Evaluation of the bone metabolism balance and traumatic reaction of minimally invasive mippo intramedullary nail internal fixation treatment of femoral shaft fractures

Objective:To evaluate the bone metabolism balance and traumatic reaction of minimally invasive mippo intramedullary nail internal fixation treatment of femoral shaft fractures. Methods:80 patients with femoral shaft fractures who were treated in our hospital between May 2011 and December 2016 were collected and divided into control group (n=40) and observation group (n=40) according to random number table, control group received conventional steel plate internal fixation treatment, and observation group received minimally invasive mippo intramedullary nail internal fixation treatment. Differences in serum levels of bone formation indexes, bone resorption indexes, inflammatory factors, and pain mediators and so on were compared between two groups of patients before operation and 1 week after treatment.Results: Before operation, differences in serum levels of bone formation indexes, bone resorption indexes, inflammatory factors and pain mediators were not statistically significant between two groups of patients. After operation, serum bone formation indexes P ICP, BGP, BALP and ALP levels in observation group were higher than those in control group;serum bone resorption indexesβ-CTX and OPG levels were lower than those in control group;serum inflammatory factors IL-1β, IL-6, IL-8 and CRP levels were lower than those in control group;serum pain mediators SP, PGE2 and 5-HT levels were lower than those in control group.Conclusion:Minimally invasive mippo intramedullary nail internal fixation treatment of femoral shaft fractures can promote the bone formation, relatively inhibit bone resorption and cause less traumatic reaction.

Treatment of femur supracondylar fracture with retrograde interlocking intramedullary nails in elderly patients

Objective： To report 32 cases of femur supracondylar fracture treated with retrograde interlocking intramedullary nails in elderly patients. Methods： According to the AO classification, all of 32 cases were classified as extra-articular type A. 32 cases were treated with interlocking intramedullary nail by closed insertion from intercondylar fossa of the knee. All cases accepted CPM exercise as early as possible after operation. Results： Following up 5 to 15 months, all fractures united within an average duration of 5.3 months （4-7 months）. According to the Shelbourne scale, the excellent rate of the knee function was 86.3%. Conclusion： Retrograde interlocking intramedullary nail is useful alternative implant for the treatment of osteoporotic supracondylar fracture of femur, particularly of the type A fracture in the elderly population. Its merits include stable fixation, high rate of fracture union and few complications.

Intramedullary Nailing of Femoral Shaft Fractures with Compressive Nailing Using Only Distal Dynamic Hole and Proximal Static Hole

Objectives: In this study we aimed to present our treatment results of intramedullary nailing of femoral shaft fractures with compressive nailing using proximal static hole and only distal dynamic hole with one screw. Methods: Forty-three patients who had a fracture of the femoral shaft were managed between 2005 and 2008 with intramedullary nailing and the use of only one screw for distal interlocking. Prospectively we evaluated the union time, possible reoperation, fixation and fracture alignment, range of knee motion and complications. Results: Union occurred within a mean duration of 18.7 weeks. No failures of the fixation and fracture alignment and no more than 1 cm shortness were detected. The knee range of motion was all more than 90 degree. Only one deep venous thrombosis was detected as complication. Conclusions: Compressive nailing using proximal hole and only distal dynamic hole with one screw is a convenient technique for femur fractures.

Selection of internal fixation method for femoral intertrochanteric fractures using a finite element method

