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Complications of Intramedullary Nailing

  • Marschall B. Berkes
  • Milton T. M. Little
  • Dean G. Lorich
Chapter

Abstract

Intramedullary nailing offers a safe and reliable means of osteosynthesis. Complications encountered when performing intramedullary fixation are malalignment, infection, hardware failure, impaired bony healing and neurovascular injuries. Primary malalignment is largely a consequence of either an inappropriate entry point or fracture site malreduction. Secondary malalignment refers to a change in fracture reduction and alignment at some point during the postoperative period. Hardware failure is seen when the implant sustains more load than intended, either due to early excessive weight bearing or prolonged cyclical loading, as in a non-united fracture. Infection can result in secondary operations, increased risk of secondary complications, delayed/nonunion and worse clinical outcome for the patient.

Keywords

Primary and secondary malalignment Hardware failure Infection Delayed union Nonunion Neurovascular Complications Impaired bone healing Malrotation Entry point Varus Valgus 

References

  1. 1.
    McKellop HA, Sigholm G, Redfern FC, Doyle B, Sarmiento A, Luck JVS. The effect of simulated fracture-angulations of the tibia on cartilage pressures in the knee joint. J Bone Joint Surg Am. 1991;73(9):1382–91.PubMedGoogle Scholar
  2. 2.
    Puno RM, Vaughan JJ, Stetten ML, Johnson JR. Long-term effects of tibial angular malunion on the knee and ankle joints. J Orthop Trauma. 1991;5(3):247–54.PubMedCrossRefGoogle Scholar
  3. 3.
    Milner SA, Davis TR, Muir KR, Greenwood DC, Doherty M. Long-term outcome after tibial shaft fracture: is malunion important? J Bone Joint Surg Am. 2002;84-A(6):971–80.PubMedGoogle Scholar
  4. 4.
    van der Schoot DK, Den Outer AJ, Bode PJ, Obermann WR, van Vugt AB. Degenerative changes at the knee and ankle related to malunion of tibial fractures. 15-year follow-up of 88 patients. J Bone Joint Surg Br. 1996;78(5):722–5.PubMedGoogle Scholar
  5. 5.
    Attal R, Hansen M, Kirjavainen M, Bail H, Hammer TO, Rosenberger R, et al. A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN). Arch Orthop Trauma Surg. 2012;132(7):975–84.PubMedCrossRefGoogle Scholar
  6. 6.
    Josten C, Marquass B, Schwarz C, Verheyden A. Intramedullary nailing of proximal tibial fractures. Complications and risk factors. Unfallchirurg. 2010;113(1):21–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res. 1995;(315):64–74.Google Scholar
  8. 8.
    Ricci WM, Bellabarba C, Lewis R, Evanoff B, Herscovici D, Dipasquale T, et al. Angular malalignment after intramedullary nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(2):90–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009;17(5):296–305.PubMedGoogle Scholar
  10. 10.
    Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma. 2001;15(4):264–70.PubMedCrossRefGoogle Scholar
  11. 11.
    Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures. J Orthop Trauma. 2011;25(12):736–41.PubMedCrossRefGoogle Scholar
  12. 12.
    Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995;(315):25–33.Google Scholar
  13. 13.
    Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma. 2005;19(10):681–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Carmack DB, Moed BR, Kingston C, Zmurko M, Watson JT, Richardson M. Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study. J Trauma. 2003;55(4):692–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Krupp RJ, Malkani AL, Goodin RA, Voor MJ. Optimal entry point for retrograde femoral nailing. J Orthop Trauma. 2003;17(2):100–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Lembcke O, Ruter A, Beck A. The nail-insertion point in unreamed tibial nailing and its influence on the axial malalignment in proximal tibial fractures. Arch Orthop Trauma Surg. 2001;121(4):197–200.PubMedCrossRefGoogle Scholar
  17. 17.
