Practice of Intramedullary Locked Nails: Scientific Basis and Standard Techniques Recommended by “Association Internationale pour I’Ostéosynthèse Dynamique” (AIOD) PDF
Preview Practice of Intramedullary Locked Nails: Scientific Basis and Standard Techniques Recommended by “Association Internationale pour I’Ostéosynthèse Dynamique” (AIOD)
Practice of Intramedullary Locked Nails Scientific Basisand Standard Techniques Recommended byAIOD Springer-Verlag Berlin Heidelberg GmbH ChiefEditors 1. KEMPF . K.S. LEUNG Co-Editors A. GROSSE' H.J.T.M. HAARMAN H. SEIDEL' G. TAGLANG Practice of Intramedullary Locked Nails Scientific Basis and Standard Techniques Recommended by "Association Internationale pour l'Osteosynthese Dynamique" (AIOD) With 239 Figures and 15 Tables Springer Chief Editors ISBN 978-3-642-62961-7 Professor Dr. 1. KEMPF AIOD, 16 Rue du Parc Library of Congress Cataloging-in-Publication Data 67205 StraBburg, France Practice of intramedullary locked nails: scientific basis and standard technique recommended by AIOD/[I. Kempf, K. S. Leung, chief editors]. Professor Dr. K. S. LEUNG p.; cm. The Chinese University of Hong Kong Includes bibliographical references and index. ISBN 978-3-642-62961-7 ISBN 978-3-642-56330-0 (eBook) Department of Orthopaedics DOI 10.1007/978-3-642-56330-0 and Traumatology 1. Internal fixation in fractures. I. Kempf, I. (Ivan), Shatin, Hong Kong SAR 1928-II. Leung, Kwok-Sui. [DNLM: 1. Fracture Fixation, Intramedullary - methods. China 2. Bone Nails. 3. Internal Fixators. WE 185 P895 2002] RD 103.15 P73 2002 Co-Editors 617.1'5-dc21 2001049375 Dr. A. GROSSE Centre de Traumatologie et d'Orthopedie This work is subject to copyright. Ali rights are reserved, whether the whole or rart of the material is concerned, 10 Avenue A. Baumann specifica1ly the rights o translation, reprinting, reuse of il 67400 StraBbourg, France lustrations, recitation, broadcasting, reproduction on mi crofilm or in any other way, and storage in data banks. Du Professor Dr. H. J. T. M. HAARMAN plication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of Academisch Ziekenhuis September 9, 1965, in its current version, and permission Department of Surgery for use must always be obtained from Springer-Verlag. Vio lations are liable for prosecution under the German Copy De Boelelaan 1117, P.O. Box 7057 right Law. 1007 MB Amsterdam, The Netherlands Dr. H. SEIDEL Al1gemeines Krankenhaus Wandsbeck http://www.springer.de Abteilung rur Unfallchirurgie © Springer-Verlag Berlin Heidelberg 2002 AlphonsstraBe 14 Originally published by Springer-Verlag Berlin Heidelberg New York in 2002 22043 Hamburg, Germany Softcover reprint ofthe hardcover Ist edition 2002 The use of general descriptive names, registered names, Dr. G. TAGLANG trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are ex Centre de Traumatologie et d'Orthopedie empt from the relevant protective laws and regulations and 10 Avenue A. Baumann therefore free for general use. 67400 StraBbourg, France Production: PRO EDIT GmbH, Heidelberg, Germany Cover design: Erich Kirchner, Heidelberg, Germany Typesetting: K + V Fotosatz GmbH, Beerfelden, Germany Printed on acid-free paper SPIN 10497445 24/3130/Di 543 2 1 O Foreword Medullary nailing is one of the oldest types of in away that did not allow the surgeon to be car surgical fracture treatment. Splinting afracture by ried away by enthusiasm. They impressed by re insertion of plugs made of ebony dates back to porting merits and pitfalls alike in a very realistic the ancient Egyptian culture. As for many other and convincing manner. types offracture treatment, some outstanding but When we consider the past, we automatically lone pioneers performed what was in their hands confront the question, "What is next?" Where are an art based on intuition. But most of them re today's problems and what could the solutions be? mained lonely pioneers since they could teach The present book discusses the view that medul neither the basics nor the surgical art without a lary nailing is able to compensate for the distur deeper understanding of the underlying science. bance to blood circulation brought by the frac It took the tenacity of Kuntscher to establish ture, the surgical procedures, the instruments and medullary nailing as an accepted method oftreat the implants. On the one hand, it is apparent that ment world-wide. It is a method that is attractive there is potential for biological improvements, because ofits apparent simplicity and tolerance of specifical in terms of avoiding or reducing trau the procedures. Kuntscher's great achievements mata due to reaming. But this will invariably be were