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Decision Making in Nailing

Nov 26 | 1:30 PM

The strongest mechanical fixation for any shaft fracture is an intramedullary nail. However, deciding whether to employ nailing or another style of hardware necessitates a complete understanding of the mechanical fixation decision-making process, as well as the condition and many other variables that aid an orthopaedic surgeon's decision. Join us as Dr. Dilip Tanna shares his experience in the decision-making process when it comes to the use of nails.

this is dr brushali from team netflix a very good evening to everyone and we welcome you for this session on decision making in kneeling today we have with us dr dilip tanna he is one of the best orthopedic surgeons in mumbai with a vast experience of 56 years in this field he is currently associated with justlock hospitals mumbai as senior orthopedic consultant he has written a book on interlocking nailing which has now become a textbook for interlocking in india his area of expertise includes revision trauma surgery and joint replacement now i would hand it over to dr dilip to start with this over to you sir you can see your present okay can you start on the first line yes sir decision making and nailing next now you can see i'm talking about there's a displaced fracture with the intact fibula and this tibia tibia fracture eight months also it has not united and even if it is fixed this is in older days when we used to do with this with distorted nail intact fibula it is not united even fixed earlier next now you can see it also here it is conserved and still everything is not you is not united so it is very simple to treat this do the fibular osteotomy and nail the things and you nail it in a dynamic mode as you can see here there is no no screws in the proximal part the arrow which shows so in a dynamic mode and the fracture heals up next so here is the again the same thing conserved eight months nothing is happening any next and as you can see the fibular osteotomy i think at this stage i have to excise the part of the fibula but that is not required you can do only the oblique osteotomy of the fibula and then it can become all right so this is in two years time everything has healed up next next how to avoid a non-union now you can see tbr this is the fresh fracture so whenever i do the primary nailing i do the oblique osteotomy explaining the patient pre-operatively that because he is the one otherwise he'll say that there was no fracture in here than the fracture but as you can see i've done the nailing and it is in a dynamic mode as you can see it here and then the fracture is healed up the it may be controversial but it's a certain healing this is what i practice i'm talking about the literature is quite quite different on to this at times some people say you don't need some people say you need but my experience is that in order to be hundred percent sure i want to just do oblique osteotomy and do the nailing and this has to be into the dynamic board next please as you can see here this is the fracture which is held up in which people are held up earlier if the fibula heals up earlier still the fracture is not united and also already there is a there is a at the end of the bone there is a newborn formation has occurred so again the treatment for that is the fibular osteotomy at a different level and the nailing and the grafted if you want to otherwise the fracture heals up next this is the one where 62 year old four surgeries nailing plating rafting non-union and walking with the non-union for 20 years no sinus and now no probabilities and as you can see the fibula is united it was easy to treat did the fibular osteotomy and then the whole thing becomes all right now next fracture heals up without dynamization randomization is not a must for healing as you can see it over here it has healed up very well so dine up next dynamization in interlocking nail when healing is not occurring in six to eight weeks time and dynamization may be considered if there is some attempted callous at six to eight weeks chances of success are higher the factor that best correlated with the success of a dynamization was diameter of the fracture callus at the time of dynamization this is the paper which has been written already but somehow i have not observed this always even if there is no even if in the next one next one now here as you can see there is no attempted healing this is day before dynamization i dynamized it and as you can see very well in seven months time it is railing up and there is this is the one which at the end of the surgery everything has held up to the nail has migrated up because of the dynamization now next please next this you can see here there is no callus formation at all and still it is in a static mode so once it is dynamized fortunately if the dynamite and even if the fibula was intact the fracture healed up that's the reason i say it is controversial but i in order to be hundred percent sure this is the one which i have spoken to you next and once you can see once it is dynamized the femur goes up here it is it is here and in the after dynamization it goes up this is what it is that once you dynamize there has to be a space for the nail to go up next how to prevent non-union in a transverse fracture at the east mass next transverse fracture in the estimates of the femur and tibia treatment is reamed one to one point five millimeter larger ream say 440 for example in nail only 415 in a dynamic mode on day one so the space for the nail to migrate down or up is already created as you can next please as you can see put it in this dynamic mode just hold on don't don't go further now here it is you you have nailed it