BACKGROUND Failure to fix unstable intertrochanteric fractures impairs return to daily activities.AIM To simulate five different internal fixation methods for unstable proximal femoral fractures.METHODS A three-dimensional model of the femur was established from sectional computed tomography images,and an internal fixation model was established.Finite element analysis of the femur model was established,and three intertrochanteric fracture models,medial defect,lateral defect,and medial-lateral defects,were simulated.Displacement and stress distribution after fixation with a proximal femoral anti-rotation intramedullary nail(PFNA),integrated dual-screw fixation(ITN),PFNA+wire,PFNA+plate,and PFNA+wire+plate were compared during daily activities.RESULTS The maximum displacement and stress of PFNA and ITN were 3.51 mm/473 MPa and 2.80 mm/588 MPa for medial defects;2.55 mm/288 MPa and 2.10 mm/307 MPa for lateral defects;and 3.84 mm/653 MPa and 3.44 mm/641 MPa for mediallateral defects,respectively.For medial-lateral defects,reconstructing the medial side alone changed the maximum displacement and stress to 2.79 mm/515 MPa;reconstructing the lateral side changed them to 3.72 mm/608 MPa,when both sides were reconstructed,they changed to 2.42 mm/309 MPa.CONCLUSION For medial defects,intramedullary fixation would allow early low-intensity rehabilitation exercise,and ITN rather than PFNA reduces the risk of varus and cut-out;for lateral wall defects or weakness,intram-edullary fixation allows higher-intensity rehabilitation exercise,and ITN reduces the risk of varus.For both medial and lateral defects,intramedullary fixation alone will not allow early functional exercise,but locating lateral or medial reconstruction will.For defects in both the inner and outer sides,if reconstruction cannot be completed,ITN is more stable.

Intramedullary nailing for pathological fractures of the proximal humerus caused by multiple myeloma: A case report and review of literature

BACKGROUND Multiple myeloma(MM)bone disease is indicative of MM,and reduces patient life quality.In addition to oncological,antineoplastic systemic therapy,surgical therapy in patients with MM is an essential treatment within the framework of supportive therapy measures and involves orthopedic tumor surgery.Nevertheless,there are few reports on intramedullary(IM)nailing in the treatment of MM-induced proximal humeral fracture to prevent fixation loss.We here describe a case of pathological fracture of the proximal humerus caused by MM successfully treated with IM nailing without removal of tumors and a review of the current literature.CASE SUMMARY A 64-year-old male patient complaining of serious left shoulder pain and limited movement was admitted.The patient was finally diagnosed with MM(IgAλ,IIIA/II).After treatment of the pathological fracture with IM nailing,the patient's function recovered and his pain was rapidly relieved.Histopathological examination demonstrated plasma cell myeloma.The patient received chemotherapy in the Hematology Department.The humeral fracture displayed good union during the 40-mo follow-up,with complete healing of the fracture,and the clinical outcome was satisfactory.At the most recent follow-up,the patient's function was assessed using the Musculoskeletal Tumor Society score,which was 29.CONCLUSION Early surgery should be performed for the fracture of the proximal humerus caused by MM.IM nailing can be used without removal of tumors.Bone cement augmentation for bone defects and local adjuvant therapy can also be employed.

PFNA2 versus 95 Degree Condylar Blade Plate in the Management of Unstable Trochanteric Fractures

