head injury and 12 had spine injuries. The average surgical time for Group 1 was 118 minutes and for Group 2 was 94 minutes (p=0.014). The average fluorscopy time for Group 1 was 4.30 minutes and for Group 2 was 4.06 minutes. The average intra-operative blood loss for Group 1 was 254 millilitres and for Group 2 was 202 millilitres. The average intraoperative oxygen saturation fall as measured at the time of reaming and nail insertion was 2% in Group 1 and 6% in Group 2. The intraoperative complications were 11 (22.91%) in Group 1 and 18 (26.47%) in Group 2. The features of ARDS were observed in 6 patients in Group 1 (12.5%) and 4 patients in Group 2 (5.88%). The average union time was 25 weeks in Group 1 as compared to 19.4 weeks in Group 2 (p=0.012). The reoperation rate was 6.25% in Group 1 and 11.76% in Group 2. Discussion: The unreamed interlock nailing is the definitive management of fractures of femur in patients with polytrauma or blunt trauma chest as it requires lesser operative time (and thus exposing the patient to shorter period of anaesthesia), lesser blood loss and lesser fluoroscopy exposure. The incidence of ARDS is significantly lower with unreamed nailing in polytrauma patients. However the union time was significantly longer in unreamed nailing as compared to reamed nailing

Background. RHF nail is an important tool for simultaneous ankle and subtalar joint stabilisation +/− fusion. Straight and curved RHF nails are available to use, but both seem to endanger plantar structures, especially the lateral plantar artery and nerve and Baxter's nerve. There is a paucity of literature on the structures at risk with a straight RHF nail inserted along a line bisecting the heel pad and the second toe (after Stephenson et al). In this study, plantar structures ‘at risk’ were studied in relation to a straight nail inserted as above. Methods. Re-creating real-life conditions and strictly following the recommended surgical technique with regards to the incision and guide-wire placement, we inserted an Orthosolutions Oxbridge nail into the tibia across the ankle and subtalar joints in 6 cadaveric specimens. Tissue flaps were then raised to expose the heel plantar structures and studied their relation to the inserted nail. Results. The medial plantar artery and nerve were always more than 10mm away from the medial edge of the nail, while the Baxter nerve was a mean 14mm behind. The lateral plantar nerve was a mean 7mm medial to the nail, while the artery was a mean 2.3mm away with macroscopic injury in one specimen. The other structures ‘at risk’ were the plantar fascia and small foot muscles. Conclusion. Lateral plantar artery and nerve are the most vulnerable structures during straight RHF nailing. The risk to heel plantar structures could be mitigated by making incisions longer, blunt dissection down to bone, meticulous retraction of soft tissues and placement of the protection sleeve down to bone to prevent the entrapment of plantar structures during guide-wire placement, reaming and nail insertion

We performed a randomised, prospective trial to evaluate the use of unreamed titanium nails for femoral fractures. Of 48 patients with 50 femoral fractures 45 were followed to union; 23 with an unreamed and 22 with a reamed nail. The study was stopped early because of a high rate of implant failure. The fractures in the unreamed group were slower to unite (39.4 weeks) than those in the reamed group (28.5 weeks; p = 0.007). The time to union was over nine months in 57% of the unreamed group and in 18% of the reamed group. In the unreamed group 14 secondary procedures were required in ten patients to enhance healing compared with three in three patients in the reamed group. Six implants (13%) failed, three in each group. Four of these six fractures showed evidence of delayed union. To achieve quicker union and fewer implant failures we recommend the use of reamed nails of at least 12 mm in diameter for female patients and 13 mm in males

