Several fixation devices have been developed to overcome the difficulties encountered in the treatment of unstable trochanteric fractures. Until recently most of these fractures were treated by sliding hip screw. Since these devices performed less well in unstable trochanteric fractures with high rates of failure, intra medullary devices have become increasingly popular. The proximal femoral nail is an effective load bearing device that incorporates the principles and theoretical advantages of all the intra medullary devices and considered to be the second generation nail (Schipper I.B. et al 2004). Biomechanically the PFN is more stiff, it has a shorter movement arm (i.e. from the tip of the lag screw to the centre of the femoral canal) whereas the DHS has a longer movement arm ( i.e. from the tip of the lag screw to the lateral cortex ). The DHS with a longer movement arm undergoes significant stress on weight bearing and hence higher incidence of lag screw cutout and varus malunion (Rosenblum et al 1992).
New design interlockingnail and plate are suitable for comminuted long bone fracture in old dog. It provided ex- cellent outcome, excellent rigid fixation, reduced major complication problem for example pin migration, and quick- ly weight baring beside that this nail does not use specific orthopedic instrument. Intramedullary pin and external skel- etal fixation are good in simple long bone fracture, low cost in surgical instrument, and short time in surgical procedure but may be induce major complication problem.
increasing trend due to road traffic accidents and firearm (war) injuries  , these injuries are on the rise in last few years in Libya due to increasing incidence of gunshot, shotgun, and road traffic accident, and their management is a common problem in trauma centers. The soft tissue management is the most important factor in determining the outcome of open tibia fractures with the optimal method of fixation is still debated. Sufficient stability of the fracture fragments and soft tissues usually can be obtained only by locked intramedullarynail or external fixator  , and this continues to be a major therapeutic problem because of poor soft tissue cover and blood supply of the tibial shaft which make these fractures vulnerable to nonunion and infection  .
After admission, two groups of patients completed the examination and were excluded of surgical contraindications, the imaging examination results were referred to preliminarily determine the intramedullarynail length and diameter, and conventional tibial tubercle traction was conducted before operation. Control group received traditional intramedullarynail inner-fixation treatment, and the specific treatment was the same as that in the literature  . Observation group received magnetic-navigation intramedullarynail inner-fixation treatment, specifically as follows: patients took supine position after epidural anesthesia, the affected limb received sustained traction, and after anteroposterior and lateral perspective showed the reduction was satisfactory, routine disinfection and draping were conducted. Magnetic-navigation intramedullarynail, locating rod and sighting device were installed, small magnetic block corresponded to the second hole of distal interlockingintramedullarynail, and distal nail of sighting device was in line with distal main nail. Conventional operative approach was taken, a longitudinal incision of 5-8 cm was made in 2cm above the femoral greater trochanter, fracture traction and reduction were performed, guide
Interlockingintramedullary nails have been the most widely used type of intramedullary nails since their first use in femoral shaft fracture repair by Kuntscher in the 1960s . This method is widely accepted among orthopedic trauma surgeons, and has the reported advan- tages of central fixation, anti-rotation and early recovery of weight bearing capacity . Addi- tionally, interlockingintramedullary nailing as- sisted CR avoids damaging the circulation of the periosteum and promotes osteogenic cal- lus formation [7, 8]. It has been suggested that the success of interlockingintramedullarynail- ing depends on the design of an appropriate
Anatomic studies have demonstrated that in particular with placement of proximal medial-to-lateral oblique interlocking screws there remains a risk of common peroneal nerve palsy . In order to minimize this risk, surgeons should consider drilling for the screw under fluoroscopic guidance with the fluoroscopic image intensifier angled perpendicular to the plane of the drill bit as opposed to standard anteroposterior and lateral views. Surgeons should be aware of the relatively thin cortical bone within the proximal tibia and should be conscientious about the fact that penetration of the far tibial cortex by the drill bit may be difficult to appreciate by tactile feedback. Moreover, the close proximity of the fibular head may obscure the tactile impression and leave the surgeon with the impression of being ‘in the bone’ when in fact the fibular head is penetrated. The screw length should not only be determined by the scaled drill, but also by appropriate depth gauge measurements. Any drilling or screw length measurements past 60 mm should raise the suspicion for posterolateral prominence which may put the common peroneal nerve at risk for injury .
