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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 35 - 35
1 Sep 2012
Friedl W Gehr J
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Clinical Problem

Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems.

We started to use the XS and XS nail as minimal invasive procedure for the management of these fractures in July 2000 first for the fibula and since for the fibula and pilon itself but extended metaphseal comminution are contraindication for the XS nail.

Because of soft tissue problems and higher loading capacity of intramedullary implants the XS Nail was also used for ankle fracture osteosynthesis but as in all articular fractures with open reduction,

Material and Methods

the XS nail is a 4.5mm or the XXS a 3.5mm straight nail witch is locked by threaded wires witch are placed with an aiming device and allows also dynamic fracture site compression with a set screw. The Fibula is fixed percutaneusly and after distal locking with traction of the aiming device also tibia length and axis can be restored and fixed with the proximal locking. From july 2000 to july2006 54 pilon fractures where treated. The mean age was 54 years (range 25–92). In all cases except one referred after 4 weeks the fibula and joint dislocations where stabilised primarily. The tibia XS nail osteosynthesis or limited invasive plate fixation was performed after 5–8 days except two fixed primarily. Up to now 43 patients could be re-examined more than 12 months after surgery. The results were classified according to the Ovadia Score.

In a second study: from 05/2000 to 03/2002 214 ankle fractures were stabilised with a XS or XXS nail. The mean age was 51 year, 59% were woman. 35% were Weber B and 25% type C fractures. The re-examination after 6 months could be performed in 91 Patients and was evaluated according to the Ovadia score (clinical and radiological).


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 548 - 548
1 Oct 2010
Friedl W Gehr J Spalteholz M
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The olecranon is exposed to high tension and bending forces. In 2/3 multifragment fractures occur. Tension belt and plate fixation in these not only transverse but also sagital and frontal plane fractures is often not possible. As a central weight bearing device the XS 4,5mm nail is exposed to a lower bending moment and a angle stable transverse fixation with 2,4mm threaded wires every 9mm is possible. Also a soft tissue independent fracture compression with a set screw (proximal longitudinal holes) is possible. Additional frontal and sagital plane fragments can be fixed to the system with fibre wire hemicerclages.

From 5.1999 to 12.2002 80 consecutive cases with XS nail osteosynthesis of a olecranon fracture were treated and 73 (91%) could be re-examined clinically and radiological 15 months after surgery. 13,7% were open fractures 67% were 3 or more part fractures. For evaluation the Murphy score was used.

The mean time for surgery was 37min for two part and 56 min. for more part fractures. The Murphy score showed in 64% very good and in 29% good results. Only in 4 patients with more part fractures with additional radius head fractures and previous surgery had fair or unsatisfactory results.

The XS nail is a new concept for stabilisation of all but specially of complex and very comminuted olecranon fractures with a very low complication rate and good functional results.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_II | Pages 351 - 351
1 May 2010
Friedl W Gehr J
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Clinical Problem: fractures under tension are common injuries and occur when patients are falling on partial flexed limbs under maximal contraction of the extensor muscles. Typical injuries are patella and olecranon. For these fractures the tension belt osteosyntheses is the mainly used procedure. A high complication rate regarding dislocation, bone healing, pain and functional outcome are reported. This is due to the unstable fixation with the tension belt because of the tendon insertion around the bone fragment witch allow secondary loosening of the tension belt under alternating load. This was found allready 1987 by Brill and Hopf in an experimental study.

Materials and Methods: To improve stabilisation a new device was developed: the XS (4,5mm diameter) and the XXS nail (3,5mm) witch is locked with threaded wires and a set screw allows fracture compression inside the nail independend from the soft tissues around. Fiber Wire cerclage transversal around the threaded wire ends allow the fixation of additional frontal plane fragments or marginal fragments.

Experimental test were performed in a patella sow-bone models and showed superior to tension bel (patella) and Plate fixation/fibula). On the other side the locked nail system allows percutaaneous osteosynthesis of the whole ulna also in shaft, distal fractures and shortening osteotomies.

All clinical cases treated with the XS/XXS nail where recorded prospectively and re-examined after 6–12 months. From may 2000 to march 2002 76 patients with olecranon fractures were evaluated. 85% of the olecranon fracture patients could be re-examined. Most patients where treated immediately or after wound healing without splint.

Results: the experimental results shows in all XS nail group no gap after alternating load of 250 and 500N and a rigidity a little higher than that of the not osteotomised patellae. In the tension belt groups in all tested patellae visible gaps of 1 to 3 mm occurred. There was no difference between the single and double XS nail Osteosynthesis.

71.7% of all patients with olecranon fractures showed a very good result according to the Murphy score. In 2 part fractures the rate was even 94.7%. Only in the group of more part fractures in 5.9% fair results were found. No patient showed a poor result.

The technical possibilities of XS nail osteosynthesis in ulna shaft, distal fractures and shortening osteotomies are presented.

Conclusions: the XS nail is a new device witch allows good anatomical reconstruction and stable fixation with immediate functional therapy in all olecranon and ulna fractures.