    Jaarsma RL, Pakvis DF, Verdonschot N, Biert J, van Kampen A. Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma. 2004;18(7):403–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Strecker W, Suger G, Kinzl L. Local complications of intramedullary nailing. Orthopade. 1996;25(3):274–91.PubMedGoogle Scholar
  19. 19.
    Ricci WM, Schwappach J, Tucker M, Coupe K, Brandt A, Sanders R, et al. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 2006;20(10):663–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Puloski S, Romano C, Buckley R, Powell J. Rotational malalignment of the tibia following reamed intramedullary nail fixation. J Orthop Trauma. 2004;18(7):397–402.PubMedCrossRefGoogle Scholar
  21. 21.
    Kahn KM, Beals RK. Malrotation after locked intramedullary tibial nailing: three case reports and review of the literature. J Trauma. 2002;53(3):549–52.PubMedCrossRefGoogle Scholar
  22. 22.
    Krettek C, Miclau T, Schandelmaier P, Stephan C, Mohlmann U, Tscherne H. The mechanical effect of blocking screws (“Poller screws”) in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma. 1999;13(8):550–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Krettek C, Stephan C, Schandelmaier P, Richter M, Pape HC, Miclau T. The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails. J Bone Joint Surg Br. 1999;81(6):963–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, et al. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma. 2006;20(8):523–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Krettek C, Miclau T, Grun O, Schandelmaier P, Tscherne H. Intraoperative control of axes, rotation and length in femoral and tibial fractures. Technical note. Injury. 1998;29 Suppl 3:C29–39.PubMedCrossRefGoogle Scholar
  26. 26.
    Brumback RJ, Reilly JP, Poka A, Lakatos RP, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part I: decision-making errors with interlocking fixation. J Bone Joint Surg Am. 1988;70(10):1441–52.PubMedGoogle Scholar
  27. 27.
    Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part II: fracture-healing with static interlocking fixation. J Bone Joint Surg Am. 1988;70(10):1453–62.PubMedGoogle Scholar
  28. 28.
    Brumback RJ, Toal Jr TR, Murphy-Zane MS, Novak VP, Belkoff SM. Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail. J Bone Joint Surg Am. 1999;81(11):1538–44.PubMedGoogle Scholar
  29. 29.
    Brumback RJ. The rationales of interlocking nailing of the femur, tibia, and humerus. Clin Orthop Relat Res. 1996;(324):292–320.Google Scholar
  30. 30.
    Kneifel T, Buckley R. A comparison of one versus two distal locking screws in tibial fractures treated with unreamed tibial nails: a prospective randomized clinical trial. Injury. 1996;27(4):271–3.PubMedCrossRefGoogle Scholar
  31. 31.
    Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators, Bhandari M, Guyatt G, Tornetta 3rd P, Schemitsch EH, Swiontkowski M, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008;90(12):2567–78.PubMedCrossRefGoogle Scholar
  32. 32.
    Arazi M, Ogun TC, Oktar MN, Memik R, Kutlu A. Early weight-bearing after statically locked reamed intramedullary nailing of comminuted femoral fractures: is it a safe procedure? J Trauma. 2001;50(4):711–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Griffin LV, Harris RM, Zubak JJ. Fatigue strength of common tibial intramedullary nail distal locking screws. J Orthop Surg Res. 2009;4:11.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Erez O, Dougherty PJ. Early complications associated with cephalomedullary nail for intertrochanteric hip fractures. J Trauma Acute Care Surg. 2012;72(2):E101–5.PubMedGoogle Scholar
  35. 35.
    Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev. 2012;(1):CD008241.Google Scholar
  36. 36.