was performed through the malunion site using a 5-mm osteotome, and transfixed provisionally with Kirschner wires after manual reduction under C-arm fluoroscopic assistance. A second 1-cm incision was made over the radial styloid, followed by blunt soft-tissue dissection and meticulous protection of the superficial radial sensory nerve. Dissection through the interval of the first and second dorsal extensor compartments was made using a starter awl in order to create a cortical bone window. This was followed by tapping sequential broaches into the intramedullary canal until the proper fit was achieved (Fig. 2). After sizing and trialing, a Micronail Ò of the measured size was gently inserted through the pre-taped track into the medullary canal of the distal radius. Three distal fixed-angle locking screws and two proximal interlocking screws were then applied through the guiding system. After satisfactory realignment and secure fixation were confirmed by fluoroscopy, all provisionally trans- fixed Kirschner wires were removed and the guide system was disassembled from the intramedullarynail. Local callus from the nascent malunion was morselized to serve as a bone graft for the osteotomy site in 14 patients (87.5 %). Two patients (12.5 %) needed additional arti- ficial bone graft substitutes due to insufficient local bone graft. The wound was closed layer by layer. A volar short arm splint was applied for protection after dressing the wound.
rod, distal sighting device were pre-installed, magnetic blocks corresponded to the distal second hole of interlockingintramedullarynail, distal hole of sighting device was in line with the distal of the main nail, and then pointer scale was recorded. Conventional operative approach was adopted, a longitudinal incision about 6 cm was made in about 2 cm above the femoral great trochanter, guide pin was pierced (in pyriform sinus) after traction and reduction until satisfactory under perspective, then medullary cavity was expanded to fracture end and the long guide pin was inserted, with auxiliary fracture traction and manual reduction. The main nail was screwed in medullary cavity and through the fracture end, and the distal was adjusted to avoid rotating shift. Locating rod was installed on the main nail, distal skin and femoral fascia were incised, and the lateral femoral periosteum was stripped. Detector and the distal locking guide sleeve were installed, the fine adjustment screw on positioning rod was adjusted and the pointer scale was determined. Distal first main nail hole was drilled, the detector in the second hole was removed, guide sleeve was imbedded, the second hole was drilled, and then the drill was taken out and fixed with nail. The first distal drill was taken out, locking nail was screwed in for fixation and should be through the main nail, the locking nail was screwed in the second hole in the same way, and the locking nail of the distal second hole should be through the main nail. Under C-arm perspective, the locking nail and fracture reduction position were confirmed and the distal rotating shift was adjusted, fracture end was compressed, proximal sighting device was used to lock proximal locking nail, tail pin was screwed in, and the operation was completed.
The patient was left in a semi-lateral position. An 8-cm curved incision was made from 2-cm below the greater trochanter to the proximal end to expose the top of the greater trochanter. The anterior border of the trochan- teric fossa was selected as the entry point of nail, and the main nail was screwed into the medullary cavity under fluoroscopy for fracture fixation following insert- ing of the locking tag. If closed reduction was difficult, open reduction and fixation was feasible. After the pa- tient was positioned in a semi-lateral or lateral position, posterolateral or anterolateral approach was selected to expose the fracture segment, in which the stripping of the periosteum was reduced as much as possible. A reamer was used to enlarge the medullary cavity, and a 2-cm incision was made on the site for withdrawal of the reamer. Next, the main nail was guided into the entry point of the trochanter and screwed into the medullary cavity for fracture fixation under direct vision followed by inserting the locking tag (Figure 3 (A1, B1, C1)).
