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A R T I C L E I N F O A B S T R A C T
Keywords: Intramedullary nailing of diaphyseal long bone fractures is a standard procedure in todays trauma and
Angular stable orthopedic surgery due to the numerous advantages (e.g. minimal invasive, limited soft tissue damage,
Intramedullary nailing load stability). In the last decade indications have been extended to the metaphyseal region. This was
Biomechanics
associated with problems and complications due to the reduced bone-implant interface. The changed
Nail locking
anatomical conditions lead to decreased implant anchorage. Newly developed locking solutions
Augmentation
overcome most of these problems. First, the number and also the orientation of the locking screws were
adapted to allow a multiplanar locking. This results in increased implant anchorage in the soft
metaphyseal bone, thus construct stability signicantly improved. Additional options like angular stable
locking have been introduced and furthermore enhanced construct stability especially in poor bone
stock. As a perspective locking screw augmentation shows promising results in rst biomechanical
testing.
2017 Elsevier Ltd. All rights reserved.
Introduction stability [9]. Fractures of the distal third of tibia treated with
intramedullary nailing frequently result in varus, valgus or
Today, intramedullary nailing is standard of care for most long torsional deformities and non-unions [1014]. To improve
bone diaphyseal fractures [14]. This technique has a lot of construct stability of intramedullary metaphyseal long bone
advantages making it superior compared to open reduction and fractures implants have been adapted. Especially the modications
internal xation using plates and screws. The soft tissue damage is of locking options improved implant anchorage. Multiplanar
reduced signicantly when using indirect reduction and intra- locking, compression screws and angular stability are a few
medullary nailing, additionally, the periosteum and the fracture options to increase construct stability and decrease complication
hematoma is preserved. Thus, complications like wound infection rates. This article will present biomechanical background of these
and non-union are decreased compared to open reduction and modern locking solutions.
internal xation procedures. The majority of patients treated with
an intramedullary nail are allowed to fully weight bear immedi- Locking solutions
ately after surgery. These characteristics make intramedullary
nailing of diaphyseal long bone fractures a minimal invasive and Various modications and new developments of locking
safe treatment option [2,5,6]. options have been introduced to reduce the complications and
In the last years indications of intramedullary nailing have been make the benets of intramedullary nailing applicable even in
extended to include even more metaphyseal fractures [7,8]. This metaphyseal long bone fractures.
was linked to some problems and complications due to the First of all the number and the sites of the locking holes were
decreased biomechanical stability [1,8]. Especially the difference in adapted to address the needs of very proximal or distal fractures.
size between the nail diameter and the metaphyseal diameter Traditional tibia nails offer two to three proximal locking holes
results in a small nail-cortex contact. Additionally, the diminished (Fig. 1A,B) in contrast the modern nails offer up to ve proximal
cortical bone support of the metaphyseal region limits construct locking options (Fig. 1C). This is the same for distal locking, the
traditional nails offer two to three, the modern four locking holes
(Fig. 1), but not only the number of holes makes the difference. The
modern nails also have different locking bolt orientation, thus a
* Corresponding author at: University Hospital Muenster, Department of Trauma, multiplanar locking can be performed to increase construct
Hand and Reconstructive Surgery, Albert-Schweitzer-Campus 1, Building W1, 48149
stability (Fig. 1C). In their biomechanical study Wolinsky et al.
Muenster, Germany.
E-mail address: dirk.waehnert@ukmuenster.de (D. Whnert). investigated the inuence of proximal locking on axial and
http://dx.doi.org/10.1016/j.injury.2017.04.032
0020-1383/ 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: D. Whnert, D. Gehweiler, Complications of intramedullary nailingEvolution of treatment, Injury (2017),
http://dx.doi.org/10.1016/j.injury.2017.04.032
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JINJ 7197 No. of Pages 5
Fig. 1. Different tibia nails showing traditional nails A and B with limited locking options and a modern tibia nail C. (A) Stryker (Schnkirchen, Germany) T2 tibia nail with
three proximal locking options (upper row) and three distal locking options (lower row). (B) Synthes (Solothurn, Switzerland) UTN tibia nail with three locking options
proximal (upper row) and distal (lower row). (C) Synthes (Solothurn, Switzerland) Expert tibia Nail with ve locking options proximal (upper row) and four locking options
distal (lower row).
Fig. 2. (A) Angular stable locking System (ASLS, Synthes, Solothurn, Switzerland). Special screws with three different diameters a preassembled with a biodegradable
polylactide sleeve. During screw locking the sleeve is expanded and thus blocks the locking screw in the nail hole. (B) Results of torsional stiffness at the different time points.
(C) Results of torsional neutral zone at the different time points. (D) Results of axial stiffness at the different time points. Signicant differences (p < 0.05) marked with *.