Purpose: The proximal femoral nail anti-rotation (PFNA) is known to have advantages in enhancing the anchorage ability of internal fixation in elderly unstable osteoporotic intertrochanteric fracture patients. However whether it is superior to condylar blade fixation is not clear. This study aimed to determine which treatment has better clinical outcomes in older patients. Materials and Methods: A total of 86 patients over the age of 60 with unstable trochanteric fractures within the past 3 weeks, were included in this prospective study conducted from June 1, 2018, to May 31, 2021. All the intertrochanteric fractures were classified according to AO/OTA classification. Among them, 44 cases were treated with the Proximal Femoral Nail (PFNA2) with or without an augmentation screw, and 42 cases were treated with the Condylar Blade Plate. In addition, the operative time, intraoperative blood loss, intraoperative and postoperative blood transfusion, postoperative weight-bearing time, hospitalization time, Harris score of hip function, Kyle’s criteria and postoperative complications were compared between the two groups. Results: The mean duration of surgery for the PFN group was 66.8 minutes (on average), whereas for the condylar blade plate group, it was 99.30 minutes (on average). The PFNA2 group experienced less blood loss (average of 80 mL) compared to the condylar blade plate group (average of 120 mL). Union and partial weight-bearing occurred earlier in the PFNA2 group (14.1 weeks and 10.6 weeks, respectively) compared to the Condylar blade plate group (18.7 weeks and 15.8 weeks). In two patients from the PFNA2 group, screw backing out and varus collapse complications were encountered;however, these patients remained asymptomatic and did not require revision surgery. In two other patients, screw cut out and breakage of the nail at the helical screw hole leading to non-union of the proximal femur were observed during the nine-month follow-up, necessitating revision surgery with prosthetic replacement. Among the condylar blade plate group, three patients experienced complications, including blade breakage at the blade and plate junction. In two cases, the fracture united in varus, and in one case, the blade cut through, resulting in non-union of the femoral head, which required revision surgery. According to the Harris hip score and Kyle’s criteria, a good-excellent outcome was observed in 92.85% of cases in the PFNA2 group and 90.90% of cases in the condylar blade plate group. Conclusion: Both the Proximal Femoral Nail A2 and Condylar blade plate are effective implants for the treatment of unstable trochanteric fractures. The intramedullary implant promotes biological healing and allows for early ambulation with minimal complications. Similarly satisfactory restoration of anatomy and favorable radiological and functional results can be achieved with the biological fixation provided by the 95-degree condylar blade plate. However, the use of PFNA2 internal fixation technique has the advantage of less trauma in elderly patients than the 95-degree condylar blade plate.

Radial nerve recovery following closed nailing of humeral shaft fractures without radial nerve exploration: A retrospective study

BACKGROUND Radial nerve palsy due to humeral shaft fracture is the most common peripheral nerve injury associated with long bone fractures.An antegrade nailing surgical technique is becoming popular for the fixation of these fractures with minimal invasiveness.We analyzed nerve recovery in patients with humeral shaft fracture and radial nerve palsy treated with humeral nail fixation without nerve exploration.AIM To assess the radial nerve recovery rate and time from humeral shaft fracture with surgical treatment using close nailing.METHODS We retrospectively collected data of patients who underwent undergone surgical nail fixation for humeral shaft fractures between October 1,2016,and March 31,2020.Subsequently,we analyzed the primary or secondary radial nerve palsy recovery rate and radial nerve motor function recovery time.RESULTS The study included 70 patients who underwent surgical treatment for closed-or Gustilo type I open humeral shaft fractures using a nail fixation technique without radial nerve exploration.The patients suffered from primary(n=5)and secondary(n=5)radial nerve palsy.A 100%radial nerve recovery rate was achieved.The mean recovery time was 4.3 mo.CONCLUSION The study results indicate full recovery of radial nerve palsies from humeral shaft fracture using close nailing treatment.Surgeons need not be concerned about the occurrence of permanent nerve palsies.

Finite Element Analysis of Coronal Shear Fractures of the Femoral Neck: Displacement of the Femoral Head and Effect of Osteosynthetic Implants

Coronal shear fractures of the femoral neck (CSFF) are the most challenging to treat among proximal femur fractures, directly affecting the life expectancy of patients with osteoporosis. However, an adequate osteosynthesis method has not been elucidated yet. This study investigated the displacement direction of the femoral head fragment and its effect on the bone using finite element method. A finite element model for CSFF was developed from CT image data of a patient with osteoporosis using Mechanical Finder (ver. 11). Subsequently, finite element analyses were performed on six osteosynthesis models under maximum load applied during walking. The compressive stresses, tensile stresses, and compressive strains of each model were examined. The results suggested that the compressive and tensile stress distributions were concentrated on the anterior side of the femoral neck. Compressive strain distribution in the femoral head and neck was concentrated in four areas: at the tip of the blade or lag screw, the anteroinferior side of the blade or lag screw near the fracture site, and the upper right and lower left near the junction of the blade or lag screw and nail. Thus, the distribution of both these stresses revealed that the femoral head fragment was prone to anterior and inferior displacement. Distribution of compressive strains revealed the direction of the stress exerted by the osteosynthetic implant on the bone. The same results were observed in all osteosynthetic implants;thus, the findings could lay the foundation for developing methods for placing osteosynthetic implants less prone to displacement and the osteosynthetic implants themselves. In particular, the study provides insight into the optimal treatment of CSFF.