Attempts have been made to modify existing adult interlocking nails to overcome the limitations of the initial rigid uniplanar nail design . Multiplanar nails, unlike uniplanar nails, allow a greater degree of freedom in choosing the entry point for nail insertion [21, 22, 52]. Earlier studies with piriformis entry had patients with complications such as avascular necrosis , coxa valga, and growth arrest of the greater trochanter . Subsequent studies of nail designs with a lateral entry point report no such complication [21, 52]. Hence, the entry point of the intramedullarynail has been a subject of much debate due to the potential impact on the vascularity of the femoral head  and malalignment or iatrogenic fractures . The entry point is largely dictated by the type/design of the nail . Recent nails [21, 22, 27] have a multiplanar/helical design to avoid the piriformis entry point, which has been shown in a recent systematic review to be associated with a higher rate of avascular necrosis . Specific paediatric nails are a welcome development and are suggested by some authors to be safe in skeletally immature patients younger than 12 years . However, it should be noted that the results from this study were preliminary.
In contrast to many available chephalomedullary nailing systems, this modified cephalomedullary nail provides a fix- ation construct with two integrated interlocking lag and compression screws and a trapezoidal nail profile designed to optimize stability . Thus, the insertion of a lag screw combined with an interdigitated compression screws may potentially minimize the risk of screw cut out from the head segment by providing immediate intraoperative linear compression, improved rotational stability, and increased bony purchase within the femoral head. The interdigitating screw insertion further allows for minimizing the risk of the reported Z-effect, which has been described as lateral and medial migration of the superior and inferior screws re- spectively .
In this study, we asked 321 adult patients, who were having surgery for a fracture of the distal tibia, to have either IM nailfixation or locking plate fixation. The decision about which type of fixation to use was made using randomisation, which is a process similar to tossing a coin. The patients reported their own outcome at 3, 6 and 12 months after their fracture using the Disability Rating Index (DRI). We also collected information on quality of life, complications and costs from patient-completed questionnaires and other NHS sources. The DRI score of both groups of patients improved in the months after their surgery, although patients were not back to normal, even 1 year later. The patients who had IM nailfixation of their tibial fracture recovered more quickly than the patients with locking plate fixation, but there were no differences between the treatments after 6 months. There was no difference in the number of complications suffered by each group, but further surgery was more common in the locking plate group. The economic analysis showed that IM nailfixation was cheaper than locking plate fixation.
The single lag screw when is rotationally unstable within the bone, results in loosening of the bone– screw interface, with the screw cutting out . An advantage of the InterTAN is the possibility of the system to maintain the reduction during the maneuvers of the screw insertion thru the anti-rotation blade . The lag screw design can significantly affect the fixation strength and cutout resistance [21,22]. The oval lag screw of InterTAN offers increased resistance to cut-out compared to a device that uses a single lag screw [23-25]. The choice of use a static or a dynamic lag screw is still controversial. There is a 12.4% reduction in axial stiffness in dynamic lag screw. When the static lag screw used for treatment of unstable peritrochanteric fractures, axial and lateral stiffness should be study . InterTAN’s’ intraoperative linear compression of the fracture and the static lag screw offers maximum stability and prevents subsequent excessive neck sliding, shortening and varus collapse, minimizing the rates of malunion and non-union. The primary intraoperative stability provide improvement in postoperative pain, mobility and consolidation time [26,27].
PFNA intramedullaryfixation at our institution. Inclu- sion criteria consisted of patients who had undergone surgery with a standardized care pathway and those who had undergone surgery with the ERAS pathway. Radio- logical data were reviewed to identify the fractures type based on the AO classification. Patients undergoing PFNA intramedullaryfixation surgery were eligible to participate in the prospective arm of the study. Written and verbal informed consent was obtained from each patient before inclusion in the study. Exclusion criteria comprised patients with open fractures, metastatic pathological fractures, patients unable to walk independ- ently before fracture, and inability to follow verbal or written instructions (Fig. 1).
In the case of post operation complication, results of our study showed translation of 2 mm in 1 (2%) patient. A distal screw was out of nail in 1 (2%) patient and proximal screw was broken after 6 months. Also one of the distal screws was tilted in 1 (2%) patient. Discharge from the wound was happened in 1 (2%) patient who was treated with antibiotic. No cases of deep infection, nerve injury or compartment syndrome were seen.
