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Objectives: The halo ring can be applied in children, through skeletal traction or a halo vest device, to treat many cervical spine pathologies, including traumatic injuries and pathologies related to deformities. However, the procedure is associated with various complications, such as infection, pin loosening, and respiratory and neurological problems. Although widely studied in adults, the best pin insertion site in children and the correlations of pin insertion sites with outcomes and complications have not been completely elucidated. This study aimed to determine alternative pin placement sites based on a morphological analysis of the infant skull by computerized tomography (CT)., Methods: An analytical-descriptive study was performed using 50 CT scans from children. The Wilcoxon and Friedman tests were used., Results: A linear and directly proportional relation was found between cranial thickness and patient age. The average thicknesses of the anterior points across all ages analyzed ranged from 4.16 mm to 4.98 mm. The thicknesses of the posterior points varied from 3.94 mm to 4.27 mm. Within each age range, points 1 cm above the standard insertion sites had thicknesses similar to those of the standard sites, and points 2 cm above the standard insertion sites had thicknesses greater than those of the standard sites., Conclusions: The cranial thickness at all points increases linearly with age. Points 1 and 2 cm above the standard insertion sites are viable alternatives for the placement of halo pins. Preoperative CT can aid in choosing the best positioning sites for pins in the skull.

Objective: Iliac crest autograft remains the gold standard for spinal fusion operations. Given risk of donor site morbidity, many centers utilize allograft. We reviewed published series of C1-2 posterolateral instrumented fusions with allograft and autograft., Methods: Online databases were searched for English-language articles reporting quantifiable outcome data published between 1994 and 2011 of posterior atlantoaxial instrumented arthrodesis with C1 and C2 screws. Thirteen studies describing 652 patients having autograft and seven studies describing 60 patients having allograft serve as the basis of this report., Results: All studies were retrospective case series (Class III evidence). There were no differences in complications or mortality between the groups. There were trends toward shorter operative times and less blood loss using allograft. A higher proportion of patients in the allograft group underwent sacrifice of the C2 nerve root and decortication and packing of the C1-2 joints (P<0.0001). There was no significant difference in the proportion of surviving patients who achieved solid fusion in the autograft (642 of 644 [99.7%]) and allograft patients (59 of 59 [100%]; P = 1.0)., Conclusions: This review is limited by the retrospective data and inconsistent methodology of fusion determination used in most studies. Modern instrumentation and proper surgical techniques result in high rates of successful C1-2 arthrodesis. The use of allograft is a treatment option (Class III evidence) during posterior C1-2 instrumentation and fusion operations. Randomized, controlled trials using standardized radiographic assessments are needed across spinal arthrodesis studies to better determine the prevalence of radiographic fusion and establish technique superiority., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Recently, results from the large, randomized study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT) trial suggested a benefit for reamed intramedullary nail insertion in patients with closed tibial shaft fractures largely based on cost-neutral autodynamizations and a potential advantage for unreamed intramedullary nailing in open fractures. We performed an economic evaluation to compare resource use and effectiveness of reamed and unreamed intramedullary nailing using a cost-utility analysis., Methods: We calculated quality-adjusted life years (QALYs) for each patient from a self-administered health utility index 3 questionnaire for the first 12 months following the intramedullary nailing. A convenience sample of 235 SPRINT patients provided data on costs associated with health care resource utilization. All costs are reported in Canadian dollars for the 2008 financial year., Results: We found incremental effects of -0.017 (95% confidence interval [CI] -0.021-0.058) and -0.002 (95% CI -0.060-0.062) QALYs for patients treated with reamed compared with unreamed intramedullary nails in closed and open fractures, respectively. The incremental costs for reamed compared with unreamed intramedullary nailing were $51 Canadian dollars (95% CI -$2298-$2400) in closed tibial fractures and $2546 Canadian dollars (95%CI -$1773-$6864) in open tibial fractures. Unreamed nailing dominated reamed nailing for both closed and open tibial fractures; however, the cost and the utility results had high variability., Conclusion: Our economic analysis from a governmental perspective suggests small differences in both cost and effectiveness with large uncertainty between reamed and unreamed intramedullary nailing., (Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

