Intramedullary nailing

lectures on intermedullary nail- application of IMN- type of IMN- locking nail- indication of IMN-

1. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo -Egypt
هتاكربو الله ةمحرو مكيلع ملاسلا

2. INTRAMEDULLARY NAILING
biomechanics:
Evolution and challenges
Dr. Bahaa Ali Kornah M.D.
Prof.. Of Orthopedic
Al-Azhar University-Cairo -Egypt
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

3. ObjectivesGOAL
Introduction
Evolution
Classification
Biomechanics
Applications
Special
Circumstances
RecentAdvances
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

4. GOAL OF OPERATIVE FRACTURE FIXATION
❖Full restorationoffunction
❖Faster returnto his preinjurystatus
❖Minimize the riskand incidence of
complications.
❖Predictable alignment of fracturefragments
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5. The purposeofimplants
❖to provide a temporary support
❖to maintain alignment during the
fracture healing
❖to allow for a functional rehabilitation
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6. fractured bone needs
➢ -A certain degree of immobilization (mechanical
stability)
➢ -Optimally preserved blood supply
➢ -Biologic or hormonal stimuliin order tounite.
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Biology and Biomechanics on Fracture
Healing

7. Stability
Request for fx treatment
Biology
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

8. Mechanical
stability,
Elasticfixation
provided by internalor
externalsplinting
of thebone
Absolutestability
rigid fixation thatdoes
not allow any micromotion
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9. High Rate ofHealing
High Rate ofHealing
SpectrumofHealing
Absolute Stability =
1
0 Bone Healing
Biology of BoneHealing
THE SIMPLEVERSION...
Relative Stability =
2
0 Bone Healing
Fibrous Matrix > Cartilage >
Calcified Cartilage > Woven
Bone > Lamellar Bone
Haversian
Remodeling
Minimal
Callus
Callus
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10. FixationStability
Reality
NocallusCallus
Relative
–(Flexible)
–EgIM nailing
-Bridgeplating
Absolute
(Rigid)
–egLag screw/ plate
– Compression
plate
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11. Introduction
Fracturestabilized byoneoftwosystems
Compression
Splinting
Intramedullaryfixation-internal splinting
Splintage -micromotionbetween bone &implant
Relative stability without interfragmentarycompression.
Entry point -distantfromfracture site –hematoma
retained.
Closedreductionandfixation (biological)
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12. IntramedullaryNails
•
•
•
•
•
•
Relative stability
Intramedullary splint
Less likely to breakwith
repetitive loading than
plate
More likely to be load
sharing.
Secondary bone healing
Diaphyseal and some
metaphyseal fractures
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13. •1. bending stability.
•2. axial stability.
•3. translational stability.
•4. rotational stability
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14. IntramedullaryFixation
•Generally utilizes closed/indirect or minimally
open reduction techniques
•Greater preservation of soft tissues as
compared to ORIF
•IM reaming has been shown to stimulate
fracture healing
•Expanded indications i.e. Reamed IM nail is
acceptable in many open fractures
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