Constant scores to those recorded in patients with 2-part or 3-part fractures (Table 4). We have noticed that the good functional results were mainly obvious shortly after surgery and 12 months post-operatively after intramedullary nailing of 4-part proximal humeral fractures. After that time, no further improvement has been recorder at the follow-up. The short intra-operative time, the limited exposure and minimal soft tissue dam- age, the preservation of periosteal blood supply and the rapid functional recovery resulted in good functional scores in this group of patients. However, in our study half of the patients with 4-part fracture proceeded to union at a less than 120° of valgus neck/shaft angle, probably due to reduced grip strength of screws at the osteoporotic bone. Yet the radiologic findings did not correlate with the functional scores. Other studies also report excellent to satisfactory results for the same frac- ture pattern [10,14,17,20,22]. Overall, excellent and satis- factory results with regard to functional outcome (Constant score) was noted in the majority of the patients in this study (92%). Rajasekhar et al.  mea- sured a median Constant score of 75 (25–88) points for patients aged over 60 years, and 70 (34–100) points for those younger than 60 years, in 25 patients treated with the Polarus nail. Sosef et al.  found a more than sat- isfactory shoulder function by recording a median Con- stant score of 89 (range 39–100). Adedapo and Ikpeme  treated 23 patients with displaced 3-, 4-part frac- tures and 3 or 4-part combined with shaft fractures using the Polarus nail and they found a mean Constant score of 88 (40–100), 67 (50–91), and 69 (40–94) points, respectively, at 1-year follow-up. Pain and loss of range of motion were the major reasons for the unsatisfactory results. However, it has been suggested that the pre- injury status of the shoulder seems to influence the Table 5 Review of all studies (215 patients) reporting on the use of Polarus nail for proximal humeral fractures
Thus, despite the fact that the expandable nail shows promising results in clinical trials, there have been published a number of biomechanical studies in which Fixion showed "failing"  and not enough good results [9-11], when assessing the stability of transverse diaphyseal fractures of long bones. One can argue, as Steinberg  does in his comments on the article  that the nail was not installed correctly. However, Blum explained that installation was carried out in exactly to the manufacturer's recommendations. Other authors have also pointed out in their articles that the expandable nails were placed exactly to the requirements of the manufacturer. Thus, Blum and coauthors believed that Fixion nail showed the lower torsional stiffness in comparison with locked nails for the reason that they have studied
Methods: This work is a cohort retrospective study in addition to the application of a questionnaire for self-rated quality of life with its 05 domains (WORC - Western Ontario Rotator Cuff Index) for patients ( N = 26) classified in the Trauma Sector of the Department of Orthopedics and Traumatology of the Federal University of São Paulo (DOT/UNIFESP) submitted to Humerus Osteosynthesis with Antegrade Locked Intramedullary Nailing. There was also the inclusion of data related to the time since surgery, age, sex, surgical laterality, dominance among members and work leave, which were not considered in the original protocol. After, the data were statistically assessed to evaluate the association between numerical and categorical variables.
Maredza, M., Petrou, Stavros, Dritsaki, M., Achten, Juul, Griffin, J., Lamb, S. E. (Sallie E.), Parsons, Nicholas R. and Costa, Matthew L. (2018) A comparison of the cost-effectiveness of intramedullarynailfixation and locking plate fixation in the treatment of adult patients with an extra-articular fracture of the distal tibia. The Bone & Joint Journal, 100‐B (5). pp. 624-633. doi:10.1302/0301-620X.100B5.BJJ-2017-1329.R2
intramedullarynail to be applied percutaneously in the fixation of femoral rotational osteotomies in children with cerebral palsy and evaluated its mechanical properties. Methods: The study was divided into three stages. In the first part, a prototype was designed and made based on radiographic measurements of the femoral medullary canal of ten-year-old patients. In the second, synthetic femoral models based on rapid-prototyping of 3D reconstructed images of patients with cerebral palsy were obtained and were employed to adjust the nail prototype to the morphological changes observed in this disease. In the third, rotational osteotomies were simulated using synthetic femoral models stabilized by the nail and by the AO-ASIF fixed-angle blade plate. Mechanical testing was done comparing both devices in bending- compression and torsion.