Comparison of Clinical Effect of PFNA and Internal Fixation with Anatomical Locking Plate of Proximal Femur in Treatment of Intertrochanteric Fracture of Femur

Purpose:To investigate the clinical value of proximal femoral nail antirotation and anatomical locking plate of proximal femur in the treatment of intertrochanteric fracture of femur.Methods:The study group is treated with PFNA internal fixation.The control group is treated by internal fixation with anatomical locking plate of proximal femur.Results:The time of operation,the amount of intraoperative bleeding and the time of fracture healing in the study group are significantly less than those in the control group.The incidence rate of complication in the study group(3.23%)is significantly lower than that in the control group(17.2%).Data comparison shows P<0.05.Conclusion:The curative effect and prognosis for patients with intertrochanteric fracture of femur treated by PFNA internal fixation are more ideal.

Screw Intramedullary Nailing for Fractures of the Humeral Shaft

The debate continues over the management of diaphyseal fractures of the humerus. There are a variety of extramedullary as well as intramedullary implants. We aim to propose a technique of passing the screw intramedullary nails and achieve union with least trauma to the shoulder and the rotator cuff. The multiple elastic screw nails achieve the inherent stability based on the principle of “three point fixation”. We aim to propose that the screw intramedullary nail is an effective implant to facilitate uneventful fracture union, with rapid recovery, low morbidity and low learning curve capable of being replicated in any smaller operative set up.

Finite Element Analysis Study of Prototype of a Novel Intramedullary Injectable Bioresorbable Polymer Fixator versus a Volar Plate for Surgical Treatment of Distal Radius Fractures

Complications and shortcomings of volar plating, which is very widely used for surgical treatment of distal radius fractures, are well known. Thus, there is scope for alternative innovative surgical methods. In the present work, we used the finite element analysis method to compare the biomechanical performance of a model of a construct comprising a simulated distal radius fracture considered fixated using a notional intramedullary injectable bioresorbable polymer-bioresorbable balloon osteosynthesis system (“fixator”) versus using a commercially-available volar locking plate (VP). The biomechanical parameters determined were longitudinal stiffness and factor of safety under each of the applied loads.?For the fixator model, 1) each of the biomechanical parameters was markedly influenced by fracture gap fill ratio (FGFR) (defined as the proportion of the volume of the fracture gap that is considered occupied by the expanded polymer-filled balloon)?but not by modulus of elasticity assigned to the polymer;2) with FGFR = 100%, stiffness was comparable to that of the Ti-6Al-4V alloy VP construct model;and 3) stiffness was within the range of literature values for stiffness of constructs comprising simulated fractures in fresh cadaveric distal radii fixated using metal volar locking plate. These results suggest that the fixator may be an alternative modality to metal volar plating and, as such, deserves further evaluation.

Bone metabolism and trauma degree of magnetic-guided intramedullary nail fixation for femoral shaft fracture

Objective:To explore the effect of magnetic-guided intramedullary nail fixation on bone metabolism and trauma degree in patients with femoral shaft fracture.Methods: A total of 128 patients with femoral shaft fractures who received surgical treatment in the hospital between April 2016 and November 2017 were divided into control group (n=64) and study group (n=64) according to the random number table method. Control group received the traditional intramedullary nail treatment, and study group received magnetic-guided intramedullary nail treatment. The differences in serum levels of bone metabolism indexes and inflammatory factors were compared between the two groups 48 h after surgery.Results: 48 h after surgery, serum bone formation indexes BGP, PⅠNP, PⅠCP and BAP levels of study group were higher than those of control group whereas bone resorption indexesβ-CTX, TRACP5b and NTX levels were lower than those of control group;serum inflammatory factors TGF-β, hs-CRP, IL-1β, IL-6 and IL-17 levels were lower than those of control group.Conclusion:Compared with traditional intramedullary nail therapy, magnetic-guided intramedullary nail fixation can more effectively balance the bone metabolism status and reduce the fracture end trauma in patients with femoral shaft fracture.