and then you put in the dynamic mode and the second slide which shows that once the fracture gap is reduced automatically because the fracture was in dynamic mode the screw which was away from the fracture it has come nearer the fracture in the hole and the fracture is it has become auto dynamized this is an auto dynamization this is what is the purpose of the dynamic hole and as you can see 440 was reamed and 415 nail was passed next please this is the typical femur fracture treated in a dynamic mode and the fracture heals up and this is after healing we have removed the nail next piece same thing here in a tibia primary refracture healed up in a dynamic mode and as you can see to start with into this arrow arrow which is seen the the screw was proximally and once the fracture is healed up the screw is now distally so it has moved a little so this is the part of it which got compressed during walking about and all and it helped the healing process next please so when you dynamize what happens here you can see in the figure one there is the fracture gap which is there in the red lines and the screw is still there in the factor two screw is removed and as you can see the fracture gap is reduced but that observe the nail which is here which is uh slightly above has come down so unless there was a space for the nail to come down this will never happen so you got to have a space for the nail to come down if you don't want to dynamize it otherwise it will not happen same thing happens next please same thing happens when you're doing it in a proximal part sorry go previously yeah same thing in this picture in a previously when the screw is removed you can see the nail migrating up next please this is in a dynamic board as you can see the screw is at the top here and when the patient is walking about and moving about now the screw has migrated down into that overhaul and the nail has to migrate up if there was no place to migrate up this auto dynamization will not occur so we must understand the dynamization to be effective the nail on whichever end you dynamize has to migrate that much area up in order to get the fracture healing but if in case the next place as you can see first picture is if the nail is subcontrol even if it is dynamized it's of no use at all or if there is a new bone formation is occur in the second one there is no mean or in the third picture when there is a piece of bone which has come over from the fracture here then it forms the bone there very quickly so there is no dynamician occurring at all and in the fourth picture you can see there is a female nail at the top there is a new mode formation this is normal so there is no dynamization occurring at all in this area that's the reason why if you want to dynamize this will not happen so i says before next please that says before dynamization six to eight weeks do not delay if at all you want to dynamize do it in six to eight weeks if there is a small callus there is a better chance so the distal end of the nail is there a place to travel down no bone plug no sub candle and weight bearing after dynamization is very very helpful two months about the judgment on healing and communicated structure no dynamization because if you dynamize it will shorten and the whole purpose of the treatment will be lost next please now in this fracture it was treated with the static nailing all it has gone into non-union all it needed was the do the dynamic nailing after leaving with the one size oversized nail and then the fracture ends up into the complete healing so this is what is the treatment of an exchange nailing which we say next please so i practice a transverse fracture in the instruments treatment ream one to 1.5 millimeter larger adequate size nail not a canal stuffing pushed by hand and not hammered except at the end in a dynamic mode that means the screw at the one end of the oval hole away from the fracture and full weight bearing on day one forget it the fracture will head up next please in this sort of a community fracture do not dynamize because if you dynamize the fracture will overlap it will heal up with shortening then so much of the nail will come out so that means if it was this much here if you can see in the nail so much comes out there'll be so much of the shortening which occurs at the fracture so please do not dynamize the communicated fracture combinated fracture if it is not healing you must graft it next please as you can see here there is going to be a badly combinated fracture you can treat it by nailing and then whole thing heals up very well because you can see very well all those fragments which are fractured but they are all near the bone we don't need to really go down and adjust them next please now here is another communicated fracture so i nailed it in a slight distraction so that there is no shortening and once there is it was nailed in and once there was a few weeks have passed by next so this was grafted and then the fracture healed up ultimately completely well without any shortening without anything so don't be tempted to shorten the limb in order to heal earlier because afterwards a little route and everything is going to be far more difficult so go ahead nail it with the gap six weeks time before there is anything problem go down and grasp it tell the patient and then you have a best chance of fracture healing next please this is the typical fracture from dr devdas this is not my own thing completely shattered tibia as you can see here and this has been nailed with distraction and next please and you can see the whole thing is held up only thing probably what has happened is the axis is maintained the x is maintained but the length is also maintained maybe a slight recurve atom as you