    Freeman AL, Craig MR, Schmidt AH. Biomechanical comparison of tibial nail stability in a proximal third fracture: do screw quantity and locked, interlocking screws make a difference? J Orthop Trauma. 2011;25(6):333–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Lenz M, Gueorguiev B, Richards RG, Muckley T, Hofmann GO, Hontzsch D, et al. Fatigue performance of angle-stable tibial nail interlocking screws. Int Orthop. 2013;37:113–8.PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Maes M, Deboer Y, Brabants K. Failure of the titanium trochanteric gamma nail in ununited metastatic fractures. Acta Orthop Belg. 2012;78(4):552–7.PubMedGoogle Scholar
  39. 39.
    Gaebler C, Berger U, Schandelmaier P, Greitbauer M, Schauwecker HH, Applegate B, et al. Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases. J Orthop Trauma. 2001;15(6):415–23.PubMedCrossRefGoogle Scholar
  40. 40.
    Young S, Lie SA, Hallan G, Zirkle LG, Engesaeter LB, Havelin LI. Risk factors for infection after 46,113 intramedullary nail operations in low- and middle-income countries. World J Surg. 2013;37:349–55.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6):781–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Malik MH, Harwood P, Diggle P, Khan SA. Factors affecting rates of infection and nonunion in intramedullary nailing. J Bone Joint Surg Br. 2004;86(4):556–60.PubMedGoogle Scholar
  43. 43.
    Yokoyama K, Uchino M, Nakamura K, Ohtsuka H, Suzuki T, Boku T, et al. Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures. Injury. 2006;37(6):554–60.PubMedCrossRefGoogle Scholar
  44. 44.
    Tornqvist H. Tibia nonunions treated by interlocked nailing: increased risk of infection after previous external fixation. J Orthop Trauma. 1990;4(2):109–14.PubMedCrossRefGoogle Scholar
  45. 45.
    Harwood PJ, Giannoudis PV, Probst C, Krettek C, Pape HC. The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma. 2006;20(3):181–9.PubMedGoogle Scholar
  46. 46.
    Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA, Bosse M, et al. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am. 2010;92(4):823–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg. 2005;13(6):417–27.PubMedGoogle Scholar
  48. 48.
    Henry SL, Ostermann PA, Seligson D. The prophylactic use of antibiotic impregnated beads in open fractures. J Trauma. 1990;30(10):1231–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma. 2007;21(4):258–68.PubMedCrossRefGoogle Scholar
  50. 50.
    Thonse R, Conway JD. Antibiotic cement-coated nails for the treatment of infected nonunions and segmental bone defects. J Bone Joint Surg Am. 2008;90 Suppl 4:163–74.PubMedCrossRefGoogle Scholar
  51. 51.
    Griffin XL, Costa ML, Parsons N, Smith N. Electromagnetic field stimulation for treating delayed union or non-union of long bone fractures in adults. Cochrane Database Syst Rev. 2011;(4):CD008471.Google Scholar
  52. 52.
    Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(3):161–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Winquist RA, Hansen Jr ST, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. 1984. J Bone Joint Surg Am. 2001;83-A(12):1912.PubMedGoogle Scholar
  54. 54.
    Lam SW, Teraa M, Leenen LP, van der Heijden GJ. Systematic review shows lowered risk of nonunion after reamed nailing in patients with closed tibial shaft fractures. Injury. 2010;41(7):671–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Rommens PM, Kuechle R, Bord T, Lewens T, Engelmann R, Blum J. Humeral nailing revisited. Injury. 2008;39(12):1319–28.PubMedCrossRefGoogle Scholar
  56. 56.
    Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14(3):162–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg. 2013;22:387–95.PubMedCrossRefGoogle Scholar
  58. 58.
    Hak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma. 2000;14(3):178–82.PubMedCrossRefGoogle Scholar
  59. 59.
    Gonschorek O, Hofmann GO, Buhren V. Interlocking compression nailing: a report on 402 applications. Arch Orthop Trauma Surg. 1998;117(8):430–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Brinker MR, O’Connor DP, Monla YT, Earthman TP. Metabolic and endocrine abnormalities in patients with nonunions. J Orthop Trauma. 2007;21(8):557–70.PubMedCrossRefGoogle Scholar
  61. 61.