Intramedullary Nailing of Type I and Type II Open Leg Fractures after 6 Hours at Yopougon Teaching Hospital

Emergency debridement has long been the standard of care for open fractures of the tibia as infection is an important complication. In developing countries, patients are admitted to teaching hospitals 6 to 24 hours after their initial trauma. We sought to evaluate outcomes of nailing and correlations between the risk of infection and the delay in surgery. Materials and methods: Medical files of 48 men and 15 women with a combined total of 63 open fractures of the leg during a 12-year period were reviewed. The mean age was 29 years. Thirty-four type I and 29 type II open fractures according to the classification of Cauchoix and Duparc were treated with Küntscher nail after excision/debridement. Preoperative CRP was performed in 27 patients and in 22 cases it was positive. Twenty-six fractures were treated within a period of 6 to 24 hours, and a further 37 was operated on beyond 24 hours. The average waiting time before surgery was 2 days. Results: The infection was present in 11 patients (17.5%). We failed to establish any correlation between the time of treatment and the occurrence of infection for both type I and type II fractures treated during the same intervals with p = 0.244 (p > 0.05). But we established a correlation between the type of open fracture and the occurrence of infection with p = 0.01 (p < 0.05). There were 10 cases of infection among 22 cases of positive preoperative CRP. We couldn’t find a correlation between the positive value of the preoperative CRP and the occurrence of infection. Seven cases of infection were treated with appropriate antibiotherapy and early revision surgery. Four others cases complicated to bone infection (n = 2) and septic nonunion (n = 2). The average time of hospitalization was 22 days. The average time for fracture healing was 7 months. Conclusion: The rule of six hours is hardly applicable in our contexts. Our study showed no correlation between the preoperative period and the occurrence of infection.

Comparison of Clinical Effect of PFNA and Internal Fixation with Anatomical Locking Plate of Proximal Femur in Treatment of Intertrochanteric Fracture of Femur

Purpose To investigate the clinical value of proximal femoral nail antirotation and anatomical locking plate of proximal femur in the treatment of intertrochanteric fracture of femur.Methods The study group is treated with PFNA internal fixation.The control group is treated by internal fixation with anatomical locking plate of proximal femur.Results The time of operation,the amount of intraoperative bleeding and the time of fracture healing in the study group are significantly less than those in the control group.The incidence rate of complication in the study group(3.23%)is significantly lower than that in the control group(17.2%).Data comparison shows P<0.05.Conclusion The curative effect and prognosis for patients with intertrochanteric fracture of femur treated by PFNA internal fixation are more ideal.

Trauma and bone metabolism of magnetic navigation intramedullary nail and traditional intramedullary nail fixation treatment of femoral shaft fracture

Objective:To analyze the trauma and bone metabolism of magnetic navigation intramedullary nail and traditional intramedullary nail fixation treatment of femoral shaft fracture. Methods:58 patients with femoral shaft fracture treated in our hospital between December 2011 and December 2015 were divided into observation group and control group by random number table (n=29). Control group received conventional intramedullary nail fixation treatment, and observation group received magnetic navigation intramedullary nail fixation treatment. 24 h after surgery, blood coagulation indexes, enzymology indexes, bone metabolism indexes and angiogenesis indexes were determined;6 months after surgery, bone mineral density levels were determined. Results:24 h after surgery, peripheral blood thrombin time (TT), prothrombin time (PT), and activated partial thromboplastin time (APTT) levels of observation group were significantly higher than those of control group, and serum fibrinogen (FIB), D-Dimer (D-D), lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase isoenzyme (CKMB), glutamic oxalacetic transaminase (GOT), sex hormone-binding globulin type I (SHBG), collagen cross-linked carboxyl-terminal telopeptide (CTX) and deoxypyridinoline (DPD) content were lower than those of control group while bone gla protein (BGP), insulin-like growth factor (IGF-1), hypoxia-inducible factor-1α (HIF-α), angiogenin 1 (Ang-1), recombinant basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) content were higher than those of control group;6 months after surgery, fracture end bone mineral density (BMD) value of observation group was higher than that of control group. Conclusions:Magnetic navigation intramedullary nail treatment of femoral shaft fracture can more effectively reduce the surgical trauma, improve bone metabolism and increase bone mineral density.