can see it over here next this is my own case 38 year old fresh fracture planning do not think of shortening the bone together take a length of a normal leg and distract till the time the length and you can put in the nail with this distraction this piece is there outside which is already turned on 360 degrees but still i didn't do anything on day one next on day two and on a day about four weeks or so i went down and unturned this patient close kneeling length maintain nail thickening and everything so here it is what is the prognosis fully rotated piece no immediate relocation so i went ahead in six to eight weeks time and i relocated it next please i relocated it and once it was relocated and also the grafted it next please so you can see this is grafted next please and in 18 months time it has healed up very well so without any shortening without any excess problem so in such a community fracture all what you need is this situation next please here was a compound fracture with this much of a bone loss which was there next please so much of a bone loss which was there so i nailed it in distraction then went ahead with ali did the segment transport as you can see it on the picture and once the segment transfer there also there is a the whole fibula is also going down and you can see ultimately the whole fracture which is once it is segment transport everything is held up and you can see that the fracture is healed up without any problem x is corrected and everything which is there so never never shorten the leg and any recombinated fracture next please and you can see the leg is very well all these compound fractures but the fracture part has healed up extremely well next such a gap big bone gap with all the muscles which were gone so there was no future for the knee joint movement and that's the reason i decided to fuse the joint so this is what in distraction put the bone graft put a nail try a nail which is going through the tibia and then at one stage it broke down still continue with the same distraction read next please it broke down next please so remove the nail next please again the re-nailing one radiate nailing done both grafting them and the whole thing heals up completely well as you can see very well okay next please here you can see again a combinated fracture the fragments are all nearby and hence ultimately it heals up very well so all these fragments which are there they will add up into direction you do not have to unturn it or do anything majority of the times next please next interlocking has now become a standard surgery still many complications are there in decision making of the nailing everyone now knows how to nail and how to do proximal and digital locking next is there sorry hold on hold on the whole game is in making the decision of locking the nail how many screws where in if nail or a plate you have to make a decision and presuming that good reduction is mandatory before nailing if no good reduction nailing is a failure even if it heals up is due to mild union it is of no use at all next now i'll come to the junctional fracture in nailing which is oversold in extreme ends of the tibia shattered the official bone do not shorten if possible fill up the gaps with bone grafts next please next please junction of the upper two third and lower one thin next uh as you can see here this is upper end of the tibia new thoughts on nailing today is lateral and lateral entry joint proximal most and semi extended position for nailing and posterior most entry point you can see it here even the it is suggested you open the joint and go in the joint between the area which is there this is this next piece this is the nail which this is the side which you can see the proximal tibia fracture nail from interiorly with multiple screws proximally distally it is not very important in proximal fracture multiple screws have to be put in next please but you can see there is some problem in which has occurred three operatively which wasn't there the axis variation has occurred so this is the one which is not necessarily a fracture is healed up but the knee joint alignment is altered next please as you can see here the knee joint alignment is altered next please no i think we are at a different level can you go previous one yes sir [Music] okay go further i think now now now sorry what you are into now previous one now here here one of the friend he got sold out by this proximal tibia nailing so he did all these things at the end of three hours he ended up into this sort of a thing so proximal tbr nailing is a very difficult procedure it's not everybody is not very happy about it so you got to understand how to do this proximal tbr nailing and this is at the end of it there is no point in just ending up like this if the patient if the surgeon would have done a small bipole plating it would have become perfectly all right next please so for this one now the suprapatellar nail entry is now a new exciting thing which has happened you go above the patella and put in a nail with that here you can see it very well these are the few slides which are there dr gary from um he has done a very good work on to this he is also the next piece he has developed a new indian made system which is well tested and works well as mentioned by him from yogeshwara surgical and it is at the indian prize next please these are some of those few slides from him next please first is that you mark out the patella then you inflate the knee joint so that it is easier for you to pass the knee i have to pass the thing once is the inflation of the knee 36 is aligned it helps in testing the movements of the thing next please and then you proceed to introduce the nail from suprapatellar area here you can see