Jaroslaw Czubak

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Elastic Stable Intramedullary Nailing in
Fractures of the Lower Limb

• Jaroslaw Czubak

Postgraduate Medical Education Centre in Warsaw,
Poland Prof. Adam Gruca Hospital Warsaw Otwock,
Poland
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Plan of the lecture

• Introduction
• Indications
• Contraindications
• Femoral fxs
• Tibial fxs
• Complications

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• Dual Flexible rod system
• Indirect reduction
• Not rigid stability
• Series 123 cases (5-16yrs)
• Acceleration of healing

Ligier, Metaizeau, Prevot et al. Elastic stable
intramedullary nailing of femoral shaft in
children. JBone Jt Surg Br 1988 70
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Biomechanical principles

• symmetrical bracing
• 2 rods - 3 POINTS bearing

flexural
axial
STABILITY
rotational
translational
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Flexible IM nailing

• steel rods / titanium rods
• antegrade / retrograde

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Flexible IM nailing
BENEFITS

• healthy envirement of fx site
• Increased callus formation
• Sufficient stability
• No additional plaster needed

DISADVANTAGES

• Risk of angular or axial deviations
• Risk of pain gt rigid fixation

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Controversies

• straight vs bent rods
• titanium vs steel
• immobilization vs no immobilization
• antegrade vs retrograde

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AO rods 2,0 - 4,0mm
PRE-OP PLANNING
Nail Ø 30-40 Ø of medullary cavity
OR
Nail Ø internal Ø/2 - 0,5mm
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Indications
Biological age

• 3-4 yrs extends to 13-14 yrs

Site of fx
Femur

• diaphyseal
• distal metaphyseal
• subtrochanteric

Tibia

• diaphyseal
• distal metaphyseal

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Contraindications

• intraarticular fxs
• overweight gt 50-60kg
• complex femoral fxs overweight

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Surgical technique

• supine position
• radiolucent table
• extention table for older children
• closed reduction manual extention
• F-tool for reduction

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Surgical technique FEMUR
Retrograde insertion
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Surgical technique FEMUR
Retrograde insertion
Insertion point

• 1-2cm above distal epiphyseal plate
• or
• fingerbreadth above prox. patellar pole

C-arm
Extracapsular!!!
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Surgical technique FEMUR
Retrograde insertion
Open medullary cavity

• Awl
• Cortical drill

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Surgical technique FEMUR
Retrograde insertion
Pre-bend nails

• 3 times Ø of the medullary canal
• Vertex at fx site
• Load nails into the bone

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Surgical technique FEMUR
Retrograde insertion
Insert first nail
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Surgical technique FEMUR
Retrograde insertion
Advance first nail to the fx zone
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Surgical technique FEMUR
Retrograde insertion
Insert second nail
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Surgical technique FEMUR
Retrograde insertion
Check position of nail tips rotation
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Surgical technique FEMUR
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Surgical technique FEMUR
Retrograde insertion
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Surgical technique FEMUR
Descending technique
Indications

• Distal third
• Distal metaphyseal fx

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Surgical technique FEMUR
Descending technique
Determine nail insertion points
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Surgical technique FEMUR
Descending technique
S-shaped nail
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Surgical technique FEMUR
Descending technique
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Surgical technique TIBIA
Indications

• Closed unstable fx gt 9yrs
• Irreducible and non-retainable fxs
• Polytrauma

ONLY descending!!!
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Surgical technique TIBIA
Insertion points
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Surgical technique TIBIA
Insert nails
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Surgical technique TIBIA
Insert nails
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Mechanical testing
External fixation
greatest rigidity
Steel rods

• stronger than titanium
• intrinsic strength less dependent on the band
  techn.
• sufficient axial and torsional stiffness
• touch down weight bearing DESPITE FX TYPE

Lee et al. Ender fixation of pediatric femur
fracrures biomechanical analysis. J Pediatr.
Orthop. 2001, 21 442-445
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Mechanical testing
Titanium rods

• satisfactor torsional stability DESPITE FX TYPE
• retrograde double C configuration
• antegrade C and S configuration

Gwyn et al. Rotational controlof
variouspediatric femur fractures stabilized with
titanium elastic intramedullary nails J.
Pediatr. Orthop. 2004, 24 172-177
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Mechanical testing
Greater stiffness and resistance to torsional
deformity
RETROGRADE double C
ANTEGRADE C and S
Frick et al. Biomechanical analysis of antegrade
and retrograde flexible intamedullary nail
fixation of pediatric femoral fractures using a
synthetic bone model. J. Pediatr. Orthop. 2004
24 167
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Mechanical testing
Mechanical properties in 4 points test
RETROGRADE double C
ANTEGRADE C and S
Kiely Mechanical properties of different
combination of flexible nails in a model of a
pediatric femoral fractures. J Pediatr. Ortop.
2002 22 424-427
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Mechanical testing
Subtrochanteric insertion preferred

