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INTERLOCKING INTRAMEDULLARY METALLOPOLYMERIC NAILING OF THE FEMORAL AND TIBIAL DIAPHYSEAL FRACTURES
I.M. Rublenik, V.L. Vasyuk, A.V. Yurtsenyuk, A.G. Shaiko-Shaikovskiy
Department of Traumatology and Orthopaedics, Bukovinian Academy of Medicine, 2, Teatralna Ploscha, 274022, Chernivtsy, Ukraine
Abstract: This work presents the results of clinical and biomechanical evaluation of several models of metallopolymeric compressive nails for intramedullar osteosynthesis. Peculiarities of their construction and usage are shown in comparison with other types of intramedullar nails. Interlocking intramedullar nailing was performed in dynamic, static and defensive variants at 615 patients and showed good immediate and remote results in 94.3% cases. By means of derotative blade the dynamic loading was possible in 73.2% casesr therefore it was considered that the developed systems are biomechanically more advanced than the existing ones.
Key words: interlocking nailing, intramedullar nailing, fractures, femur, shank, surgical treatment
Introduction
According to the few recent years' experience the interlocking intramedullary nailing has been recognized as one of the best methods of treatment of diaphyseal fractures and their complications (nonunions, malunions, pseudartliroses). Application of this method in traumatological practice opened new ways to solve various problems connected with treatment of the most complicated (comminuted, splintered, double, doublesegmental) femoral and tibial shaft fractures as well as rotationally unstable fractures in these segments at the medullar cavity dilatation level [8,10,13].
The interlocking nailing can be performed in dynamic or static variant depending on the fracture type and location.
In the dynamic variant the nail is only locked in one fragment (proximal or distal) at the metaphyseal level The dynamic interlocking nailing is indicated in cases of rotationally unstable transverse and transverse-comminuted fractures with sufficient cortical integrity at
the fracture site (>50%).
Partial loading is allowed from the next day after the dynamic osteosynthesis, bringing it to full weight bearing in 1.5-2 months. That affects bone consolidation positively in case of rotational stability [7,9].
The static nailing allows interlocking the nail in both proximal and distal bone fragments. It is indicated in cases of highly comminuted, oblique, spiral and double diaphyseal fractures for which axial and rotational unstability is usual. In these cases static interlocking nailing provides rotational stability of the fixator and prevents fragments' dislocation and therefore creates optimal conditions for their consolidation with no additional immobilization and with partial loading onto the operated limb [7,9].
Performing interlocking osteosynthesis requires high skill level, in particular nailing and inserting the interlocking screws into the distal fragment [3,14].
These operation steps require the X-ray checking which is accompanied by considerable X-ray irradiation for patients and the staff [11,12].
material (polymeric insertions), 3 - caning compressive nut, 5 - carving,
channel, 4 - slit.
According to the data by G.A. Hanks [6], the total exposure time was 3-4 minutes per operation at the time the method was introduced.
Further improvement of the method, especially using the «free hand» technique and the new X-ray equipment generation with memory made it possible to cut the irradiation time do wn to 1 minute [4].
However, the most effective way to reduce the X-ray irradiation is using electronic devices with laser aiming device which provides accurate (after the first attempt) access to the fixator aperture in 97% cases. The irradiation exposure time is reduced to 0.4 minute [5].
Taking into consideration advantages and disadvantages of metallic interlocking nails we developed several models of compressive metallopolymeric interlocking nails (CMPIN).
Subject!* and methods
The compressive metallic polymeric nail CMPIN-2 (USSR patent No.806019) [1] shown in Fig. 1 is a round metallic rod with several oblong transverse slots filled with bioinert polymeric substance polyamide-12 (2) which allow us to insert interlocking screws at almost any level. It enhances the fixator's effective application. At the proximal end of the rod there is a carving channel (3) for joining it with the instrument during its insertion and removal. For the correct interlocking screw's orientation there is a slit at the proximal part of the rod [1]. CMPIN-3 (USSR patent No.946531) [2] shown in Fig.2 is a metallic rod (1) with the only slot filled with polyamide-12 (2) at the distal end. At the proximal part there is a derotational blade (3) which prevents rotation in the central fragment and provides the possibility of the dynamic compression.
The one-time compression is achieved by turning the compressive nut (4) into the carving rod segment (5).
There is a slit (6) parallel to the transverse slot at the distal end of the rod which ensures the screws' correct orientation.
Combined usage of metal and polymeric material in different models of metallopolymeric nails allows us to unite biomechanical advantages of both. The metallic
CMPIN-3.
base provides the nail with necessary rigidity and resistance to dynamic loading while polymeric segments give the possibility of quick, intraumatic and stable bonding the rod to the compact substance at the medullar cavity dilatation level as well as the splinters' fixation.