The treatment of unstable trochanteric femoral fractures is still challenging. The ideal implant should be easy to handle, allow for immediate full weight-bearing postoperatively and should have sufficient purchase in the femoral head/neck-fragment to limit cut-outs due to varus-deviation and rotation. The proximal femoral nail antirotation (PFNA), designed by AO, is an intramedullary device with a helical blade rather than a screw for better purchase in the femoral head and was tested in a clinical study. Consecutive patients with unstable trochanteric fractures (AO-classification 31.A.2 and A.3 only) were included and followed for 1 year. Primary objectives were assessment of operative and postoperative complications, whereas secondary objectives included surgical details, general complications and final outcome measurements. In 11 European clinics, 315 patients were included and treated with a PFNA. Almost all fractures healed within 6 months. Fifty-six percent of the patients regained the pre-trauma mobility and 18% died within the follow-up period. Forty-six implant-related complications--leading to 28 unplanned re-operations--were recorded, with four acetabular penetrations (three of which were after a new fall on that hip) and seven ipsilateral femoral shaft fractures as the most serious ones. As the joint-penetrations did not resemble the cut-out seen with other implants it is concluded that the PFNA--due to its helical blade--possibly limits the effects of early rotation of the head/neck-fragment in unstable trochanteric fractures and therefore seems currently to be the optimal implant for the treatment of these fractures especially in osteoporotic bone.

Introduction: Intramedullary nailing has long been used successfully in the treatment of aseptic nonunions of the femur and tibia. However, recently the efficacy of reamed intramedullary nailing in the treatment of nonunions of the femur has been questioned by some publications reporting unfavourable results. The purpose of this study is to evaluate the treatment results of femoral and tibial diaphyseal nonunions with intramedullary nailing., Patients and Methods: We retrospectively reviewed thirty-two patients with femoral or tibial diaphyseal nonunions who were treated with reamed intramedullary nailing between May 2002 and April 2006. Fixation status at the time of treatment were nail in twenty-eight patients (12 femurs, 16 tibiae), plate in three cases (2 femurs, 1 tibia), no implant in one femur. We used a dynamically locked, reamed intramedullary nailing. Only in bone defects greater than 50% of the cortical diameter and more than 2 cm in length was open bone grafting performed., Results: Solid union was achieved in 93% (fourteen of fifteen) of femoral nonunions and 94% (sixteen of seventeen) of tibial nonunions., Conclusions: Our protocol with a dynamically locked, reamed nailing with the use of an oval hole and no open bone grafting for a defect less than 50% of the diameter and immediate weight bearing was successful in the treatment of femoral and tibial diaphyseal nonunions.

Objective: To evaluate and present our current clinical experience in the treatment of closed and open tibial shaft fractures using the expandable intramedullary nailing system., Design: Prospective study., Setting: One level-1 trauma centre., Participants: Twenty-six patients with acute tibial shaft fractures with at least 10 cm of intact cortex on both sides of the fracture., Intervention: Internal fixation using the Fixion expandable intramedullary nail (Disc-O-Tech Medical Technologies Ltd., Herzliya, Israel)., Main Outcome Measurements: Operative and fluoroscopy time, healing time and perioperative complications were recorded., Results: Twenty-six tibial fractures were treated (OTA classification: 3 type A1, 8 A2, 8 A3, 3 B1, 3 B2, and 1 B3), six of which were open. All fractures healed by week 18.5 with an mean of 12.8+/-3.8 weeks. The operating time ranged from 20 to 50 min with an mean of 40+/-12.17 min. The fluoroscopy time ranged from 6 to 22s with a mean of 10+/-5s. In one case the nail failed to expand, as detected by X-ray control, and had to be exchanged intraoperatively. Two patients reported anterior knee pain during the follow up, but did not wish any further treatment. In a low demanding patient rotational malalignment was noted and no further action needed., Conclusion: According to the results of this study, the use of the Fixion nailing system, where indicated, is associated with minimal complications and very good functional outcomes in fractures OTA types A and B. The advantages of the expandable nail include the decrease in the operating and fluoroscopy time and the simplicity of its application.