    Klemm K, Schellmann WD. Dynamic and static locking of the intramedullary nail. Monatsschr Unfallheilkd Versicher Versorg Verkehrsmed. 1972;75(12):568–75.PubMedGoogle Scholar
  62. 62.
    Wu CC. The effect of dynamization on slowing the healing of femur shaft fractures after interlocking nailing. J Trauma. 1997;43(2):263–7.PubMedCrossRefGoogle Scholar
  63. 63.
    Wu CC, Shih CH. Effect of dynamization of a static interlocking nail on fracture healing. Can J Surg. 1993;36(4):302–6.PubMedGoogle Scholar
  64. 64.
    Dagrenat D, Moncade N, Cordey J, Rahn BA, Kempf I, Perren SM. Effects of the dynamization of static bolt nailing. In vivo experimentation. Rev Chir Orthop Reparatrice Appar Mot. 1988;74 Suppl 2:100–4.PubMedGoogle Scholar
  65. 65.
    Shroeder JE, Mosheiff R, Khoury A, Liebergall M, Weil YA. The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions. J Orthop Trauma. 2009;23(9):653–7.PubMedCrossRefGoogle Scholar
  66. 66.
    Weresh MJ, Hakanson R, Stover MD, Sims SH, Kellam JF, Bosse MJ. Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma. 2000;14(5):335–8.PubMedCrossRefGoogle Scholar
  67. 67.
    Riina J, Tornetta P, Ritter C, Geller J. Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails. J Orthop Trauma. 1998;12(6):379–81.PubMedCrossRefGoogle Scholar
  68. 68.
    Coupe KJ, Beaver RL. Arterial injury during retrograde femoral nailing: a case report of injury to a branch of the profunda femoris artery. J Orthop Trauma. 2001;15(2):140–3.PubMedCrossRefGoogle Scholar
  69. 69.
    Rajaesparan K, Amin A, Arora S, Walton NP. Pseudoaneurysm of a branch of the profunda femoris artery following distal locking of an intramedullary hip nail: an unusual anatomical location. Hip Int. 2008;18(3):231–5.PubMedGoogle Scholar
  70. 70.
    Grimaldi M, Courvoisier A, Tonetti J, Vouaillat H, Merloz P. Superficial femoral artery injury resulting from intertrochanteric hip fracture fixation by a locked intramedullary nail. Orthop Traumatol Surg Res. 2009;95(5):380–2.PubMedCrossRefGoogle Scholar
  71. 71.
    Fernandez FF, Matschke S, Hulsenbeck A, Egenolf M, Wentzensen A. Five years’ clinical experience with the unreamed humeral nail in the treatment of humeral shaft fractures. Injury. 2004;35(3):264–71.PubMedCrossRefGoogle Scholar
  72. 72.
    Noger M, Berli MC, Fasel JH, Hoffmeyer PJ. The risk of injury to neurovascular structures from distal locking screws of the Unreamed Humeral Nail (UHN): a cadaveric study. Injury. 2007;38(8):954–7.PubMedCrossRefGoogle Scholar
  73. 73.
    Prince EJ, Breien KM, Fehringer EV, Mormino MA. The relationship of proximal locking screws to the axillary nerve during antegrade humeral nail insertion of four commercially available implants. J Orthop Trauma. 2004;18(9):585–8.PubMedCrossRefGoogle Scholar
  74. 74.
    Hussain W, Balach T, Leland JM. Vascular injury involving proximal medial-to-lateral oblique locking screw insertion in tibial intramedullary nailing. Acta Orthop Belg. 2011;77(3):414–8.PubMedGoogle Scholar
  75. 75.
    Shuler FD, Busam M, Beimesch CF, Block JJ. Retrograde femoral nailing: computed tomography angiogram demonstrates no relative safe zone for prevention of small diameter arterial vascular injury during proximal anteroposterior interlocking. J Trauma. 2010;69(5):E42–5.PubMedCrossRefGoogle Scholar
  76. 76.
    Rupp RE, Chrissos MG, Ebraheim NA. The risk of neurovascular injury with distal locking screws of humeral intramedullary nails. Orthopedics. 1996;19(7):593–5.PubMedGoogle Scholar
  77. 77.
    Mills WJ, Chapman JR, Robinson LR, Slimp JC. Somatosensory evoked potential monitoring during closed humeral nailing: a preliminary report. J Orthop Trauma. 2000;14(3):167–70.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Marschall B. Berkes
    • 1
  • Milton T. M. Little
    • 1
  • Dean G. Lorich
    • 2
  1. 1.Orthopaedic Trauma ServiceHospital for Special SurgeryNew YorkUSA
  2. 2.Orthopaedic Trauma ServiceHospital for Special Surgery, New York Presbyterian Hospital/Weill Cornell Medical CollegeNew YorkUSA

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