15. IntramedullaryFixation
•
•
•
Rotationalandaxial
stabilityprovidedby
interlockingbolts
Reduction can be
technically difficult in
segmental and
comminuted fractures
Difficult to Maintain
reduction of fractures
in close proximity to
metaphyseal flare
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16. Evolution of IMN
1
st
generation
Splints(1˚)
Rotational
stability minimal
Closed fit
Longitudinal slot
along entire length
Eg –K nail , Vnail
2
ndgeneration
•Locking screw -
improved
rotational stability
•Non-slotted.
•Eg-russeltaylornail,
delta nail
3
rdgeneration
•Fit anatomically as
much as possible
•Aid insertionand
stability
•Titanium alloy
•Eg-trigennail, universal
femoral nail nails with
multiple curves
, multiple fixation
systems
•Tibial nail with malleolar
fixation
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17. ClassificationIMN
Entry Portals:
❑Centromedullary
❑Knail,1
st
generation IMN
❑Cephalomedullary
❑Gammanail
❑Russell taylornail
❑PFN
❑Condylocephalicnail
❑Endernail
Direction:
❑Antegrade
❑Retrograde nailing
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18. CentromedullaryNails
First generation
Contained withinmedullary canal
Usually inserted frompiriformis
fossa
Proximal locking bolts -transverse or
oblique in pertrochanter
Requires LT be attached toproximal
fragment for adequate # stabilization
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19. Cephalomedullary
Nails
second generation nails
More efficient load transfer than DHS
Shorter lever arm of IM device
decreases tensile strain on implant-
low risk of implant failure
screws/blade inserted cephaldinto
femoral head and neck.
◼Gamma nail
◼Recon nail
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20. CondylocephalicFixation
Morotenails
Nancynails
Prevotnails
Bundlenails
Elastic stable intramedullary nailing (ESIN) -
primary definitive pediatric fracture care .
3 –point fixation or bundle nailing.
Elastic and small -micro-motion for rapid fracture healing.
Flexible -insertion through a cortical window.
Examples
Lottesnails
Rushpins
Endernails :
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21. Opposite Apex of curvature –at level of fracture
site.
Nail diameter -40% of narrowest
medullary canal diameter
Entry point -opposite to one another
Used without reaming.
Commonest biomechanical error is lack
of internal support.
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22. Schneider nail [ solid, four fluted cross
section and self broaching ends.
Harris condylocephalicnail [curved in two
planes, and designed for percutaneous,
retrograde fixation of extra capsular hip
fractures.
Lottestibial nail specially curved to fittibia,
and has triflangedcross section.
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23. EnderNails
Solid pins with oblique tip and an
eye in flange ator end
Designed for percutaneous, closed
treatment of extra capsular hip
fractures
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24. RushNails
❑Intended for fractures of diaphyseal or
metaphyseal fractures of long bones like
femur, tibia, febula, humerus, radius and
ulna.
❑Pointed tip facilitates easy insertion.
❑Curve at top prevents rotation and
stabilizesfracture.
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25. BundlePinning
C-or S –shaped, act like
spring.
Principle introduced by hackethal.
Many pins are inserted in tobone until
jammed within medullary cavity to provide
compression between nails andbone.
Bendingmovementsneutralized,but
telescopingandrotationaltorsionnot
prevented
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26. ApplicationsIMN
❑Diaphyseal fractures of long bones
❑High proximal and low distal fractures of
long bones
❑Floating hip, floating knee, floating
elbow.
❑Aseptic and septic non-union
❑Osteoporotic long bonefractures
❑Pathologicalfractures
❑Open fractures up to gradeIIIA
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

27. ContraindicationsIMN
Narrow and anomalous medullarycanal
Open growthplates
Prior malunion-prevents nailplacement
History of intramedullaryinfection
Associated ipsilateral femoral neck or acetabular
fracture(relative)
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28. Mechanics (KNail)
Elastic deformation or “elastic
locking” of nail within
medullary canal
Adequate friction of nail in both
fracture fragments
To achieve elastic impingement-
“V” profile or even better “clover-leaf”
design.
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29. ❑Compressible in twodirections
❑Directionsright angles toeach
other
VNail Clover LeafNail
❑Compressible in onlyone
direction
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30. ElasticCompressibilityOfClover –LeafNail
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31. SolidNail
ElasticNail
❑Not occupy full width of
medullary canal
❑Nail with elastic cross section
adjust to constrictions of
medullary canal.
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32. Grosse –Kempfnail Russell –Taylornail Brooker–Willsnail
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33. Biomechanics of deformingforces
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34. D
F =Force Bending moment = F xD
D
PlateIMNail
Bendingmoment forplate
greaterduetoforcebeingapplied
overlargerdistance.
D = distance fromforce
toimplant.
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35. Comparision
•Nail cross section round
•Resisting loads equally in all
directions.
•Platecrosssection
•rectangular resisting greater
loads in one plane versus
the other
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36. Corticalcontact
 -compressive loads
borne bybony cortex
 compressiveloads
transferred to interlocking
screws(“four-point
bending of screws ”)
+
--
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37. Ideal IntramedullaryNail
Strong and stable -maintain alignment and position
Preventrotation -interlocking transfixing screws
Promoteunion -contact-compression forces at fracture
surfaces
Accessible for easy removal
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38. Ideal IntramedullaryNail set
✓thenumberofinstrumentsshouldbekepttoaminimum
simpletouse.
✓minimisethenumberofimplantsnecessaryfora
completesizeinventory.
✓Foragivensizeofimplant,thestrengthshouldbeas
highaspossibletoguardimplantfailure.
✓itisdesirabletomaximisetheflexibilityoftheimplant
✓tofacilitateinsertionwithoutcomninution;
✓totransmitloadtothebonetoprotecttheimplantwhile
minimisingstressprotectionresorbtion.
✓Tostimulatethenaturalfracturehealingmechanismsby
allowingadequateatthefractureinterface.
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