We differentiated three variants of the interlocking intramedullary metallopolymeric nailing (IIMPN) according to the fracture type, the surgery equipment peculiarities and biomechanical conditions. They are compressive dynamic, compressive static and detensional variants (Fig.3, 4),
Besides one-time axial compression between fragments the compressive dynamic nailing also provides dynamic compression throughout the rehabilitation period.
This interlocking nailing variant is indicated in cases of transverse and comminuted fractures with sufficient (30% or more) cortical integrity at the fracture site, oblique and spiral fractures at the medullar dilatation level with quite a short fracture line.
In the compressive static nailing, transverse compression is ¿reated at the fracture site by means of interlocking screws installed perpendicularly to the bone's axis through both of the splinters and polymeric segments of the rod. In this interlocking nailing variant, the main dislocative loading is placed on the polymeric segments and the interlocking screws.
Detensional interlocking nailing aims at exclusion of dislocative forces in the fractured area that can lead to fragments' telescopic displacement and result in shortening of the limb.
Results
Different IIMPN variants were performed on 615 patients aged from 12 to 86 (under clinical conditions). Their average age was 36.5 years old. 422 patients were operated because of recent fractures, 193 were operated because of their complications (malunions, nonunions, false joints, osseous defects). Total of 654 operations were performed (35 patients with composite fractures underwent operations on two segments, 2 patients - on three segments). 492 (80%) patients had comminuted fractures, 90 (14.6%) patients were people of an elderly age. IIMPN with CMPIN-3 was performed on 478 (73.2%) femoral and tibial bones. Some examples of their effective usage are given below.
by CMPIN-2,
The patient M,, 22 years old was hospitalized 4.11.1995 with the diagnosis: nonunion in the middle third of the right femoral bone after osteosynthesis with the plate, the break of the plate (Fig. 5). The break of the plate happened 4 months after the operation as a result of repeated trauma (6.11.95). The removal of the broken plate, osteoperiosteal decortication of the fractured fragments, IIMPN with CMPIN-3 was performed.
The patient was observed 4 months later: the full weight-beanng of the operation limb, movements in the hip and knee joints as well as the osseous union in radiographs were obik ~ved (Fig. 6).
itie patient P,„ 35 years old was hospitalized 11.03.91 with the diagnosis: pseudarthrosis (osseous defect) of the left tibia on the border of the upper and middle third, extensive contracture of the left knee joint (Fig. 7).
Before hospitalization the open comminuted fracture of the patient was healed by the Ilizarov's apparatus. The wound of soft tissues was closed up, but there was no union of the fractured fragments because of big osseous defect. 14.03.91 IIMPN with CMPIN-3 was performed (Fig. 8).
The postoperative period was without complications; the patient got dosage loading 1 month after the operation and the full weight-bearing after 3 months after the operation. The radiographs taken 4 months (Fig. 9) and 1.5 years after the operation showed adaptation and full recasting of the grafts on the place of the osseous defect.
At 101 patients with the diaphysial fractures of the femoral and tibial bones a compressive static variant of IIMPN was performed. With this variant of IIMPN the compression of fractured fragment was performed with interlocking screws, inserted through both fractured fragments and polymeric segments of the fixator.
Detension variant of IIMPN was used with 79 patients with polycomminuted fractures and their results. Here is one of such cases.
The patient M., 32 years old, a traffic inspector, was hospitalized 14.04.94 2.5 months after trauma with the diagnosis: nonunited poly com minuted fracture of the upper and middle third of the left femur (Fig. 10). 17.04.94 he had detension variant of IIMPN with CMPIN-2.
Fig. 6. The radiographs of the right femur of the patient M, 4 months after the operation.
Fig. 5, The radiograph of the right femur of the patient M. at the beginning of hospitalization.
Fig. 7. The radiographs of the left shank of the patient P. at the beginning of the hospitalization.
Fig. 9. Radiographs of the same patient 4 months after the operation.
Fig. 10. The radiograph of the left femur of the patient M. 2.5 months after trauma.
Fig. 1L The radiographs of the left femur of the patient M. 3 months after operation.
The postoperative period was without complications. He began to take dosage loading of the limb in two months after the operation and full weight-bearing in 3 months after the operation. During the observation at that period the full recover of the operated limb and of the volume of movements in the thigh joint as well as radiographically osseous union were noted (Fig. 11). 1 year after the operation the fixator was removed.
All immediate and remote results of the patients who underwent an operation were
studied.
580 (94.3%) -patients had consolidation and full recovery of the function of the operated limbs with quite considerable (1.5-2 times) shortening time of disablement in comparison with the traditional methods of operative treatment.
The postoperative osteomyelitis was observed in 15 (2.5%) patients, 12 (1.9%) patients had nonunions, 8 of them (1,3%) had deformation or break of the metallopolymeric fixator, 3 (0,48%) patients of an elderly age died from cardiovascular insufficiency.
