Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Biomechanics of Intramedullary Fracture FixationKyle, Richard F, MDOrthopedics; Nov 1985; 8, 11; ProQuest Centralpg. 1356

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

JOURNAL OF INDUSTRIAL DESIGN AND ENGINEERING GRAPHICS 5

Abstract: Tibia shaft fractures are the more frequent fractures of lower limb. To determine the behavior

during the fixation process there was used a CAD parametric software which permits defining models with

a high degree of difficulty. First, there were defined the main bone components as tibia using CT images.

These images were transferred to AutoCAD where the outer and inner contours of the bone were

approximate to polygonal lines composed by many segments. These contours were transferred to

SolidWorks where, step by step, and section by section, was defined the virtual tibia. At the first time, the

tibia was complete and, after that, it was divided in 2, 3 or more components to simulate different types of

fractures. Using the direct measurement method the virtual metallic components as nail and orthopedic

screws were generated. All these virtual components were combined to obtain four cases of tibia fractures

studies. The idea to design a tibia nail, which eliminates the use of orthopedic screws was given by the

study of surgical techniques imposed by the classical tibia nails. Classical nails had some important

disadvantages, such as the difficulty of manipulation and positioning in the bone and, in the same time, the

complicate orientation and displacement of the distal screws using the nail guide. Also, all these operations

can give failures or/and wrong holes in the bone which can make tibia more breakable. The virtual models

were exported to a software for kinematical and FEA simulation. Using similar initial parameters for each

studied case (as total force and torque) there were obtained dynamic maps of stress, strain and

displacement. These results were analyzed and compared and, in the final, it was extracted an important

conclusion.

Key words: tibia fracture, virtual bones, tibia nail, biomechanics, CAD, FEA.

1. INTRODUCTION

Tibia shaft fractures are the second most common

after distal radius fractures and the more frequent fractures of lower limb, their frequency being 15-20% of all fractures in adults.

Fractures of the shaft of the tibia cannot be treated by following a simple set of rules. By its very location, the tibia is exposed to frequent injury; it is the most commonly fractured long bone. Because one third of the tibia surface is subcutaneous throughout most of its length, open fractures are more common in the tibia than in any other major long bone. Furthermore, the blood supply to the tibia is more precarious than that of bones enclosed by heavy muscles. High-energy tibia fractures may be associated with compartment syndrome or neural or vascular injury. The presence of hinge joints at the knee and the ankle allows no adjustment for rotary deformity after fracture, and thus special care is necessary during reduction to correct such deformity. Delayed union, nonunion, and infection are relatively common complications of tibia shaft fractures [2].

Fixation is the process which the fragments are fixed in anatomical position and maintained in this position until consolidation using metal implants or other. It should be noted that the position must be anatomic for the fracture. Sometimes the fixation is made, for example in the case of osteotomy, where anatomic reduction of the fracture isn’t achieved, but the contrary is aimed at modifying bone anatomy.

Biomechanics fixation is the fixation after which the used material takes over the forces that occur in fracture focus to achieve consolidation. After a biomechanical

fixation without a cast immobilization recovery is much better and faster (Figure 1) [1,8].

Fig. 1 Biomechanical fixation.

Sometimes a cast immobilization is necessary because tasks that occur in the outbreak of fracture can overcome strength of materials used, or their points of attachment to bone, causing new fractures in these areas, or rupture of fixation material [8] (Figure 2).

Fig. 2 New fractures or rupture of fixation material.

For the shaft fractures of the long bones fixation with rigid intra-medullary nails are used. Two techniques of

Gabriel BUCIU, Dan GRECU, Dragos NICULESCU, Luminita CHIUTU, Maria STOICA,

Dragos POPA STUDIES ABOUT VIRTUAL BEHAVIOR OF TIBIA FRACTURES AND

NAILS DURING THE FIXATION PROCESS

Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (3): 203-207 203

INTRODUCTION

Tibia is the most commonly fractured long bone due toits superficial location. Tibial fracture is common in allages and is a major cause of morbidity in patients withlower extremity injuries.1

Mostly these fractures are sustained during high energytrauma, such as motorcycle accidents, pedestrianaccidents, fall from height, motor vehicle accidents andrarely gunshot injuries. Delayed union, malunion, non-union and infections are common complications of tibialshaft fractures.1

Proponents can be found for treatment with plaster cast,by open reduction and internal fixation with plates andscrews, external fixators and by locked or unlockedintramedullary nails.2,3 The best treatment should bedetermined through thoughtful analysis of themorphology of the fracture, the age and generalcondition of the patient and most importantly the statusof the soft tissue.