39. PreRequisites
Adequate preoperativeplanning
Patienttolerancetoa major surgicalprocedure
Availabilityofnails of suitable length anddiameter
Suitable instruments, trained assistants, and optimalhospital
conditions
Closed nailingtechniques-wheneverpossible
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40. INDICATIONS
Standard intramedullary nail
Non comminutedmisdshaft
fractures(A).fornon-comminuted
misdhaft
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41. Interlockingfixation
Interlockingindications:
•Comminuted shaft fractures
(B).
•Subtrochantericfractures(C).
•Distalthirdfractures(D).
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

42. Reconstructivefixation
Reconstructive indication:
•Combination fracture of the
shaft and neck (E).
•Intertrochanteric fractures (F).
•Combined intertrochanteric and
subtrochanteric fractures (G).
•Reconstruction following
tumour resection.
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43. Pre OperativePlanning
Biplaner Radiographic
Images
•BoneMorphology
•CanalDimensions
•FracturePersonality
•Comminution
•FractureExtensions
LengthOfNail
•Radiographs of contra
lateral femur (magnified)
•Traction radiographs
(comminuted #)
•Palpable greater
trochanter to lateral
epicondyle
•TMD(tibial tubercle–
medial malleolar
distance) for tibial nail
Diameter OfNail
•Narrowest portion of
femoral canal at femoral
isthmus –lateral
radiograph
•1.0 to 1.5 mm greater in
diameter than anticipated
nail diameter.
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44. NailLength
Preoperativeradiographsoffractured long bone
with proximal and distaljoints
APradiographofopposite normal limb at atube
distance of 1meter
Kuntscher measuring device:
Ossimeter used to measure length andwidth
Magnificationis taken intoaccount
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45. Biomechanics
Stabilitydeterminedby
fracturesite
1.Naildesign
2.Number andorientationoflockingscrews
3.Distanceoflocking screwfrom
4.Reaming or nonreaming
5.Qualityofbone
IM nails assumed to bear most of load initially,
gradually transfer it to bone as fracture heals.
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46. NailDesign
Factorscontributingtobiomechanical profile:
I.Materialproperties
II.Cross-sectionalshape
III.Diameter
IV.Curves
V.Length and workinglength
VI.Ends ofnail
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47. Naildesign
I-Material properties
Titanium alloy and 316l
stainless steel.
Modulus of elasticity
◼Titanium alloy –same
as cortical bone
◼SS –twice as cortical
bone
II-CROSS SECTIONAL
SHAPE
Determines bending
and torsional strengths
Polar moment of inertia
◼Circular nail diameter
◼Square nail edge
length
◼High in nails with sharp
corners or fluted edges
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48. A-schneider
B-diamond
C-sampson fluted
D-kuntscher
E-rush
F-ender
G-mondy
H-halloran
i-huckstep
J-AO/ASIF
K-grosse –kempf
L-russell-taylor
J,k,l-now commonly used
‘intramedullary nails’ cross-sectional designs
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49. III. Naildiameter
Nail diameter affects bending rigidity
❑solid circular nail,
Bending rigidity third power ofnail
diameter (D
3
)
Torsional rigidity fourth power of
diameter (D
4
)
Largediameterwithsamecross-
sectionarebothstifferandstrongerthan
smallerones.
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50. III. Naildiameter
•assessing medullary canal diameter in AP
and LV both site
•pre-operative radiograph by using the
templates provided.
•The canal must be reamed to at least 1 mm to
accept nail less than it
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51. IV. Nailcurves
Long bones have curved medullary cavities
Nails contoured to accommodate curves of bone
Straight, curved or helical
Average radius of curvature of femur -120(±36) cm.
Complete congruency minimizes normal forces and
hence little frictional component to nail’s fixation.
Femoral nail designs have considerably less curve,
with radius ranging from 150 to 300 cm
Imnails -straighter (larger radius) than femoral
canal
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52. Nailcurves
Angle of herzog:
11
o bend in AP direction at junction of upper
1/3
rd
and lower 2/3
rd
of tibia nail
Mismatch in radius of curvature –
Distal anterior cortical perforation
more reaming required during insertion
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53. Hoopstress
Circumferential expansion
stress during nail insertion
Larger hoop stress can splitbone
Hoop stress reduction :
Use flexible nails
Over-ream entry hole by 0.5 to 1 cm
Selection ofideal entry point
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54. Posterior -loss of
proximal fixation
Ideal -posterior portion
of piriformis fossa
Anterior -generates
huge forces, can lead to
bursting of proximal
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55. V. Naillength
A-Totalnaillength-Anatomicallengthtip of the greater
trochanter to the intercondylar notch.
length between proximal and
distal point of firm fixation
to bone
B-working length -
Working length
Affected by various factors
➢Type of force (Bending ,Torsion )
➢Type of fracture
➢Interlocking and dynamization
➢Reaming
➢Weight bearing
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56. V. Naillength
Shorterworking length stronger fixation
Transverse fracture has a shorter working length than
comminuted fracture
Torsional stiffness 1/to l
Bending stiffness 1/to l
2
Surgeon’s techniques to modify “ l ”
Medullary reaming
Interlocking
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57. VI-Extremeends
K-nail
Slot/eye in ends forextraction
One end tapered to facilitate insertion.
❑Holes for interlockingscrews
Some nails have slotsneardistalend
for placement of anti rotationscrew
Anterior slot-
Improved flexibility
Posterior slot -
Increased
bending strength
Non-slotted -
Increased torsional
stiffness and
strength in smaller
sizes
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58. Interlocking ofnail
Recommended for most cases of IM nailing.
Principle:
Resistance to axial and torsional forces depends on screw –bone interface
Length of bone maintained even in bone defect.
Number of interlocks:
 Fracture location
 Amount of fracture comminution
 Fit of nail within canal.
Placing screws in multiple planes -reduction of minor movement
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59. Interlockingscrew
Location of distal locking screws affects
biomechanics of fracture
Distal locking screws
Closer to fracture site-lesscortical
contact -increased stress onlocking
screws
Distal fromfracture site-fracture
becomes more rotationally stable
Interlocking screwspositioned at least2 cm
from fractureprovides sufficientstability
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60. Poller /blockingscrews
Correctsmal-alignment.
Centers IM nail.
Planned and inserted before
IM nail insertion.
Saggitalor coronal plane.
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61. Pollerscrew
•When malalignmentdevelops
during nail insertion,
placement of blocking (Poller
screws) screw, andnail
reinsertion improves
alignment.
•Most reliable in proximal and
distal shaft fractures of tibia.
•A posteriorly placed screw
prevents anterior angulation
and laterally placed screw
prevents valgus angulation.