Titanium elastic nailing in diaphyseal femoral fractures of children below six years of age

AIM To report the clinical and radiographic results of titanium elastic nail(TEN) in diaphyseal femoral fractures of children below age of six years.METHODS A retrospective analysis of 27 diaphyseal femoral fractures in children younger than six years treated with TEN between 2005 and 2015 was conducted. Patients were immobilized in a cast for 5 wk and the nails were removed from 6 to 12 wk after surgery. Twenty-four cases were clinically and radiographically re-evaluated using the Flynn's scoring criteria, focusing on: Limb length discrepancy, rotational deformity, angulation, hip and knee range of motion(ROM), functional status, complications, and parent's satisfaction.RESULTS Sixteen males and eight females with a mean age of 3.2 years at the time of treatment were re-evaluated at an average follow-up of 58.9 mo. No cases of delayed union were observed. The mean limb lengthening was 0.3 cm. Four cases experienced limb lengthening greater than 1 cm and always minor than 2 cm. Twelve point five percent of the cases showed an angulation < 10°. Complete functional recovery(hip and knee ROM, ability to run and jump on the operated limb) occurred in 95.7% of cases. Complications included two cases of superficial infection of the TEN entry point, one case of refracture following a new trauma, and one TEN mobilization. According to the Flynn's scoring criteria, excellent results were obtained in 79.2% of patients and satisfactory results in the remaining 20.8%, with an average parent's satisfaction level of 9.1/10.CONCLUSION TEN is as a safe, mini-invasive and surgeon-friendly technique and, considering specific inclusion criteria, it represents a useful and efficacy option for the treatment of diaphyseal femoral fractures even in patients younger than six years of age.

Proximal Femoral Nail in Reverse Trochanteric Femoral Fractures: An Analysis of 53 Cases at One Year Follow-Up

Treatment of reverse oblique trochanteric femoral fractures poses a lot of challenges. There have been proponents of intramedullary devices as well as extramedullary devices. We present the results of proximal femoral nailing surgery performed for reverse obliquity intertrochanteric fractures using two proximal lag screws and a nail of 250 mm. There is prospective study of fifty three patients with AO/OTA 31 A-A3 fractures being treated by proximal femoral nailing in our institute after seeking approval from the Hospital ethics board. The quality of the reduction, the operative time, complications and the functional status of the patients were the parameters on which the results were evaluated. The mean Harris hip score was 76.66 (range 70 - 93) and the mean Barthel activity score was 16.21 (range 12 - 20). The average surgical time was 50 minutes and the mean consolidation time was 11.5 weeks. Intramedullary nailing with proximal femoral nails seems to be a good option in the treatment of reverse obliquity intertrochanteric fractures as against the various existing options available for the management.