Interlocking intramedullary nailing is considered to bethe treatment for closed and Gustilo type I and II opentibial shaft fractures.1 The use of intramedullary nailing inpatients who have open tibial shaft fractures has highrisk of infection especially in grade 2 and grade 3 openfractures. So, many surgeons reserve intramedullarynailing for closed and grade 1 open fractures. Delayedfixation of the open fractures of the tibial shaft inmultitrauma patients give significantly better radiologicaland clinical results when compared with emergentfixation.4 Patients with non-union of tibial fracture showpromising results with same device.5

Intramedullary nailing preserves the soft tissue sleevearound the fracture site and allows early motion ofadjacent joints. The ability to lock nails proximally anddistally provides control of length, alignment and rotationin unstable fracture and permits stabilization of fractureand achieves better union (97.5%).6

Main complications of intramedullary interlocking nailare superficial wound infection, deep wound infection,compartment syndrome, deep vein thrombosis, delayedunion, non-union and implant failure.6

The Surgical Implant Generation Network (SIGN) wascreated as humanitarian, non-profit corporation inWashington, USA, with a goal to provide improvedhealth care and proper orthopaedic treatment of fractureat little or no cost to people in need throughout the world.

ORIGINAL ARTICLE

Outcome of Intramedullary Interlocking SIGN Nail in Tibial Diaphyseal Fracture

Irfanullah Khan, Shahzad Javed, Gauhar Nawaz Khan and Amer Aziz

ABSTRACTObjective: To determine the outcome of intramedullary interlocking surgical implant generation network (SIGN) nail indiaphyseal tibial fractures in terms of union and failure of implant (breakage of nail or interlocking screws).Study Design: Case series.Place and Duration of Study: Orthopaedics and Spinal Surgery, Ghurki Trust Teaching Hospital, Lahore Medical andDental College, Lahore, from September 2008 to August 2009.Methodology: Fifty patients aged 14 – 60 years, of either gender were included, who had closed and Gustilo type I andII open fractures reported in 2 weeks, whose closed reduction was not possible or was unsatisfactory and fracture waslocated 7 cm below knee joint to 7 cm above ankle joint. Fractures previously treated with external fixator, infectedfractures and unfit patients were excluded. All fractures were fixed with intramedullary interlocking SIGN nail and werefollowed clinically and radiographically for union and for any implant failure.Results: Fourty one (88%) patients had united fracture within 6 months, 5 (10%) patients had delayed union while 4 (8%)patients had non-union. Mean duration for achieving union was 163 + 30.6 days. Interlocking screws were broken in2 patients while no nail was broken in any patient.Conclusion: Intramedullary interlocking nailing is an effective measure in treating closed and grade I and II open tibialfractures. It provides a high rate of union less complications and early return to function.

Key words: Tibia. Diaphyseal fracture. Intramedullary interlocking nail. SIGN nail.

Department of Orthopaedics and Spine Surgery, Ghurki TrustTeaching Hospital / Lahore Medical and Dental College,Lahore.

Correspondence: Dr. Irfanullah Khan, Gandapur Cottage,Darabin Road, Dera Ismail Khan, KPK.E-mail: drirfan.ortho@gmail.com

Received July 12, 2011; accepted January 05, 2013.

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J Bone Joint Surg Am. 1985 Jun;67(5):709-20.

Closed locked intramedullary nailing. Its application to comminutedfractures of the femur.Kempf I, Grosse A, Beck G.