Winner of ISFR Best Paper Award. Introduction: Surgeons agree on the benefits of intramedullary nailing of tibial shaft fractures. We assessed the impact of reamed versus unreamed intramedullary nailing on re-operation rates. Methods: The Study to Prospectively Evaluate Reamed Intamedullary Nails in Tibial Fractures (SPRINT) was a multi-center, randomized trial including 29 clinical sites. 1339 patients with tibial shaft fractures were randomized to either reamed or unreamed intramedullary nail insertion. Re-operations before 6 months were not permitted unless there was critical bone loss. The primary outcome was re-operation to promote healing, treat infection, or preserve the limb. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. Results: Of 1339 enrolled patients, 1226 patients were followed to 1 year. Across treatment groups, patients did not differ in age, gender, and fracture types. The overall event rate was 17.8% (13.7% closed, 27%, open fractures). In 826 patients with closed fractures, patients with a reamed nail had a relative risk reduction of 33% (95%CI: 4–53%, P=0.03). This treatment effect was largely driven by differential autodynamization rates (rel risk: 0.42, p=0.01). Among 400 patients with open fractures, there was a trend towards an increased risk of an event (rel. risk=1.27, p=0.16) for those who received a reamed nail. Conclusions: Our overall incidence of revision surgery was lower than reported in previous studies. Optimizing peri-operative care and avoiding premature re-operation may substantially decrease the need for re-operation in tibial fracture patients

Purpose: Accurate prediction of re-operation following tibial nailing may facilitate optimal patient care. We recently completed the SPRINT trial, a large, multi-centre trial of reamed versus non-reamed intramedullary nails in 1226 patients with tibial shaft fractures. Using the SPRINT data, we conducted an investigation of baseline and surgical patient characteristics to determine if they are associated with increased risk of re-operation within one year. Method: Using multivariable logistic regression analysis, we investigated 15 characteristics for association with increased risk of re-operations. Because the primary SPRINT analysis found that reamed nailing reduced events in patients with closed but not open fractures, we considered both open and closed as well as treatment status in our model. Results: We found an increased risk of re-operation in patients with a high energy mechanism of injury (odds ratio, OR=1.57, 95% CI 1.05 to 2.35), stainless steel versus titanium nail (OR=1.52, 95% CI 1.10 to 2.13), fracture gap (OR=2.40, 95% CI 1.47 to 3.94) and post-operative weightbearing (OR=1.63, 95% 1.003 to 2.64). Open fractures increased the risk of re-operation in patients who received a reamed nail (OR=3.26, 95% CI 2.01 to 5.28) but not in patients who received a non-reamed nail (OR=1.50, 95% CI 0.92 to 2.47). Patients with open fractures who had either wound management without any additional procedures, or delayed primary closure, had a decreased risk of re-operation when compared to patients who required subsequent reconstruction (respectively, OR=0.18, 95% CI 0.09 to 0.35; OR=0.29 95% CI 0.14 to 0.62). Conclusion: To ensure optimal patient care surgeons should consider the characteristics identified in our analysis to reduce risk of re-operation

Aims: To present the experience of our department in the treatment of the closed shaft tibial fractures using the unreamed nail of Orthoþx. Material- Method: Between 1991–2001 we treated 180 closed fractures. There were162 men and 18 women. The preferred method of stabilization is unreamed nailing. Results: The average follow-up was 38 months. 165 of the fractures that were treated with uiin, healed in the proper time (3–6 months). The rest of them did not have callus signs and we revised the nailing using reamed nails. No screws and nail failure was observed. Three deep venous thrombosis, healed with no further complications. 65% of our patients were able to return to their usual activities within 4 months and the rest between 4–8 months. 15 non-unions and 2 malunions occurred and were treated with correction and reamed interlocking nailing. P.W.B. allowed for fractures type A and B according AO classiþcation from the beginning. F.W.B. allowed at mean 3 months. Conclusions: Immediate stabilization of the close fractures of the tibia using uiin (Orthoþx device): advances the healing of the fractures, decreases hospitalization time, helps early return to social activities, is easier for the surgeon, easier to place the distal locking screws, requires less operative time and less radiation. We did not þnd this method inferior to reamed interlocking nailing