certainly crowned by his success in convinc achieved at the expense ofstability or strength of ing other pioneers, such as 1. Bohler and M.E. the fixation. Similar to the possibilities for im Muller, to accept his procedure and to use it in proving the afferent blood supply, the effects of addition to their own special approaches. nailing on a patient local circulation and general, Itisinterestingtonotethatinrespecttowhatwe disseminated, microvascular aggregation must be todayunderstandtobethestateoftheartinlocked resolved, especially for patients with thoracic medullary nailing. Kuntscher had visionary ideas trauma. We are convinced that the spirit estab that led the waybut did not come to fruition. This lished by the group in Strasbourg and Hong Kong gave the next generation the opportunity to made and maintained by their colleagues and pupils an essential contribution. Kuntscher's "detention provides good reason to hope that the next step nail" remained a Cinderella until Klemm and forward is not far beyond the horizon. The pre Schellmanprovedtheclinicalmerits oflockednail sent book will not only help the clinically active ing.Thistechnologywidenedthespectrumofindi surgeon and his team, but will serve as a guide to cations for nailing and improved its safety. As im the researcher and developer in the insatiable pressive as their achievements were, it took the vi urge to strive for improvements. sionanddeterminationofIvanKempfstograspthe It is obvious that no single method can solve idea and to push for its realization. To Arsene all the problems of fracture treatment. Progress Grosse, an ingenious developer and surgeon, we and success depend on clean concepts and opti owe atechnology thatwould be acceptedandsoon mal employment of each single method. This is find world-wide recognition. where the present book, made with care, deep in Early on, Iwas impressed not only by the tech sight and great experience concerning the impor nology, its simplicity and its safety, but even more tant technology of medullary nailing by the so by the school of thought of the Strasbourg authors and editors 1. Kempf and K.S. Leung, team that devised away ofteaching the system to contributes in an outstanding way. encourage general acceptance. An important fac tor that contributed to this acceptance was the Stephan Perren fact that this school reported clinical experience Davos, 16 December 2000 Preface Following the steps of Gerhard Kiintscher, the be stabilised using this technique without em father of intramedullary fixation of fractures, Dr. barking on more complicated and invasive meth Klemm and Dr. Schellmann from Frankfurt am ods. With many innovative modifications, this Main, Germany, took up the idea of locking the technique has been applied to managing difficult nail to the bone in the early 1970s. Professor Ivan trauma conditions as well as a number of other Kempf and Dr. Arsene Grosse from Strasbourg, orthopaedic conditions. Today, it is our strong be France, further developed these concepts, putting lief that the use ofintramedullary locked nails in intramedullary locked nails into clinical practice the management of long bone fractures has be in a systemic and scientific manner for the first come a well-established philosophy of patient time. In fact, the introduction of the intramedul management. The principles and applications are lary locked nail system to musculoskeletal trauma universal and far beyond the limit ofany particu was considered to be one of the major advance lar instrument or implant. Based on this faith, ments ofthe 1970s. Throughout these years, hun Practice ofIntramedullary Locked Nails is written dreds of training courses were organised to pro in the hope that this technique will evolve further mote the concept and practice ofthe closed treat for the betterment ofpatients. ment of long bone fractures with this technique. This book describes the use and relevance of Numerous clinical results have proven the benefi the closed technique of intramedullary locked cial effect of the technique to patients. Intrame nails in orthopaedic and trauma surgeries. The dullary locked nail has become an indispensable Practice ofIntramedullary Locked Nails comprises instrument in fracture management as well as re oftwo volumes: Vol. 1covers the scientific princi constructive surgery in orthopaedics. Fixing long ples and standard surgical techniques ofintrame bone fractures with intramedullary locked nails dullary locked nails; Vol. 2 covers the advanced agrees with the modern concept of minimally in surgical techniques in extended indications. This vasive surgery. work would