AbstractFor many fractures of the femoral shaft, closed intramedullary nailing will not control rotation or telescopingof the fragments. Locked intramedullary nailing combines closed nailing with the percutaneous insertion ofscrews that interlock the bone and nail. This method permits static locking that controls rotation andtelescoping and subsequently conversion to dynamic locking when weight-bearing is started afterapproximately twelve weeks. By providing greater stability, this method extends the indications forintramedullary nailing to severely comminuted, oblique, and spiral fractures as well as to fracturescomplicated by loss of bone and fractures in the proximal and distal ends of the femoral shaft. Of fifty-twopatients with forty-nine severely comminuted fractures of the femoral shaft and three fractures that werecomplicated by loss of bone, forty-seven patients had uneventful consolidation of the fracture, with a meantime of 4.5 months for the severely comminuted fractures and seven months for the fractures that had aloss of bone. At follow-up, all forty-seven patients had normal motion of the hip, and forty-five had normalmotion of the knee. Of the remaining five patients, four had a non-union that eventually healed (three aftera second locked nailing and one after a third) and one had a septic non-union that eventually healed afterremoval of the nail and screws, débridement, and immobilization with an external fixator. Based on thisexperience, we concluded that this form of treatment has many advantages. The risk of infection and non-union is low, the incidence and severity of malunion are reduced, the hospital stay is short, and earlymobilization of the patient is possible.

PMID: 3997923

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ISPUB.COM The Internet Journal of Orthopedic SurgeryVolume 4 Number 1

1 of 5

Retrograde Locked Intramedullary Nailing For TheStabilisation Of Femoral Fractures With Ipsilateral TibialFractures (Floating Knee): A Case ReportC Kok Yu, V Singh, S Chong

Citation

C Kok Yu, V Singh, S Chong. Retrograde Locked Intramedullary Nailing For The Stabilisation Of Femoral Fractures WithIpsilateral Tibial Fractures (Floating Knee): A Case Report. The Internet Journal of Orthopedic Surgery. 2006 Volume 4Number 1.

Abstract

Floating knee is referred to when there is an ipsilateral fracture distal end of femur and proximal tibia. It is considered anorthopaedic emergency as it an unstable situation. Such injuries can lead to kinking or injury of the popliteal artery by the mobilefracture segment. This is so because the artery is fixed at 2 points, the adductor hiatus proximally at the femur and the solealarch distally at the tibia. Therefore, immediate stabilization of such fractures is crucial. There are various methods of fixationavailable. We describe a method that we feel is safe and technically less demanding compared to others.

CASE REPORT

A 27 years old male was involved in a road traffic accidenton 29th December 2005. He is a motorcyclist who was hit bya car. He was brought in to our accident and emergency unit.He had a cerebral concussion with open fracture of midshaftleft tibia (Winquist type III, Gustillo grade II) and closedfracture midshaft of left femur (Winquist type II), as shownin figure 1.

Figure 1

Figure 1: Preoperative x rays of the left femur and tibia.

Retrograde Locked Intramedullary Nailing For The Stabilisation Of Femoral Fractures With IpsilateralTibial Fractures (Floating Knee): A Case Report

3 of 5

Figure 3

Figure 2: Immediate postoperative x rays of the left femurand tibia.

He was subsequently followed up in our outpatientorthopaedic clinic. His wounds healed well withoutcomplications. His knee range of motion improved to full (0to 135 degrees) after 3 months. Serial radiographs at 6 weeksand 3 months showed gradual formation of callus at thefracture site of both the left femur and left tibia. He wasallowed partial weight bearing at 6 weeks follow-up and fullweight bearing at 3 months after the surgery.

DISCUSSION

There are various methods that have been described in thelitreture for stabilization of the fractures in cases of floatingknee. We prefer the use of locked intramedullary nails,which are done through a single incision. Lockedintramedullary nailing currently is considered the treatmentof choice for most types I, II, and IIIA open and closed tibialshaft fractures [1]. Intramedullary nailing preserves the soft

tissue sleeve around the fracture site and allows early motionof the adjacent joints [1]. The ability to lock the nails

proximally and distally provides control of length,alignment, and rotation in unstable fractures and permitsstabilization of fractures located below the tibial tubercle or3 to 4 cm proximal to the ankle joint [1]. The same principles

also apply to the femur. The interlocking intramedullary nailis able to fulfil the above principles when used in thestabilization of femoral shaft fractures and is thus the goldstandard for femoral fracture treatment [1].