Minimally invasive treatment of forearm double fracture in adult using Acumed forearm intramedullary nail: A case report

BACKGROUND Currently,open reduction internal fixation is the conventional surgical method for treatment of double ulna and radius fracture.However,open reduction is associated with a high risk of complications.This case of forearm double fracture involved a patient treated using an Acumed intramedullary nail.The patient experienced good follow-up outcomes.The Acumed forearm intramedullary nail enables early functional exercise and hastens healing of the fracture.Few studies have reported on the use of this approach for the treatment of fractures.CASE SUMMARY A 23-year-old male patient was admitted to hospital after 5 h of pain,swelling,and limited activity of left forearm caused by a careless fall.Physical examination showed stable basic vital signs,swelling of the left forearm,and severe pain when pressing on the injured part of the forearm.Further,friction was felt at the broken end of the bone;the skin was not punctured.Movement of the left hand was normal,and the left radial artery pulse was normal.Three-dimensional computed tomography examination showed an ulna fracture of the left forearm and comminuted fracture of the radius.The fracture was located in the upper third of the radius,with significant displacement on the fracture side.Clinical diagnosis further confirmed the left radius comminuted fracture and ulna fracture.After analyzing the fracture pattern,age,and other patient characteristics,we chose an Acumed nail for treatment and achieved good follow-up outcomes.CONCLUSION Acumed forearm intramedullary nail for fixation of ulna and radius fracture reduced complication risk and resulted in good follow-up outcomes.

Olecranon anatomy:Use of a novel proximal interlocking screw for intramedullary nailing,a cadaver study

AIM: To define the optimum safe angle of use for an eccentrically aligned proximal interlocking screw(PIS) for intramedullary nailing(IMN).METHODS: Thirty-six dry cadaver ulnas were split into two equal pieces sagitally. The following points were identified for each ulna: the deepest point of the incisura olecrani(A), the point where perpendicular lines from A and the ideal IMN entry point(D) are intersected(C) and a point at 3.5 mm(2 mm safety distance from articular surface + 1.5 mm radius of PIS) posterior from point A(B). We calculated the angle of screws inserted from point D through to point B in relation to D-C and B-C. In addition, an eccentrically aligned screw was inserted at a standard 20° through the anterior cortex of the ulna in each bone and the articular surface wasobserved macroscopically for any damage.RESULTS: The mean A-C distance was 9.6 mm(mean ± SD, 9.600 ± 0.763 mm), A-B distance was 3.5 mm, C-D distance was 12.500 mm(12.500 ± 1.371 mm) and the mean angle was 25.9°(25.9°± 2.0°). Lack of articular damage was confirmed macroscopically in all bones after the 20.0° eccentrically aligned screws were inserted. Intramedullary nail fixation systems have well known biological and biomechanical advantages for osteosynthesis. However, as well as these well-known advantages, IMN fixation of the ulna has some limitations. Some important limitations are related to the proximal interlocking of the ulna nail. The location of the PIS itself limits the indications for which intramedullary systems can be selected as an implant for the ulna. The new PIS design, where the PIS is aligned 20°eccentrically to the nail body, allows fixing of fractures even at the level of the olecranon without disturbing the joint. It also allows the eccentrically aligned screw to be inserted in any direction except through the proximal radio-ulnar joint. Taking into consideration our results, we now use a 20° eccentrically aligned PIS for all ulnas. In our results, the angle required to insert the PIS was less than 20° for only one bone. However, 0.7° difference corresponds to placement of the screw only 0.2 mm closer to the articular surface. As we assume 2.0 mm to be a safe distance, a placement of the screw 0.2 mm closer to the articular surface may not produce any clinical symptoms.CONCLUSION: The new PIS may give us the opportunity to interlock IMN without articular damage and confirmation by fluoroscopy if the nail is manufactured with a PIS aligned at a 20.0° fixed angle in relation to the IMN.

Ankle Arthrodesis Nail Combined with Locking Compression Plate to Stabilize Two-Level Pathologic Tibial Fractures

Treatment of fragility fractures of the distal tibia in the elderly is demanding because of osteopenic bone quality, the delicate soft tissue cuff and frequent critical circulation. We report the case of two-level tibial pseudarthroses in an 83- year-old woman caused by multiple myeloma successfully stabilized by a long ankle arthrodesis nail combined with locking compression plate osteosynthesis. This case is unique, as to our best knowledge, herein diaphyseal fractures were treated for the first time using a technique reported hitherto primarily for fragility ankle and pilon fractures.