not have been possible without the Intramedullary fixation fulfils the biological re contribution and collaboration of world-leading quirement for fracture healing and minimises sur trauma centres. The contributions from surgeons gical trauma. Intramedullary locked nails provide with different areas of expertise throughout the a favourable biomechanical environment, from world are essential in providing international and fracture stabilisation to post-operative rehabilita comprehensive views ofthese nailing techniques. tion. In accordance with the principles of closed biological treatment of fractures and minimally Ivan Kempf invasive techniques, most long bone fractures can Kwok-Sui Leung Acknowledgements This book could not have been completed after • The council members of the AIOD who have such an exceptionally long period of preparation supported the project throughout these years of without the support and contribution of our preparation. friends and colleagues. Our special gratitude goes • The secretarial staff of the AIOD, especially to: Mrs. Margot Hamm, Mrs. Michele Obringer • Our friends and colleagues who prepared the and Ms. Audrey Muller for their patience, en manuscripts based on the framework proposed durance and perseverance in making the pro by the editorial board. Without their patience ject progress, for their excellent and profes and relentless support, this book could never sional secretarial support in preparing the have become a reality. manuscripts. • Our co-editors and the members of the editor • Mrs. Christiane Schaeffer-Cinqualbre, who pre ial board who share our vision in promoting pared the illustrations. the concept and practice of the closed treat • Mr. Robert Cooley for improving the English ment of fractures developed by Prof. Gerhard ofthe manuscripts. Kiintscher with the intramedullarylocked nails. • The staff of Springer-Verlag in Heidelberg, • Professor Stephan Perren, our dear friend and especially Mrs. G. Schroder, who supported the colleague, for his kind remarks in the Fore project from the very beginning, and for their word. expertise in producing and publishing this book. Contents Chapter 1 Chapter 9 Introduction . Femoral Fractures ..... 73 0 • 0 • • • • • • • • • • • • 1. KEMPF and H. SEIDEL K.So LEUNG and Ao GROSSE Chapter 2 Chapter 10 The Biology of Fracture Healing as Related Tibial Fractures 87 to IntramedullaryLocked Nailing . 5 K.So LEUNG F. BIGGI Chapter 11 Chapter 3 Proximal Femoral Fractures: Operative Bone Circulation and Effects ofExperimental Techniquefor Peritrochanteric Fractures ..... 101 Interventions ... 11 G. TAGLANG 0 •• 0 ••••• 0 ••• 0 ••••••• M. BROOKES Chapter 12 Chapter4 Humeral Fractures 113 Biologyand PhysiologyofIntramedullary Ho SEIDEL Reaming in the Fixation of Fractures . 31 0 ••• 0 • K.S. LEUNG and E.N.M. CHEUNG Chapter 13 Ulnar Fractures 127 0 •• 0 0 •••• 0 ••• 0 0 0 •• 0 0 0 0 Chapter 5 C. LEFEVRE and D. LE NEN Biomechanics of Locked Intramedullary Fixation of Fractures 43 Chapter 14 0 •• D. DAGRENAT and 1. KEMPF Complications of Intramedullary Locked Nailing: Infection and Infected Nonunion . 135 Chapter 6 K. KLEMMt and D. SELIGSON IntramedullaryNail Systems 51 Ao SPEITLING Chapter 15 Complications ofCentromedullary Nailing Chapter 7 (Excluding Infection) 147 0 •••••••••••• Time of Radiation Exposure During C. LEFEVRE and Do LE NEN Intramedullary Nailing Procedures 61 J.-c. DOSCH and M.G. DUPUIS Subject Index . 167 0 0 0 0 0 •••• 0 0 0 • 0 0 • 0 0 0 0 0 • Chapter 8 Distal Targeting in Locking Nails 67 G. TAGLANG Contributors Dr. F. BIGGI Dr. K. KLEMM t Ospedale Maggiore LandgrabenstraBe 5 Azienda USL Citta di Bologna 61118 Bad-Villbeck, Germany 40133 Bologna, Italy Prof. C. LEFEVRE Prof. M. BROOKES H6pital de la Cavale Blanche 68 Lakenheath, Southgate Service d'Orthopedie N14 4RP London, u.K. 29200 Brest, France Dr. E.N.M. CHEUNG Prof. D. LE NEN The Chinese UniversityofHong Kong H6pital de la Cavale Blanche Department ofOrthopaedics and Traumatology Service d'Orthopeclie Shatin, Hong Kong SAR, China 29200 Brest, France Dr. D. DAGRENAT Prof. K.S. LEUNG Cabinet de Chirurgie Orthopedique The Chinese UniversityofHong Kong, 16 Allee de la Robertsau Department ofOrthopaedics and Traumatology 67000 Strasbourg, France Shatin, Hong Kong SAR, China Prof. J.-C. DOSCH Dr. H. SEIDEL Centre de Traumatologie et d'Orthopedie Allgemeines Krankenhaus Wandsbeck 10 Avenue A. Baumann Abteilung fur Unfallchirurgie 67400 Strasbourg, France AlphonsstraBe 14 22043 Hamburg, Germany Dr. M.G. DUPUIS Centre de Traumatologie et d'Orthopedie Prof. D. SELIGSON 10 Avenue A. Baumann School ofMedicine 67400 Strasbourg, France Department ofOrthopaedic Surgery UniversityofLouisville Dr. A. GROSSE 40292 Louisville, KY, USA Centre de Traumatologie et d'Orthopedie 10 Avenue A. Baumann Dr. Ing. A. SPEITLING 67400 Strasbourg, France Stryker Trauma GmbH Prof.