We were able to achieve stable fixation for both the femoraland tibial fractures with the use of interlocking nail. Closednailing also means preservation of the periosteal bloodsupply and soft tissue envelope around both fractures,enabling early union by callus formation. It has a distinctadvantage over open reduction and Internal fixation with theuse of plates as the procedure of plating involves stripping ofsoft tissue from the bone ends to reduce the fracture beforefixation. This eventually leads to delay or non-union and ahigher risk of infection [2,3]. In this case, the patient achieved

complete union of the fractures within 3 months.Furthermore, plating being a load-shielding device, is not asstrong compared to a nail [5]. It is the load sharing properties

of the nail that enabled early weight bearing in these patientsand thus earlier rehabilitation. This is why we choose tostabilise this patient's fractures by locked intramedullarynails.

Closed nailing of the tibia is done via a midline infrapatellarincision and dividing the patellar tendon to obtain an entrypoint through the anterior aspect of the intercondylar area ofthe tibial plateau. However, the femur can be nailed eithervia antegrade approach via the piriformis fossa as entry pointor retrograde approach, through the intercondylar notch ofthe femur. Most interlocking nails of the femur are done via

the antegrade approach (even for lower 3 rd fractures), asmany surgeons believe that an entry point through the kneecan cause knee complications of reduced motion, pain andpossible patello-femoral arthritis [5]. The published papers so

Iranian Red Crescent Medical Journal

Iran Red Crescent Med J 2011; 13(3):178-180 ©Iranian Red Crescent Medical Journal

ORIGINAL ARTICLE

Complex Fractures of the Tibia and Femur Treated with Static Interlocking Intramedullary Nail S Solooki1*, SAR Mesbahi2 1Department of Orthopaedic Surgery, Shiraz University of Medical Sciences, Shiraz, 2Orthopaedic Surgeon, Bandarabbas, Iran

Abstract

Background: Reamed interlocking intramedullary nailing is considered the gold standard treatment for complex fractures of the femoral and tibial shaft. There has been some controversies about dynamization of statically locked nails, and some authors recommended routine dynamization for promotion of healing. This study aims to evaluate treatment of complex fractures in tibia and femur with static interlocking intramedullary nail method. Methods: In a retrospective study from January 2003 to April 2008, 173 patients with femoral and tibial shaft fracture that were treated with this method were enrolled. No rod was dynamized in our patients. Results: All patients with tibial fractures achieved union without any need for dynamization during 12-18 weeks (mean; 13.4 weeks). Four patients developed delayed union but all achieved union without any intervention. In femoral fracture, all but one patient achieved complete union during 10-30 weeks (mean: 18.3 weeks). One patient developed non-union who was treated by an exchange nailing and iliac bone graft method. No significant complication was observed in our patients. Conclusion: It is not necessary to routinely dynamize nails in tibial and femoral shaft fractures as all fractures united in acceptable alignment without any complication.

Keywords: Complex fractures; Dynamization; Intramedulary nailing

Introduction Open reamed interlocking intramedulary nailing is the preferred treatment option for complex femoral and tibia shaft fractures.1-5 Some authors recom-mended routine dynamization of static interlocking nails to promote healing.6,7 Even complex femoral and tibia shaft fractures treated with static interlock-ing nailing without dynamization have been reported to have union rates as high as 98 to 100%.4,8,9 The results of previous works gave rise to the question if dynamization of static interlocking nailing of femoral and tibial fracture is always necessary?

The aim of this retrospective study was to help re-solving this controversy and determine the union rate

of complex femoral and tibia shaft fractures treated with static interlocking nailing without dynamization. Materials and Methods From January of 2003 to April 2008, 61 patients (53 males and 8 females) with complex closed fracture of tibial shaft and 112 patients (101 males and 11 fe-males) with complex closed fracture of femoral shaft were treated with static proximal and distal interlock-ing intramedullary nails. All patients developed frac-tures due to high energy trauma (a motor vehicle ac-cident or falling from the height) and all underwent surgery for treatment of fracture soon after a systemic condition that was stabilized.

