Elsevier

Injury

Volume 39, Issue 2, February 2008, Pages 170-175
Injury

Targeting device for intramedullary nails: A new high-stable mechanical guide

https://doi.org/10.1016/j.injury.2007.06.006Get rights and content

Summary

One of the most demanding steps of an intramedullary nailing is the distal locking. The aim of this study is to evaluate clinically and prospectively a new targeting guide. Twenty-five patients were treated consecutively in two different trauma centres (level one and one general hospital) by two different surgeons who were instructed on using the new device. Reduction of the fracture, intramedullary nailing and proximal locking are performed according to standard procedures. Then the new targeting device is used for distal locking.

Evaluations are focused on the time it takes to perform the distal locking, the duration of the irradiation exposure and the duration of the complete procedure. In terms of duration, our results are comparable to those reported in the literature but this new device has more advantages than any other system. This new device is fully mechanical and is solidly linked to the patient. It can be used with any existing radioscopic equipment in any hospital. The guide is manually adjustable out of the X-ray field avoiding the surgeon being irradiated. The procedure is easy to learn and reproducible.

Introduction

Closed intramedullary nailing has shown its efficacy in the treatment of diaphyseal fractures of long bones.6, 22 The most demanding step of the operation is the insertion of the distal locking screws. Great efforts have been made over the years to find a satisfactory solution for this problem. Many publications provide tricks, technical notes and personal solutions.1, 3, 4, 5, 8, 9, 11, 13, 15, 17, 23, 24, 25, 26, 30, 34, 37, 38, 40, 46, 48, 50

In accordance with Whatling and Nokes,47 we can divide the different techniques into four main groups.

The freehand technique is probably the most popular technique. It seems to be easy to set-up. However, the main disadvantages of freehand techniques are prolonged exposure to radiation and results that depend mostly on the dexterity of the surgeon.27, 28, 39, 43 To perform the targeting, the image intensifier is aligned with the distal nail holes and successively moved until obtaining a perfect circle on the image. An incision is made through the skin and fascia down to the cortex. A sharp trocar or a sharp drill26 with a radiolucent handle is aligned on the cortex with the centre of the circle. The trocar is used to penetrate the lateral cortex and the hole is drilled. The drilling is followed by the insertion of the screw. The same process is repeated for the other distal holes. Knudsen et al.17 use a Kirschner wire to open the cortex. MacMillian and Gross24 describe a method using a 2 mm Steinmann pin. Owen and Coorsh30 improve the procedure by using cannulated drill passing on the guide wire. Pennig et al.33 developed an instrument consisting of a handle with a radiolucent cylinder at one end. The cylinder contains a metal ring at each end. The position of the nail hole is determined as the standard technique by the image intensifier. The circles of the handle are then superimposed on each other before the pin or the drill is driven trough the cortex. Hashemi-Nejad et al.11 propose a jig that aligns the second hole after the first has been obtained by the free hand technique.

Kempf et al.16 describe a device attached to the X-ray tube. The device resembles a fork containing a guide sleeve. Manipulation on the C-arm aligns the hole with the distal nail hole.

A laser guidance system was proposed by Goulet et al.9 A laser light is mounted on the tube of the image intensifier indicating the direction and the angle of the drilling.

These devices are generally unstable and of little use.

Krettek et al.18 propose a mechanical, radiation-independent distal aiming device based on morphometric analysis.19 The system uses a channel to allow the location of the distal holes following nail deformation and needs a contact with the anterior cortex. Gugala et al.10 report a study using a similar device. They demonstrate that such a device decreases the mean fluoroscopy time when compared with the freehand technique.

An H-shaped device, described by Steriopoulos et al.,42 improves distal locking by holding two similar intramedullary nails parallel to one another. The device reduces the use of the image intensifier. Azer et al.2 report a clinical experience with an externally self-guiding device. The image intensifier is used only at the end of the procedure for confirmation. Tyropoulos and Garnavos46 used a targeting device fixed to the patient. It offers an excellent stability and reduces the irradiation needed.

Surgical navigation provides spatial information and real time interactive targeting as proposed by Slomczykowski et al.41 The system uses a C-arm, optoelectronic position sensors, steriotactic tools and computer software. The accuracy of the method is demonstrated. However, the system is complex, expensive and time consuming.

Section snippets

Description of the new device and technique

The aim of this study is to evaluate clinically and prospectively a new targeting guide for distal locking of intramedullary nails. This new device belongs to the mechanical targeting device group. It is mounted not only on the handle but also on the traction table improving stability. The system requires an image intensifier. This study was accepted by our university ethical committee.

The new device is a mechanical system with two fixed points. One fixation point is at the handle of the nail

Materiel and method

Between July 2002 and September 2004, eight women and 17 men with a mean age of 47 years were treated. There were 11 tibia fractures and 14 femur fractures. Two different surgeons participated in this study.

This evaluation is focused on the time it takes to perform the distal locking and on the irradiation exposure time. The duration of the complete procedure is also recorded.

All the fractures were reduced on the traction table. Two lateral screws were used for the distal locking.

The duration

Results

The mean duration time for the complete procedure for the femoral fractures is 154 min (80–270 min) and 89 min (65–200 min) for the tibial fractures. The mean duration time for the targeting is 31 min for the femur (20–60 min) and 24 min for the tibia (20–30 min). These results as well as the mean irradiation exposure time are reported in Table 1.

All but one of the screws were perfectly inserted. This failure was due to the breaking of the handle fixation point of the targeting device.

Discussion

In comparison with other techniques needing fluoroscopy, this new targeting device gave similar results in comparison to other mechanical gives techniques.5, 47, 50 Our system has the advantage of being fully mechanical. It is solidly linked to the patient both by the nail and the traction table and is absolutely stable. It is mechanically independent from the radioscopic equipment and can be used with any existing radioscopic equipment in any hospital. Furthermore, the system requires no

Conclusion

This new targeting device is certainly not to be compared to any kind of surgical computer-assisted navigation in terms of rapidity. It can be compared with any system in terms of efficiency and financial considerations. This study validates the device and its operation procedure. Only a short time is necessary to learn the new distal locking technique. The time to perform the distal locking is comparable to other mechanical techniques. Nevertheless, comparison with the freehand technique could

Conflict of interest

The authors disclose any financial and personal relationships with other people or organisations that could influence this work.

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