Please cite this article in press as: D. Whnert, D. Gehweiler, Complications of intramedullary nailingEvolution of treatment, Injury (2017),
http://dx.doi.org/10.1016/j.injury.2017.04.032
G Model
JINJ 7197 No. of Pages 5
torsional stiffness in a proximal tibia fracture model. They study angular stable locking had no signicant inuence on the
compared four different locking procedures and found that adding number of cycles until failure, but the angular stability reduced the
a transverse locking screw signicantly increased axial stiffness by inuence of the bone mineral density within the rst 20,000 cycles
28% and torsional stiffness up to 28% compared to proximal two [21].
screw locking [15]. These results were conrmed by the work of Within another study Gueorguiev et al. investigated the
Freeman at al. [16]. potential of angular stable locking in unstable distal tibia fractures.
Another innovation introduced to enhance metaphyseal nail Therefore, ten pairs of fresh-frozen human tibiae were randomly
anchorage was the angular stable locking. Angular stability was assigned to either conventional locking (three conventional
introduced for plate and screw osteosynthesis to provide a higher locking screws proximally and three distally) or angular stable
bone implant stability even in osteoporotic bone. Biomechanical locking (two conventional and one angular stable screw proximally
and clinical studies showed the advantages of angular stable and two angular stable screws distally). Cyclic testing was
plating compared to conventional screw and plate xation [1720]. performed using combined axial and torsional loading until
This concept has been adapted to intramedullary nails to address failure. In this investigation the angular stable group showed
the problems of reduced implant anchorage especially in the signicant higher torsional stiffness and a signicant reduced
metaphyseal region. Therefore, different angular stable locking neutral zone as well as signicant less torsional deformation.
options for intramedullary nails were introduced. One option to Therefore, Gueorguiev et al. concluded that angular stable locking
achieve an angular stable locking is the implementation of a thread has the potential to maintain xation stability while reducing the
or a kind of sealing ring into the nails locking hole. Another number of locking screws [22].
possibility to achieve angular stable locking represents the angular Our group investigated the angular stable locking system (ASLS,
stable locking system (ASLS, Synthes, Solothuern, Switzerland). Synthes, Solothurn, Switzerland) working with a special screw and
Whereby a sleeve is applied over a special locking screw (Fig. 2A). biodegradable polylactide sleeve. Therefore we used eight pairs of
During locking procedure the sleeve expands (due to different porcine tibiae in combination with the Expert Tibia Nail (ETN,
screw diameters) and thus angular stable locked screws are Synthes, Solothurn, Switzerland) and a three screw distal locking
created. (either angular-stable or conventional). Measurements of axial
This technique was investigated in several biomechanical stiffness and range of motion (50 N) as well as torsional stiffness,
studies. Gueorguiev et al. compared the interfragmentary move- range of motion and neutral zone (5 Nm) were done after
ment of angular stable versus conventional locked tibia nails in an instrumentation and after four, six, eight and twelve weeks using a
unstable distal tibia fracture model. Therefore, they used eight servo hydraulic testing machine (Instron 8874, Instron, High
pairs of fresh-frozen human tibiae with either two conventional or Wycombe, Bucks, United Kingdom). Meanwhile the specimens
two angular stable medio-lateral distal locking screws in an expert were stored in phosphate-buffered saline at a temperature of 37 C
tibia nail (ETN, Synthes, Solothurn, Switzerland). Under cyclic and a pH-value of 7,4. The initial measurements after instrumen-
testing they found signicant reduction of the neutral zone in tation showed a signicant (70%) higher torsional stiffness for the
medio-lateral direction. Additionally, the fracture gap angulation angular stable locked group (Fig. 2B). Additionally, the range of
was signicantly reduced in the angular stable locked group. In this motion and the neutral zone were signicantly reduced in the
Fig. 3. Implants compared in the study: T2 nail (Stryker, Schnkirchen, Germany) with two distal locking bolts (upper row left), SCN (Stryker, Schnkirchen, Germany) with
four distal locking bolts (two with medial nuts, upper row right), DFN (Synthes, Solothurn, Switzerland) with distal screw and spiral blade locking (lower row right) and the
AxSOS angular stable plate (Stryker, Schnkirchen, Germany) with ve angular stable locking screws and two cancellous screws (lower row left).
Please cite this article in press as: D. Whnert, D. Gehweiler, Complications of intramedullary nailingEvolution of treatment, Injury (2017),
http://dx.doi.org/10.1016/j.injury.2017.04.032
G Model
JINJ 7197 No. of Pages 5
Please cite this article in press as: D. Whnert, D. Gehweiler, Complications of intramedullary nailingEvolution of treatment, Injury (2017),
http://dx.doi.org/10.1016/j.injury.2017.04.032
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JINJ 7197 No. of Pages 5
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Please cite this article in press as: D. Whnert, D. Gehweiler, Complications of intramedullary nailingEvolution of treatment, Injury (2017),
http://dx.doi.org/10.1016/j.injury.2017.04.032