We evaluated the performance of the Targon PF nailing system in the treatment of complex proximal femoral fractures with a retrospective analysis of prospectively collected data for 94 patients with a complex proximal femoral fracture (subtrochanteric fracture or fracture with reversed fracture line pattern) treated with a Targon PF nail. There were no intra-operative femoral fractures. Late complications requiring reoperation were one femoral fracture and one fracture around the nail secondary to tumour. Seven nails had to be dynamised and a further six 'self-dynamised' at the site of the distal locking screw. One patient required revision of the distal locking. Only one other patient required secondary surgery for a wound haematoma. There were no cases of implant cut-out or non-union. The Targon PF nail represents a progressive development in the design of intramedullary nails for proximal femoral fractures and the results compare favourably with other intramedullary systems used to treat complex proximal femoral fractures.

We present the clinical and radiographic results of a prospective study with the Orthofix tibial nailing system. The ease and safety of distal locking with the use of an improved targeting system was also evaluated. Sixty fresh tibial fractures in 60 patients with a mean age of 37.3 years (range 17-73 years) were treated. Eighteen of the fractures were grade I open fractures. All operations were performed in a conventional operating theatre on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site. Hand reaming was then performed to ensure, where possible, the insertion of a nail of at least 9 mm in diameter. Fracture healing was observed at a mean of 17 weeks (12-28 weeks). No tibial non-unions occurred in our series, and only three fractures, two segmental and one severely comminuted, showed delayed union. No infection, either superficial or deep, was found and no cardio-pulmonary complications were recorded. Following surgery, all patients gained a full range of pain-free movement of the ankle and knee joints and only six patients (10%) complained of mild anterior knee pain. All patients returned to their previous jobs one month after fracture healing had been confirmed clinically and radiographically. Following nailing, no deviation from normal tibial alignment was detected. No mechanical failure of either the nails or the locking screws was recorded. The mean duration of operation (skin to skin) was 30 min (range 20-45 min) and the mean total theatre time was 55 min (range 40-75 min). The mean total intensification time was 5 s. In total, 120 distal locking screws were inserted using the external targeting device. All attempts at distal locking except five (4.2%) were successful with two failures in the same patient being a result of inappropriate use of the system. We conclude that this nailing system is clinically effective and that distal locking can be performed easily, without exposure to radiation.

One hundred thirty-nine patients underwent 181 arthrodeses of finger distal interphalangeal joints (144) and/or thumb interphalangeal joints (37). Techniques included (1) crossed Kirschner pins (111 joints), (2) interfragmentary wire and longitudinal Kirschner pin (43 joints), and (3) Herbert screw (27 joints). Each technique had a similar nonunion rate. There were 21 nonunions: 13 were pain free, 6 were successfully fused on the second attempt, 1 was painful (but the patient refused further surgery), and 1 was amputated. Inadequate bone stock, inadequate bone resection, premature pin removal, and infection appear to complicate the attainment of bony union. Twenty percent of the fusions had major complications (nonunion, malunion, deep infection, and osteomyelitis). Minor complications (dorsal skin necrosis, cold intolerance, proximal interphalangeal joint stiffness, paresthesias, superficial wound infection, and prominent hardware) occurred in 16% of the joints fused.

A variety of small-bone external fixation methods were evaluated to determine bending and torsional stiffness. Several methods of external pin stabilization with bone cement and with a commercial device were used. Among experimental variables examined were: the number of pins, pin diameter, pin length, pin spacing, and pin threading. The most rigid fixation was achieved with four pins held with a wire-reinforced bone cement fixator. Pin diameter was the most significant variable in the determination of stiffness with this configuration.