Purpose: Surgeons agree on the benefits of intramedullary nailing of tibial shaft fractures. The SPRINT primary objective aimed to assess the impact of reamed versus unreamed intramedullary nailing on rates of re-operation in patients with tibial shaft fractures. Method: The Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Fractures (SPRINT) was a multi-centre, randomized trial including 29 clinical sites. SPRINT enrolled 1319 patients with open or closed tibial shaft fractures. Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were not permitted unless there was critical bone loss. Patients received a statically locked intramedullary nail with either reamed or unreamed insertion. The primary outcome was re-operation to promote healing, treat infection, or preserve the limb. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. Our sample size calculations required 1200 patients followed for 1 year. Results: Of 1319 enrolled patients, 1226 patients were followed to 1 year. Across treatment groups, patients did not differ in age, gender and closed and open fracture types (I-IIIB). The overall event rate was 17.8% (13.7% closed, 26.5%, open fractures). A significant subgroup interaction effect in patients with open versus closed fractures (p=0.01) mandated a separate analysis for each subgroup. In 826 patients with closed fractures, patients with a reamed nail had a relative risk reduction of 33% (95%CI: 4–53%, P=0.03). This treatment effect was largely driven by differential autodynamization rates (rel. risk: 0.42, p=0.01). Among 400 patients with open fractures, there was a trend towards an increased risk of an event (rel. risk=1.27, p=0.16) for those who received a reamed nail. Conclusion: Our overall incidence of revision surgery was lower than reported in previous studies. Possible reasons for the overall lower event rates in SPRINT are:. standardization of surgical and post-surgical care resulted in superior care among the SPRINT centres and surgeons and. proscription of surgery until after 6 months. Optimizing peri-operative care and avoiding premature re-operation may substantially decrease the need for re-operation in tibial fracture patients

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed. In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008). These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction. Cite this article: Bone Joint J 2014;96-B:385–9

Aim. Post traumatic distal tibia osteomyelitis (DTOM) with an upper ankle joint involvement is a serious complication after primary osteosynthesis and can be a nightmare for the patient and the surgeon as well. Our aim was to identify mayor complications during treatment and to find the way to prevent or treat them. Method. It is a retrospective analysis of eight patients with DTOM and an upper ankle joint involvement treated in our institution from 2012 to 2018. The average size of a bone defect after a debridement was 9 centimeters (4–15). Patients were treated in two stages. First stage was segmental bone resection, external fixation and soft tissue envelope reconstruction if necessary. At second stage a distraction frame was applied and proximal corticotomy performed. In all but one case a circular frame was used. Results. We have had one major intra-operative complication, an injury of arteria tibialis posterior during the corticotomy procedure. Except in one patient we did not observe major problems with pin-track infections. Despite bone-grafting in all patients, we observed three nonunions of docking site. We treated them by external fixator in two and retrograde intramedullar nail in one case. In two patient the distraction callus was weak. We had to bone graft and secure the callus with a plate in one and use a retrograde reamed intramedullar nail in second patient. We have observed two callus fracture after removal of the frame. A surgery was needed for both because of the deformation. The first patient was treated by new external frame, the second by retrograde reamed intramedullar nail. Conclusions. Callus distraction is a valuable option to treat a bone defect. The procedure has many possible problems and complications, especially during treatment of defects larger than six centimeters. It is very difficult for patients to tolerate a frame more than one year. We have found the use of an intramedullar tibial nail inserted in a retrograde way as a helpful option not just to shorten the time of external frame, but in combination with reaming also to accelerate the healing of the distraction callus and the upper ankle joint arthrodesis as well

Background. In a systematic review of 1125 distal tibia fractures treated with an intramedullary nail, the reported incidence of malalignment was 14%. The purpose of our study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved radiological outcomes. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing. Methods. We searched computerised records at a UK level 1 major trauma centre. The joint alignment was measured on the immediate post-operative radiograph and compared to the most recent radiograph. We used a difference of 2 degrees to indicate a progressive deformity and a RUST score greater or equal to 10, to indicate radiographic fracture union. Results. Twenty-seven patients were included. Nineteen patients had no blocking screw and 8 patients had a blocking screw. Five patients had a difference in their coronal plane alignment of 2 degrees or more (3/5 had no blocking screw). The results were analysed and found to be not statistically significant (p=0.88). The addition of a blocking screw has also been shown not to have an effect on the time to union. Conclusion. We have changed our surgical practice. We use a 2.5mm blocking wire to aid in fracture reduction prior to reaming / nail insertion and then remove the wire when the nail has been adequately locked. Implications. This could save surgical procedure time, radiation exposure for the patient, implant costs and potential complications