in this slide he is trying to reduce the fracture from outside and this is the one which gives a very good result and this is the one which is he it is like at the moment quite a lot of people have started doing it you need the special set of instrument set so unless you have a special instrument set and a volume to learn the situations better is not really people who are doing a casual surgery is not their cup of tea next please you also have to use a polar screw it helps in the direction of the guide wire and the nail next please probably this is the surgery which will be done by many people in coming few years for the proximal tibia fracture thought expects by quite a few orthopods for this proximal tbr nailing first and foremost you can have an abrasion of the articular surface while passing instruments and that may lead to a early osteoarthritis second is injury to the articular surface of the upper tibia and to the meniscus and the acl third is if any infection then intra articular infection and there's going to be a catastrophe so only time will decide whether it is better or it is the whether the old thing which we are doing it from proximal tibia that is the one which is the better treatment as far as the result wise suprapatellar nailing has given consistently good results into those surgeons who are getting used to it but all these are the factors which will have to be seen so there are a few are few people who are doing the arthroscopy after three months and six months to see if there is any articular cartilage damage so immediately after the operation three months after six months after and then they may be able to give us some guideline next please but those who are not doing frequently this is a simple surgery a mippo surgery axis and everything is preserved as you can see both these things for infrequent low volume surgeons of the proximal tb i feel this is worth considering plating is a very good system you can maintain the reduction and you can keep the reduction and this is the one which is a good system as you can see the same one here i feel in my hands nailing doesn't give me a consistently anatomical reduction while a plating i can say that consistently you will get an anatomical reduction so that the reason why i feel that if in case there is you are trying nearly if in case there is a problem then you stop and start doing the other surgery next please as you can see it over here in this fracture nailing as you applicating has given a perfect anatomy restoration next please so oblique fracture rotational deformity perfect anatomy restoration is always perfect result try nailing and cannot get it change over to plating do not let your ego come in the way next please here the surgeon had done the mailing unfortunately as you can see in the second screw and mid the interlocking it's gone into for a non-union and then you can very easily treat with this double plating and in two years time you can see the perfect anatomy is restored so if you are a good nailer nail it if you are like me fussy about the final result and you want a 100 result plating will probably give you a hundred percent result in conclusion interlocking [Music] interlocking may give you a good result often it may not be perfect and the perfect restoration of the anatomy assures a perfect result if one has the skill of the other faculty here one must do a polar screw nail and hope the minor axis variation does not occur but if one is average soldier like me and too fussy about the final result i will feel you change over to a plating in time and relax you are more likely to get a good result out of that so proximity next please proximal tbr fractures are hard to nail and even paul tornado has made this statement they are hard to nail even with experienced hands and admitted that if you get a perfect portal and the proper trajectory nailing extension and the use of the blocking screws then only the nailing is okay here are the reports there was no difference next piece there was no difference in the rates of non-union of either treatment treated by intramural inhaling experience more mild union and compartments than those treated with plating implant failure occurred only in patients treated by inflammatory nailing so you can see the comparison of nailing and plating which was done by people in past they have shown that the whichever surgery you can do better is the surgery of choice for you i don't think the nailing is any better than the plating and as you can see the strike complication rate is slightly more in nailing than in plating next please the incidence of male reduction associated with the intermediate dealing proximal frequency has substantially decreased with the use of new technique and a reduction as juventus blocking through temporary plating universal detractor in a semi-extended position next please upper two third and lower one third tibia so the easiness of my reduction i have mentioned to you now we go to the upper two third and lower one third tibia at this junction next please next please sorry can you go previous previous yeah you can see here the transverse fracture still the nailing is a good option and the fracture heals up but you must plate the fibula if the fracture is at the same level of fibula so lower one third tibia nailing is a very good option because the skin problem is avoided if you do the nailing and the fibula must be plated and if the decent medullary cavity is there even in a transverse structure like this you can put in an intramural but majority of the time the medullary cavity is so small that you may not be able to put in a snail which is long enough and that's the reason you may have to do to the plating nailing or plating it does not make a difference in the final result next please next please you can see here the tv at lower end it starts and it goes on funneling and there's a reason the hold of the nailing in the lower end is not as good as it is in the upper end this is the typical problem of the junctional level the funneling of the metallary cavity in a long oblique fracture will be unstable in nailing i feel this is the one which is not suitable for nailing all the time next please and here you can see the nailing which was done and then the screws were removed so unfortunately by the surgeon and then it has gone into non-union this is not the not necessary there is no need to have been dynamized for this and this is the one which was not even reduced properly so if you get a 100 deduction and with the block screws you may be able to treat this with nailing but for an average surgeon plating may be a better option now here it is this is a good nailing this is a bad combination there will be a next piece there will be a swelling around quite a lot and that's the reason i feel the nailing is a very good option you've done the nailing and you've done the wire because there was a possibility of a fibula wire because this was a fairly decent magnetic cavity it's perfectly all right it is held up but you see ultimately this is the current good treatment one must get a perfect reduction but you can see occasionally even if a perfect reduction is there there may be a small excess change may occur in the ankle in the ankle joint which should not occur and if the reduction in everything is perfect you will not get this change this is very minor probably it won't make a difference next please now you can see this oblique fracture before the days of digital tv are locking plate somewhere in seventies i used to put in these only leg screws only leg screws and fibula plate and then the fracture used to be right next place or a leg screw then a fibula plate like this fracture united next please again the same situation leg screw then the fracture unites next place next next you can see all these fractures only with the plating and the pelleting of the fibula and the and the screw fixation leg screw of the tibia the fractured unit next please no i think you can you go on a lot further you want me to go back can you go three slides back [Music] so is it this one there's still one back okay next next night sorry can you go back yeah this is the one for a frequent low volume surgeon of the distal tibia i feel this plating is a worthwhile treatment next please for such a fracture again you can you can do the plating and still you will get a very good result only problem is the skin so you got to be very careful that if you're doing the plating you got to look after the skin problem and so it is recommended to do it early as possible before the swelling occurs next please next please here the typical newer implant distant lateral plate now the legs flu and the fibula is the key so you can really treat it very well and then the fracture is a very good chance of healing so the nailing is still a much better option if it can be nailed but in an oblique and a very low down fracture nailing is probably not as good as whatever we desire next please so in this sort of an oblique fracture nailing may open up the structure here and that's the reason as you can see it over here so the leg screw and the plating is a much better treatment for such fractures next please as you can see here the leg screw and even a thin plate still structure heals up very well so such spiral fractures but i would feel this fracture is very suitable for nailing if you reduce it and hold it from outside a good reduction and nail it with the now new nails with three to four screws distally this will be a very good option this is before those days were available but today i will nail this fracture and with the three or four four screws for minimum three screws digitally this will be a good option next please but such an oblique fracture i'll always do the plating next please this fracture is on the borderline you can next please sorry previous one yeah this fracture is on the borderline you can treat with the nailing you can treat with the plating i have chosen to do with the plating in those days and this has become perfectly normal as the time goes by next please now as you can see if there is a long oblique fracture and if it is plated without the leg screw this will not heal up so it went into non-union and as you can see the leg screw which is being done and then the fracture heals up into the healing process so the non-union digital tibia fibula next please i show you one case here non-union digital tibia fibula this is the typical fracture next please this is the typical fracture plated plate removed because of the infection and then the fracture was put into plaster next piece put into plaster it got displaced it got non-union so here it is next please again it was plated and fibula was plated this fracture next please this uh the plate broke down you can see it again here so see this is the very very once the problem occurs you got to do everything next please so this is the stage when the plate broke down i came into the picture next please so i put in the fibula intra medullary fibula you can see the intramedullary fibula you put in next please put in a few drill holes into that fibula so that you can hold it and push it into the digital fragment next please push it fully in the proximal fragment and then pivot down to the digital fragment next please so bend the things and now put it in the digital fragment next please here you can see the x-ray fibula is in axis is very well corrected tibia and fibula has been reduced it has been neutralized next please it has been neutralized with this plate next please few months still not healing but no pain next please as you can see the healing goes on proceeding further but you can see the fibula has a problem next please now the tibia is uniting tibia is almost fully united and you can see very well the fibula you can see it inside and the tv is fully united next please as you can see here in one year time the fracture is completely consolidated patient is able to move about walk about next please in two years time now you can see radiologically also it has fully united so this takes a long time at times for two three operations which are done and that is the end you can if you observe the fibula here it is fibula which is probably getting absorbed in between and ultimately the whole fibula will revascularize but that takes a very very long time next please so lower 130 tbr nailing is the better in digital tv fractures if anatomy is restored and three distal screws and fibula plating is done plating is also a good option in oblique fractures hesitation of plating is due to the wound healing problem hence plating in thin plate we should do it and must be done earlier within 24 hours of the injury before the swelling sets in and i have this small variation next please this is the fracture long oblique fracture now when i do the nailing such can be nail but reduction is not always anatomical due to spiral nature so i do not hesitate next please and i put these mono cortical screws and reduce the fracture and neutralize with nailing this was a this is a 10-year result this was done also many years back before the newer nails were available this is the leg screw and this is the two screws in the digital fragment interior posteriorly again the same next piece same sort of a fracture again a leg screw and the fracture is held up into the next x-ray next please again the same situation you can use this cortical unicornical leg screw which can heal the fracture next please next is the segmental fracture again fixed up next again a segmental fracture your leg screw which is done and in the last one you can see the fracture is very well held up so this is a variation if you can handle it then you will be able to put this leg screw but before putting the screw what i would suggest is hold the fracture with reduction pass a nail keep those clamps on and then put a leg screw because otherwise the screw will come into the near part of the nail and you will have a problem so don't put the leg screw first hold them up with the clamp which you will be able to two clamps if you apply on that you will be able to do it very well next here was the fracture which i had shown you i think there is slightly been misplaced so this is the non-union 20 year and you can now do this you can see this is how in the dynamic nailing which was done after the fibula things here was the next patient next this was a badly nailing and plating rafting eliza are now four years after the fracture it is not yet held up this is the stage i came into the picture next please the corrective osteotomy of the fibula polar screws and a nail in the center and you can see here perfectly anatomy restore and the limb is perfectly normal okay friends medifix now you take over whatever you want to ask questions and all yes sir thank you thank you so much for the session we have a couple of questions so the first question being in case of tbl fractures uh what would be the better choice reamed intra-medullary nailing or the unreamed one if you are in a shaft in the middle shaft rheemed intramedullary nailing is the ideal treatment for them but at the proximal end the distal end it depends on your experience and your availability of the implant so as i said if you have a experience and can do the nailing it's a better one but if you do not have the experience and you do not have those newer implants then you may also do a plating which will give you a same good result and what would be the cost effectiveness in both the nail fixation or the locking plate fixation i will not be able to mention that because i do not know about the cost in the place where i work the cost is not the issue so i have not been able to find out that no so for the patients yeah yeah for the patient only because the okay okay in bombay into five star hospitals where i work the other charges are far more exciting than the problem so i think the cost of the implant is probably not not a very significant difference okay and uh one more is what are the chances of fatigue failure in interlocking nail yeah if over the years even if the fracture is healed up after five years we have seen the nail breaking down because the flexibility or elasticity of a limb and elasticity of a metal is not the same and that's the reason why even if the fracture is held up in a heel fracture so many times we have seen nail breaking down so that is possible but most of the time the nail breaks down only with the non-union all right so and when we do the intramedullary nailing we generally have to ream the intramedullary canal so how is the blood supply maintained at that time no i think there is no problem at all undream nails are very inferior to the ring nail do not think of doing an answering nail if i have to say it in our one word always do a ream nail unreal nail does not exist even in a compound fracture it is shown to give you a poor result okay okay uh the i think those were the questions sir thank you so much for the session so thank you so much sir uh i'm sure many of our audience has their doubts cleared about mailing and i would also like to thank the audience for attending this session thank you so much sir thank you audience

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