The effectiveness of the external distal aiming device in intramedullary fixation of tibial shaft fractures

IntroductionIntramedullary nailing has become a popular and effective procedure for the treatment of most fractures of the tibial diaphysis. However, distal interlocking screw placement under fluoroscopic control is responsible for the majority of the radiation exposure and a significant loss of surgical time in the entire nailing procedure. To limit fluoroscopy use, during distal interlocking screw placement, Orthofix® has developed a distal targeting device which compensates for the inevitable deformation of the nail in the sagittal plane during its insertion. This prospective clinical study evaluates the efficacy of this distal targeting device for distal locking.Materials and methodsOne hundred and fifteen fresh tibial fractures in the same number of patients with a mean age of 37.5 years (17–85 years) were treated with operative stabilization using the Orthofix tibial nailing system.ResultsThe mean duration of the operation was 38 min (20–55 min). A mean of four intra-operative plain X-rays (2–6 X-rays) were used in 103 cases to confirm guide wire placement, final nail insertion and accuracy of screws placement. The mean duration of the use of the image intensifier utilized in the remaining 12 fractures was 5 s (3–8 s). The distal targeting device failed in 12 (5.2%) distal locking screws.ConclusionThis study demonstrates that distal locking can be performed easily and successfully with minimal exposure to radiation, once the surgeon develops a reasonable experience with the use of this distal targeting device.

[1]  C. Krettek,et al.  Analyse implantationsbedingter Nagelverformung und röntgenmorphometrische Untersuchungen als Grundlage für ein Zielgerät zur distalen Verriegelung ohne Röntgenbildverstärker , 1996, Der Unfallchirurg.

[2]  S. Skjeldal,et al.  Interlocking medullary nails — Radiation doses in distal targeting , 2004, Archives of orthopaedic and traumatic surgery.

[3]  Radiation exposure from fluoroscopy during orthopedic surgical procedures. , 1990, Clinical orthopaedics and related research.

[4]  T. Karachalios,et al.  The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device. , 2000, Injury.

[5]  G. Guyatt,et al.  Operative Management of Lower Extremity Fractures in Patients With Head Injuries , 2003, Clinical orthopaedics and related research.

[6]  T. P. Barry.  Radiation Exposure to an Orthopedic Surgeon , 1984, Clinical orthopaedics and related research.

[7]  T. Dipasquale,et al.  Radiation exposure to the orthopaedic surgical team during fluoroscopy: "how far away is far enough?". , 1997, Journal of orthopaedic trauma.

[8]  M. Davis,et al.  Radiation exposure and associated risks to operating-room personnel during use of fluoroscopic guidance for selected orthopaedic surgical procedures. , 1983, The Journal of bone and joint surgery. American volume.

[9]  S A Riley,et al.  Exposure of the orthopaedic surgeon to radiation. , 1994, The Journal of bone and joint surgery. American volume.

[10]  P M Rommens,et al.  Radiation exposure to the hands and the thyroid of the surgeon during intramedullary nailing. , 1998, Injury.

[11]  C. Krettek,et al.  Experimental study of distal interlocking of a solid tibial nail: radiation-independent distal aiming device (DAD) versus freehand technique (FHT). , 1998, Journal of orthopaedic trauma.

[12]  D. Pennig,et al.  Intramedullary locked nailing of femur and tibia: insertion of distal locking screws without image intensifier. , 1997, Injury.

[13]  L. Nokes,et al.  Literature review of current techniques for the insertion of distal screws into intramedullary locking nails. , 2006, Injury.

[14]  J Cordey,et al.  AO/ASIF self-tapping screws (STS). , 1993, Injury.

[15]  S. Madan,et al.  Radiation exposure to surgeon and patient in intramedullary nailing of the lower limb. , 2002, Injury.

[16]  C. Court-Brown,et al.  Closed intramedullary tibial nailing. Its use in closed and type I open fractures. , 1990, The Journal of bone and joint surgery. British volume.

[17]  J. Taylor,et al.  Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming. , 1992, The Journal of bone and joint surgery. American volume.

[18]  R. Gustilo,et al.  JSBS classics. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. Retrospective and prospective analyses. , 1976, The Journal of bone and joint surgery. American volume.

[19]  S. Weller.  Internal fixation of fractures by intramedullary nailing. Introduction,historical review and present status. , 1993, Injury.

[20]  C. Krettek,et al.  A mechanical distal aiming device for distal locking in femoral nails. , 1999, Clinical orthopaedics and related research.

[21]  B. Browner,et al.  Radiation exposure to the surgeon during closed interlocking intramedullary nailing. , 1987, The Journal of bone and joint surgery. American volume.

[22]  A. Alegakis,et al.  Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures. , 2006, The Journal of bone and joint surgery. British volume.

[23]  Z. Gugala,et al.  Tibial intramedullary nail distal interlocking screw placement: comparison of the free-hand versus distally-based targeting device techniques. , 2001, Injury.

[24]  S. Kelley,et al.  A Simple Technique for Insertion of Distal Screws into Interlocking Nails , 1995, Journal of orthopaedic trauma.

[25]  J. Watson.  Treatment of unstable fractures of the shaft of the tibia. , 1994, The Journal of bone and joint surgery. American volume.

[26]  C Krettek,et al.  Deformation of femoral nails with intramedullary insertion , 1998, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[27]  W. Obremskey,et al.  Comparison of intramedullary nailing of distal third tibial shaft fractures: before and after traumatologists. , 2004, Orthopedics.

[28]  T D Bunker,et al.  Radiation dosage during AO locking femoral nailing. , 1988, Injury.

[29]  D Pardiwala,et al.  The AO distal locking aiming device: an evaluation of efficacy and learning curve. , 2001, Injury.

[30]  Maurice E. Muller,et al.  The Comprehensive Classification of Fractures of Long Bones , 1990 .

[31]  C Krettek,et al.  A new technique for the distal locking of solid AO unreamed tibial nails. , 1997, Journal of orthopaedic trauma.

[32]  C Krettek,et al.  The deformation of small diameter solid tibial nails with unreamed intramedullary insertion. , 1997, Journal of biomechanics.

[33]  P. Blachut,et al.  Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. , 1997, The Journal of bone and joint surgery. American volume.

[34]  Kalid M Abdlslam,et al.  Experimental model for a new distal locking aiming device for solid intramedullary tibia nails. , 2003, Injury.

[35]  C. Krettek,et al.  A new mechanical aiming device for the placement of distal interlocking screws in femoral nails , 1998, Archives of Orthopaedic and Trauma Surgery.

[36]  I. Hudson.  Locking nailing: an aid to distal targetting. , 1989, Injury.

[37]  S A Riley,et al.  Radiation exposure from fluoroscopy during orthopedic surgical procedures. , 1989, Clinical orthopaedics and related research.

[38]  J. Styf,et al.  Displaced tibial shaft fractures: A prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients , 2000, Acta orthopaedica Scandinavica.