• fewer knee symptoms
• earlier patients independence
• insertion proximally to standard medial-lateral

Bourdelat D. Fracture of the femoral shaft in
children advantages of the descending medullary
nailing J. Pediatr. Orthop. 1996 110-114
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Mechanical testing
Recommendations for ESIN

• 3-4mm titanium or steel rods
• in children 6-10 yrs
• multiple system injury, head injury,
  spasticity, multiple long bone fxs

Selected groups

• extended indication for
• other children with isolated femur fx
• more 6 yrs old
• discontinue external plaster fixation

Ligier 1988 Mann 1986 Heinrich 1992.
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Complications FEMUR
Flynn J. et al. J. Pediatr. Orthop. 2001 21 4-8
56 fxs
4 axial malalignment gt 10
Narayanan et al. J. Pediatr. Orthop. 2004 24
363-369
79 fxs

• 41 skin irritation at insertion site
• 8 malunion
• 2 refractures
• 2 superficail wound infection

Recommendations

• rods straight tight against metaphysis
• always used match diameter rods

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Complications FEMUR
Luhmann et al. J. Pediatr. Orthop. 2003 23
443-447
43 fxs

• 41 complications
• Most minor problems
• Hypertrophic nonunion
• Infection of the joint

Recommendations

• Largest nails
• Leave 2,5 cm out of cortex

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Complications FEMUR - summary

• No randomized series steel vs titanium rods
• Both high successful rate
• Less than 5 of nonunion in most series
• Flexible rods required less operative and
  fluoroscopy time than steel rods

The same satisfactory outcome
Gregory et al. Orthopedics 1995 18 645-649
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Complications FEMUR - summary
351 fxs collected from 7 papers
13 complication rate consists of

• nonunion
• mild varus axial deformation
• LLD 3 (either overgrowth or shortening)

Gregory et al. Orthopedics 1995 18 645-649
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Complications FEMUR - summary
COMPLICATION RATE RISES IN

• Comminuted fx
• Large patients
• In which we have to look for other type of
  treatment

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Complications FEMUR - summary
Technique related complications

• too long rods painful bursae, limited ROM
• Early rods removing (2-5mths)
• Skin irritation 7
• Lead to deeper infection in 3
• Refracture rate in prelimiray rods removing
• Rod removing time fx line no more visible

Mazda et al. J. Pediatr. Orthop. 1997 6 198-202.
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Complications FEMUR - summary
Comparison traction (90-90) with TESIN
Group 83 fxs
Complication rate

• 34 Traction
• 21 TEN

• TEN sooner
• TEN sooner

Returning to school Overall recovery
Similar costs!!!
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Complications FEMUR - summary

• mainly technical errors
• too-thin rods
• asymmetry of the frame
• malorientation of the implants
• nonunion never at femur fxs tmt
• infection 2
• overgrowth lt10mm in fx less 10yrs of age

Lascombes P. et al. J. Pediatr. Orrthop. 2006
26 827-834
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Tibial shaft fractures
90 tibial fxs require non op treatment
Parsch K. 1997. J. Pediatr. Orthop. B 6 117-125
Few requires surgical stabilization - requires
implants that do not violate open physes
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Tibial shaft fractures op. treatment
Indications

• acceptable positioning not maintan
• gt10 yrs and older
• selected open fxs
• impending compartment syndrome
• spasticity due to head surgery or CP
• multiple long-bone fxs
• multiple system injuries
• concomitant severe soft-tissues injury

Kubiak EN 2005 Sankar WN 2007 Srivastava AK
2008
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Tibial shaft fx
Results complications
Av. Time of healing

• 20,4 weeks (Srivastava)
• 11 weeks (Sankar)
• 7 weeks (ex-fix 18 weeks)(Kubiak)

The functional outcomes for intramedullary group
better than ex-fix group in categories

• Pain,
• Happiness
• Sports
• Global function

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Tibial shaft fractures
Possible complications

• Compartment syndrome 4/19
• Axial deviations (0-6) in saggital plane
• (9-9) in coronal plane
• Skin irritation 5/19
• LLD 0/19 and 1/24
• Remanipulation 2/19
• Infections 2/24
• Malunions 2/24

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THANK YOU!!!