Our tibial fracture patients were 17 to 70 years old (mean: 28.29) and our femoral fracture patients aged from 17 to 75 years old (mean: 26.57). In tibial frac-ture group, 33 patients had right sided fracture and 28

*Correspondence: Saeed Solooki, MD, Assistant Professor of Orthopaedic Surgery, Chamran Hospital, Shiraz University of Medi-cal Sciences, Shiraz, Iran. Tel/Fax: +98-711-6246093, e-mail: saeed_solooki@yahoo.com Received: July 20, 2010 Accepted: October 18, 2010

Static interlocking intramedullary nail

WWW.ircmj.com Vol 13 March 2011 179

had a left sided one. In femoral fracture group, 59 patients had right sided fracture and 53 had a left sided one. All patients had comminuted fracture (Winquist type III or IV). In tibial fracture group, 37 patients had fracture in the middle third of tibial shaft; 9 patient had fracture in proximal third and 2 patients had fracture in distal third of tibial. Thirteen patients had segmental pattern of fracture.

In femoral shaft fracture group, 66 patients had fracture in middle third; 16 patients in proximal third and 2 patients in distal third and 28 patients had seg-mental fracture in the femur. In femoral fracture group, 46 patients and in tibial fracture group, 25 pa-tients had other associated injuries that required spe-cific surgical or medical care (eg: internal bleeding; head trauma etc.).

All patients underwent static interlocking in-tramedulary nailing as soon as general condition of patients was stabilized. In all patients, open reduction was performed under general anesthesia and the canals were reamed as large as possible (usually 13-14 mm in diameter) and an adequate size static interlocking nail was inserted (usually 12 or 13 mm in diameter).

A proximal interlocking was performed with spe-cific interlocking guides and a distal locking under an image intersifier. Post-operatively, the patients started partial weight bearing ambulation as early as possible (usually after 48 hours post-operation). An isometric quadriceps exercise and a range of motion in the knee, hip and ankle were encouraged. The patients were followed at the OPD clinic by the same surgeon at 3-6 week intervals until complete union was achieved. The clinical and roentgenographic signs of healing process were recorded.

All patients were followed for at least for 9 months (range: 9-36 months). Fracture union was de-fined as follows: Clinically there was no tenderness or pain and fracture had no motion and patients were walking without any walking aids. Roentgenographi-cally, solid bridging callus with cortical density con-nected fracture fragments in at least 3 from 4 cortices. Delayed union was defined as an incomplete healing during a 6 months period after the fracture fixation. Results All patients with tibial fracture achieved union with-out any need for dynamization or any surgical inter-vention during 12-28 weeks (mean: 13.4 weeks). Two patients with tibial fracture developed wound infection

that improved with antibiotic treatment. Four patients in tibial fracture group developed delayed union but all of them achieved union completely without any surgical intervention up to 28 weeks. Alignment of tibial fracture was perfect in all patients without any shortening and rotation. In femoral fracture group, all but one patients achieved complete union during 10-30 weeks (mean: 18.3 weeks). There was no signifi-cant complication in femoral fracture group. Seven patients with femoral fracture developed delayed un-ion that were completely united by 24-30 weeks after fracture fixation without any surgical intervention. One patient developed non-union that was treated with changing of the nail and iliac crest bone graft after 36 weeks of primary surgery and achieved union by 16 weeks after bone grafting. Alignment of femo-ral fracture was perfect without any significant short-ening and rotation in our patients with femoral shaft fracture. Discussion Intramedullary nailing has become the treatment of choice for fractures of the femoral and tibial shaft.1-

4,9 In complex and comminuted fractures of femoral and tibial shaft, it is not possible to dynamize the intramedullary nailing because of concern about shortening and rotational instability.4,10,11 So it is mandatory to use interlocking intramedullary nails in such fractures.

During recent years, many authors recommended dynamization for promotion of healing in statically locked intramedullary nails of femoral or tibial diaphyseal fractures.5,6,9,12,13 In review of articles, we found that some complications may occur after dy-namization of a statically locked intramedullary nail-ing such as loss of length and rotational malalign-ments,5 so we reviewed the results of treatment of femoral and tibial shaft fractures in 173 patients who underwent statically locked intramedullary nailing. In a retrospective study in Taiwan, 220 acute complex femoral shaft fractures were treated with static inter-locking nails, 28 nails had been dynamized during treatment course and 5 patients from this dynamiza-tion group developed significant (more than 2 cm) shortening,5 and they reported only a 58% union rate achieved after dynamization. In another study per-formed in India, no significant promotion of healing was observed in 26 patients out of 50 dynamization cases of statically locked IM nailing.6