-Kuntscher-StraBe 1-5 Prof. I. KEMPF 24232 SchOnkirchen, Germany Association Internationale pourl'Osteosynthese Dynamique Dr. G. TAGLANG 16 Rue du Pare Centre de Traumatologie et d'Orthopedie 67205 Strasbourg, France 10 Avenue A. Baumann 67400 Strasbourg, France CHAPTER 1 Introduction I. KEMPF and H. SEIDEL Since time immemorial, man has been the victim the pioneers, Hansmann, Sherman, Hey-Groves, of accidents which led to fractures, and it is Lambotte - inventor of the expression osteosyn known that cave men, when faced with this prob thesis - and others, it was with Danis [2], who lem, devised ways of immobilization in order to created the compression plate later taken up and treat and heal injuries which were a threat to sur perfected by Muller et al. [8] and the Arbeitsge vival. Splints made ofbranches and fixed in place meinschaft flir OsteosynthesefragenlAssociation with lianas, applied after an approximate align for the Study of Internal Fixation (AOIASIF), that ment of the fragments, ensured, in line with the this technique with the compression screw defini still eternal principles offracture treatment today, tivelyacquired its position ofeminence. the immobilization ofthe fracture until it healed. The closed procedure developed more slowly. Gradually methods improved, with splints, ban Using mainly intramedullary implants, pegs made dages and different devices and especially with of metal, ivory, bovine cortical bone, etc., are in the development of continuous traction and plas troduced initially through an open site technique. ter bandages. These methods were used for mil Extra-articular closed nailing of femoral neck lennia right down to the first halfofthe twentieth fractures devised and implemented by Senn, Del century with Lorenz Bohler [1] at the height of bet, Royal-Whitman, and Smith Petersen opened his career and accomplishments. His treatise Die the way to closed intramedullary nailing ofwhich Technik der Knochenbruchbehandlung (The Tech Kuntscher [5, 6, 7] is rightly considered to be the nique ofFracture Treatment) [1] represents an un creator. As early as 1940, he set out its principles equaled survey of this field, taken up and im and the way it could be performed. First he de proved by Sarmiento with his Functional Bracing vised the hollow nail with a slot and clover-leaf [9], which freed the joints adjacent to the fracture. section, then reaming, which made it possible to The indications for this method should still apply use larger nails, and finally, at the end of his life, and slow down the current trend in developed he laid down the basis for locked nailing. countries ofoperating on everything. It is still the Kuntscher started a revolution in fracture man basis of fracture treatment in the developing agement with this new treatment. He was 40 years countries. old when he published his technique and philoso Operative treatment of fractures emerged only phy of fracture treatment in the 64th volume of after the advent ofantisepsis and asepsis. Its ori the Deutsche Gesellschaftfur Chirurgie [5] in 1940 gins lie in the first halfof the nineteenth century in Berlin. His concept was completely new and re and it developed in two directions: volutionary for the establishment. Kiintscher • The open procedure with exposure and open reaped a storm of controversy, denial, and perso reduction ofthe fragments followed by internal nal attacks. His ideas were rejected on the fixation using the most varied means: bone su grounds of the existing anatomical science and tures, wiring, stapling, screws, plates and the accepted standards offracture treatment. Even screws, pegs, pins, nails. today we hear some of these arguments used • The closed procedure combining reduction against the intramedullary nailing technique. without opening the fracture site and fixation However, the clinical background is more ad using implants introduced or placed at a dis vanced than in those pioneering days and there tance from the fracture. are sufficient experimental data and clinical ex perience to support the technique. In proposing a As far as the open technique is concerned, devel direct approach to the medullary canal, Kuntscher opment focused mainly on techniques using was running against the widely accepted science screws and plates with screws. After the age of of the bone marrow. In the nineteenth century,
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