62. Staticlocking
Screwsplaced proximal anddistaltofracturesite
Restrict translation androtationatfracturesite.
Acts as a “bridgingfixation”
Indications:
Communited
Spiral
Pathologicalfractures
Fractures with boneloss
Atropic nonunion
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63. Dynamiclocking
❑Screws inserted only at one end (short fragment)
❑Unlocked end stabilized by snug fit inside medullary cavity
(long fragment)
❑Prerequisite: at least 50% cortical circumferential contact
❑Indications
❑Fractures with good bone contact
❑Non unions
❑With axial loading , working length in bending and torsion
is reduced -improving nail-bone contact
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64. Dynamisation
❑“Weaken stability”
❑Never done in progressive normal healing
❑Indications
❑Established nonnunion
❑Pseudoarthrosis
❑Caution: premature dynamization adds to
shortening, instability and non-union.
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65. Dynamisation
Primary Dynamisation
Dynamic locking of axially and rotationally stable
fractures at time of initial fracture fixation
Secondary Dynamisation
Removing interlocking screw from longer
fragment / movingproximal interlocking screw
from static to dynamic slot in nail
Done inlong bone delayed union and nonunion
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66. ReamedVersusUnreamed
Endosteal thermo-necrosis & endosteal cortical blood supplydisruption
➢Minimized by using sharp reamers with deep cuttingflutes.
➢Reaming -slow andsmooth.
Endosteal blood supply regeneratesrapidly-high healing rates inreamed
nails.
No difference in infectionrates
No overall difference in time tounion
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67. ReamedVersusUnreamed
❑Reamed nail :
❑High chance of embolization of bone marrow fat to lungs but this phenomenon is
limited & transient
❑Fat extravasation greatest during insertion of nail in medullary cavity
❑Not dependent upon increased intra medullary pressure
Reamed nailing generally report no statistical difference in pulmonary
complications as compared tounreamednailing
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68. Open intramedullarynailing(OIN)
Primary indication :
Failure to do closed nailing
Nonunions
Fractures requiring intramedullary
existing fixation in internal fixation
device.
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69. Advantages(OIN):
Lessexpensiveequipmentrequiredthanfor closednailing.
No specialfracturetable/ preliminarytraction
Absolute anatomicalreduction
Directobservationofbone-undisplaced/ undetected
comminution
Improvedrotationalalignment andstability.
Preventstorquing and twisting in segmentalfractures
In nonunions,openingofmedullarycanalsofsclerotic bone is
easier.
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70. DISADVANTAGES(OIN):
❑Skinscars
❑Fracture hematomaevacuated.
❑Bone shavings createdbyreamingmedullary canal often arelost.
❑Infectionrateincreased.
❑Rateofuniondecreased.
❑If a locking nail is used, locking is difficult without image
intensification
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71. Nailing in openfractures
If initial debridement adequate and timely , definitive stabilization with
reamed intramedullary nailing
with severe soft tissue injuries that require a second debridement,
temporary external fixationreasonable
increased risk of infection after use of external fixation pins longer than 2
weeks followed by reamed intramedullary nailing.
Rapid initial management approach allows delayed conversion to a
medullary implant at 5 to 10 days.
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72. Nailing in openfractures
❖Fractures with delay in initial debridement of more than
8 hours -staged nailing.
❖Acceptable complication rate (11 % infection rate in
type iii open fractures)
❖No relationship between infection rate, non union with
timing of nailing or associated soft tissue injury
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73. Aseptic nonunions
Without bone defects-primary imnailing or exchange
Nailing if well aligned
With bone defects -IM nailing with bone grafting
corticocancellousgraft material -harvested with
ria(little donor morbidity)
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74. Exchangenailing
➢Biological effects:
Reaming of medullary canal –promotesunion
➢Mechanical effects:
Larger-diameter intramedullary nail –improved
stability
❖Exchagenail –at least 1mm
larger than previous nail
❖Canal reaming until osseous tissue
observed in reaming flutes
Removal of current
intramedullary nail
Reaming of medullary
canal
Placement of an larger
intramedullary nail
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75. Septic nonunion
Main aim -eradicatinginfection
Osseous stability important in managementofinfectednonunion
Stabilization with antibiotic impregnated cement coated nail after
serial debridement.
Cementnail elute high concentration of antibiotic in local sites for
up to 36weeks.
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