We performed a prospective, randomised study on 50 patients with Tscherne C1 tibial diaphyseal fractures comparing treatment with reamed and unreamed intramedullary nails. Our results show that reamed nailing is associated with a significantly lower time to union and a reduced requirement for a further operation. Unreamed nailing should not be used in the treatment of the common Tscherne C1 tibial fracture

There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series

Purpose. There is no clear definition of a critical sized defect of the tibia. We defined it as a fracture gap at least one centimeter in length and involving over 50% of the cortical diameter. We explored if the presence of a critical-sized defect predicted reoperation, and which other factors predict reoperation in patients with the critical defect. The patient based outcomes of these patients were compared to patients without a critical defect. Method. Patients enrolled in the SPRINT trial with a critical sized defect were evaluated for secondary interventions to gain union. Other factors predicting the need for reoperation were studied. We also compared the patients with critical sized defects to the larger cohort of patients without a defect with respect to demographics, injury mechanism, fracture characteristics, and patient-based outcome. Results. Tibial diaphyseal defects of greater than or equal to one centimeter and >50% cortical circumference healed without additional surgery in 47% of cases. Fewer reoperations were required in patients treated with a reamed nail (p=0.04). The mean of the SF-36 physical component summary in patients with a critical sized defect was poorer than the overall cohort (p=0.02, difference = 5.2, 95% confidence interval 0.8 to 9.6). Conclusion. This definition of a critical sized defect is not critical in terms of predicting reoperation, as 47% of cases healed without additional intervention. However, patients with these bone defects had a higher rate of reoperation and worse patient based outcomes compared to the overall cohort of tibial fracture patients. Further investigation is recommended

Unreamed, small diameter nails with interlocking capability have become the preferred treatment for most unstable tibial fractures, but have been shown to have a high rate of hardware breakage and frequently require secondary procedures to obtain union. Reamed nailing may offer advantages for fracture healing due to the use of larger implants and increased stability, but may cause higher rates of infection and compartment syndrome. In order to determine if there is a difference in healing or complications in open and closed tibial fractures treated with reamed or unreamed intramedullary nailing, we performed a prospective, surgeon-randomized comparative study. Ninety-four closed and open, unstable tibial shaft fractures (excluding Gustilo Types IIIB and C) treated with intramedullary nailing were studied. Our findings support the use of reamed nailing in closed tibial fractures, which led to earlier time to union without increased complications. In addition, reaming did not increase the risk of complications in open tibial fractures

Purpose. The aim of this study was to investigate whether growth factors essential for fracture healing are released in the immediate aftermath following fracture and whether reaming of IM cavity causes increased liberation of these autocoids. Methods. Consecutive adult patients with femoral shaft fractures forming two groups (a group who received unreamed nail (n=10) and a second group who received reamed nail (n=10) were recruited for this study. Peripheral blood samples and samples from the femoral canal before and after reaming and before and after the solid nail insertion were collected. Serum was extracted and using Elisa colorimetric assays the concentration of Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF), Insulin-like Growth Factor I (IGF-I) Transforming Growth Factor beta 1 (TGF-. 2. 1) and BMP-2 levels was measured. Results. In total 20 patients were studied. The mean age was 38 years (range 20-63). Reaming substantially increased all studied growth factors locally in the femoral canal. VEGF and PDGF were increased after reaming by 111.2% and 115.6% respectively. IGF-1 was increased by 31.5% and TGF-b1 was increased by 54.2%. In the unreamed group the levels of PDGF-BB, VEGF and TGF-. 2. 1 were not changed while the levels of IGF-I were decreased by 10%. The levels of these factors in peripheral circulation were not altered despite the technique used. BMP-2 levels during all time points were below the detection limit of the immunoassay. Conclusion and significance. This study indicates that reaming of IM Canal is associated with increased liberation of growth factors. The osteogenic effect of reaming could be secondary not only to grafting debris but also to the increased liberation of these molecules