Thus, the interlocking intramedullary metallopolymeric nailing with compressive metallopolymeric fixators is a very effective method of treatment of complicated diaphysial fractures of femoral and tibial bones and their after-effects.
Discussion
The possibility of a wide usage of the dynamic IIMPN variant is connected with the compressional metallopolymeric fixators' peculiarities. The CMPIN has a flat antirotational blade in the proximal part which prevents the fixator's rotational unstability in the proximal fragment. Proximal interlocking of the Grosse-Kempf and other similar fixators is mainly performed to prevent rotational unstability; however, together with the distal interlocking it leads to the static variant in 85% cases (Brurnbak R.J., 1989). Absence of physical loading in the fracture zone negatively affects the consolidation terms. That is why dynamization by removing proximal or distal interlocking screws is needed. On the other hand, it raises the recovery terms and prices.
When using CMPIN-3, the antirotational blade provides the rotational stability instead of proximal interlocking screw, and that allows us to combine rotational stability with the possibility of dynamic loading onto the regenerate in the fracture zone during the postoperative period.
Basing on these results we can conclude that CMPIN is biomechanically more advanced than other existing metallic fixators and gives the possibility to use the dynamic interlocking nailing in 73,2% cases.
References
1. РУБЛЕНИК И. M. Внутрикостный фиксатор. Открытия, изобретения. 28: 18, 1982 (in Russian).
2. РУБЛЕНИК И.М. Компрессионный фиксатор Открытия, изобретения. 33; 19, 1985 (in Russian).
3. BARRICK E.F. Distal locking screw insertion using canriulated drill: technical note. J Orthop Trauma, 7(3): 248-251, 1993.
4. FRIEDI W. Eine einfache, schnelle und kostengünstige distale Verriegelungsmentode bei Ober-und Unterschenkelmarknagelungen. Chirurgie, 62(5): 423-426, 1991 (in German).
5. GOULET J.A., LONDY F., SALTZAM C.L. et al. Interlocking intramedullary nails. An improved method of screw placement combining image intensificator and laser light. Clin Orthop, 228: 199-203, 1992.
6. HANKS GA, FOSTER W.C., CARDEA J.M. Treatment of femoral shaft fractures with the Brooker-Wills interlocking intramedullary nail. Clin Orthop, 220: 206-219, 1988.
7. KEMPF L, JAEGER J.H., GROSSE A. et al. Notre attitude actuelle dans le traitment des fractures fermees de jambe. Acta Orthop Belg, 43(1): 19-28, 1977 (in French),
8. KEMPF lM GROSSE A., TAGLAND G. et al. L'enclouage centromedullaire avec verrouillage des fractures recentas du femur et du tibia. Etude statisticque a propos de 835 cas. Chirurgie, 117(5-6): 478-487, 1991 (in French).
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11. KWONG L.M., JOHANSEN P.H., ZINAR D.M. et al. Shielding or patient gonads during intramedullary interlocking femoral nailing. J Bone Jt Surg, 72A(10): 1523-1526, 1990.
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13. MORAN C.G., GIBSON M.J., GROSS A.T. Intramedullary locking nails for femoral shaft fractures in elderly patients. J Bone Jt Surg, 72B(1): 19-22, 1990.
14. RABIN S.I., NAENI F., ROBLEDO S.L. et al. Inserting distal screws into interlocking I.M. nails -revisited. Methods to make it easier. Orthop Rev, 22(9): 1062-1068, 1993.
БЛОКИРУЮЩИЙ ИНТРАМЕДУЛЛЯРНЫЙ МЕТАЛЛОПОЛИМЕРНЫЙ ОСТЕОСИНТЕЗ ДИАФИЗАРНЫХ ПЕРЕЛОМОВ БЕДРА И ГОЛЕНИ
И.М. Рубленик, В.Л. Васюк, A.B. Юрценюк, А.Г. Шайко-Шайковский
(Черновцы, Украина)
В работе представлены результаты клинической и биомеханической оценки нескольких моделей металлополимерных компрессионных фиксаторов для интрамедуллярного остеосинтеза. Особенности их конструкции и применения даны в сравнении с существующими системами для интрамедуллярного блокирующего остеосинтеза.
Блокирующий интрамедуллярный остеосинтез был выполнен в динамическом, статическом и детензионном варианте у 615 больных, хорошие результаты лечения получены в 94,3% случаев. Благодаря деротационной лопасти динамические нагрузки в послеоперационном периоде были возможны в 73,2% случаев. Библ. 14.
Ключевые слова: блокирующий остеосинтез; интрамедуллярный остеосинтез; переломы, бедро, голень, хирургическое лечение
Received 10 January 2000