76. Antibiotic impregnated cementnail
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

77. 40gms of bone cement is
taken and mixed with 2 to 4
gms of powder when dough is
semi solid.
It is wrapped around K nail
of size 6 to 7 mm and rolled
between two palms.The rod
is then passed through the
holes of the nail major
usually 8 to 9mm diameter
to maintain uniformity of
diameter.

78. In polytrauma , early femoral stabilization decreasesincidence of
severe fat embolism and pulmonary complications (ARDS).
Nailing with reaming will not increasepulmonary complications
Early intramedullary nailing may be deleterious and is associated
with elevation of certain proinflammatory markers -(il)-6.
Early external fixation of long bone fractures followed by delayed
intramedullary nailing –high risk patients.
Nailing in damage control orthopaedics (DCO)
/ early total care (ETC)
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

79. ❑50% (↓)in mortality patients who underwent femoral shaft
fracture stabilization beyond 12 hours
This timing was hypothesized to allow for adequate
resuscitation
Exact and optimal timing of femoral shaft fracture nailing
remains unclear in polytrauma(esp. Chest injuries)
Nailing in damage control orthopaedics
(DCO)/early total care (ETC)
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

80. Removal
Timingcontroversial
Indications:
Patient request(afterunion)
Pain, swelling secondary to backingoutofimplant.
Infectednailing
Fullweightbearingimmediatelyafterremoval
Femoralnailremoved after 24-36 months ,
Tibialnail18-24months
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

81. Failure IMN
❑When fracture healing is delayed or nonunion occurs.
IM nails usually fail in predictable patterns.
Unlocked nails
◼failatfracture site or through a screw hole or slot.
Locked nails
◼screw breakage or fracturing of nail at locking hole
sites(proximal hole of distal interlocks )
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

82. Recentadvances
Biodegradable polymers
Nickel-titanium shape-modifiable alloys
can improve stability as they change shape after
insertion and recover curvature as they warm.
IM nails coated with bmp
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

83. Conclusion
➢IMN -Implant of choice in diaphyseal
fractures
➢Multiple factors determine final construct
stiffness, should be understood and
considered when choosingIM nail
➢Ideal intramedullary nail is yet to be invented
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

84. 1
•.CAMPBELL OPERATIVE ORTHOPAEDICS 11
TH EDITION
2.The science and practice of Intramedullary Nailing –Bruce D. Brown
3.ROCKWOOD AND GREENS
4.INTERLOCKING NAILING-DD.TANNA
5.The elements of fracture fixation –Anand J Thakur
6.Prospective study of distal end radius fracture by an
intramedullary nailing JBJS aug3 2011
Bibliography

85. Bahaa Ali Kornah
[email protected]
د/ةنرق ءاهب
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT