The valgus cut angle (VCA) of the distal femur in Total Knee Arthroplasty (TKA) is measured preoperatively on three-joint alignment radiographs. The anatomical axis of the femur can be described as the anatomical axis of the full length of the femur or as the anatomical axis of the distal half of the femur, which may result in different angles in some cases. During TKA, the anatomical axis of the femur is determined by intramedullary femoral guides, which may follow the distal half or near full anatomical axis, based on the length of the femoral guide. The aim of this study was to compare using the anatomical axis of the full length of the femur versus the anatomical axis of the distal half of the femur for measuring VCA, in normal and varus aligned femurs. We hypothesized that the VCA would be different based upon these two definitions of the anatomical axis of the femur.
Full-length weight bearing radiographs were used to determine three-joint alignment in normal aligned (Lateral Distal Femoral Angle; LDFA = 87º ± 2º) and varus aligned (LDFA >89º) femurs. Full-length anatomical axismechanical axis angle (angle 1) and distal half anatomical axis-mechanical axis angle (angle 2) were measured in all subjects by two independent orthopedic surgeons using a DICOM viewer software (PACS). Angles 1 and 2 were compared in normal and varus aligned subjects to determine whether there was a significant difference.
Ninety-seven consecutive subjects with normally aligned femurs and 97 consecutive subjects with varus aligned femurs were included in this study. In normally aligned femurs, the mean value of angle 1 was 5.05° ± 0.76° and for angle 2 was 3.62° ± 1.19°, which were statistically different (P= 0.0001). In varus aligned femurs, the mean value of angle 1 was 5.42° ± 0.85° and for angle 2 was 4.23° ± 1.27°, which were also statistically different (P=0.0047).
The two different methods of outlining the anatomical axis of the femur lead to different results in both normal and varus-aligned femurs. This should be considered in determination of the valgus cut angle on preoperative radiographs and be adjusted according to the length of the intramedullary guide.

Total knee arthroplasty (TKA) has been known as a definitive treatment for advanced knee osteoarthritis. Both intramedullary (IM) and extramedullary (EM) tibial guides have been used to restore the desired extremity alignment. However, controversy exists regarding the superiority of either technique We aimed to compare the functional outcomes and accuracy of IM and EM tibial guides in providing neutral alignment after TKA. In a randomized, double-blinded clinical trial, we studied 98 patients undergoing primary TKA in two groups of IM and EM. We measured the medial proximal tibial angle (MPTA), varus angle (VA), and joint-line convergence angle with normal ranges of 90°±3°, 0-2°, and 0±3°, respectively, on a three-joint alignment view after three months. We also assessed the functional outcomes at the last follow-up. Finally, we compared these outcomes between the two groups.  Eighty-four patients (IM=42, EM=42) were included in the final analysis (16 males, 68 females, mean age: 63.9±8.6 years, mean follow-up: 13±2.9 months). The mean postoperative (post-op) alignment angles showed no significant difference, although MPTA outliers were significantly more frequent in the EM group (26.2% vs. 9.5% in IM, P=0.04). None of the functional outcomes showed a significant difference between the two groups. However, the mean increase in knee range of motion (ROM) was significantly higher in the knees with VAs within ±3° of neutral than those outside this range (30.8 vs. 27.4, respectively, P=0.039). We conclude that both techniques were not different regarding the mean alignment angles and functional outcomes. However, fewer MPTA outliers can be seen with the IM technique. A post-op mechanical axis within ±3° of neutral can result in a more ROM increase after one year.  Level of evidence: I

Intramedullary nailing is probably the best procedure for treating the long bone fractures in the lower limb. Such operation is guided by fluoroscopy for the guide-wire insertion like fracture reduction and distal locking. Radiation exposure during interlocked nailing continues a matter of challenge.

The aim of this experimental study was to design and test the new aiming device for closed intramedullary nailing and to reduce the radiation exposure and the operation time during the procedure.

A stainless steel femoral intramedullary guide wire equipped with a small magnet on its end was designed; and also an exchange tube that would enter into the bone canal upon the guide wire to maintain the alignment. Besides these mentioned parts, we applied the standard classic interamedullary nailing set. Pin guide was inserted in the femoral intramedullary canal from periformis fossa. Another equipped magnetic guide wire was inserted from distal portal which was created in the lateral epicondyle. Two opposite magnetic poles supposed to find each other in the fracture site. After replacing the guide-wire with guide pine; the alignment would be checked by a C-arm. The study has been designed in 4 phases including moulage phase, animal phase on young cows, and a human cadaveric phase. The last step of the study is under design and it consists of a randomized controlled clinical trial on the elective patients.

Outcomes of applying the new system on 15 fiberglass artificial femurs and 20 bovine femurs as well as 10 human cadaveric femurs were successful.

We found the magnetic field assistant device to be an accurate, radiation-independent jig for close passing of guide wire after close reduction of femoral fracture. It can reduce the need for radiation during placement of guide wire for closed intramedullary nailing of the long bones. More studies are required to improve and evaluate the technique and equipment.

Intramedullary screw fixation provides a less-invasive means of surgically managing metacarpal fractures. While thereare advantages to using this technique compared to CRPP and ORIF, disadvantages of intramedullary screw fixationinclude loss of reduction intraoperatively due to sagittal and coronal plane translation. The blocking screw techniquehas been previously described as a solution for this problem in intramedullary fixation of long bone fractures. Wedescribe the blocking screw technique as applied to aid intramedullary screw fixation of metacarpals.Level of evidence: V

Background and Ëxternal fixation is currently considered as a standard treatment for open tibial fractures; however, due to the long-term hospitalization and some other complications, some researchers have proposed intramedullary nailing as the alternative surgical treatment. This study was conducted to compare the treatment of open tibial shaft fractures by external fixation and intramedullary nailing. This randomized controlled clinical trial was conducted on 113 patients with open tibial fractures type Ï and ÏÏ (Gustilo classification) during a two year period. These patients were divided in two groups and 59 cases were operated using external fixation and 54 fractures were fixed with intramedullary nailing. The patients were compared for complications such as union time, delay in the union, nonunion and infection. Ône hundred and thirteen patients (95 males and 18 females) with the age range of 18-50 years (average age: 34.3) were enrolled in this study. Âmong the 59 patients treated with external fixator, 8 had delayed union. Three of these eight patients suffered from the nonunion and did not have any progress in callus formation till 6 months after the treatment. Ôn the other hand, among the patients (54 cases) treated with intramedullary nailing, 2 cases suffered from the delayed union and one had nonunion. The difference between the two methods of treatment in delayed union and nonunion situation was not statistically significant (P>0.05).Çonclusion: Due to the reduced hospital stay in intramedullary method and the necessity of doing repeated surgery and applying intramedullary nailing when the patients are not treated with external fixation, the researchers recommend intramedullary nailing as the first option in treating such patients.

Tibial shaft fracture is one of the most common fractures in the lower limb which in the case of displacement or instability may need internal fixation. The aim of this study was to compare the results of plating and intramedullary nailing (IMN) for the treatment of closed tibial shaft fractures. In a prospective study 106 cases of closed tibial shaft fractures admitted to two of the teaching hospitals of Ahwaz during a 15 months period were treated alternatively with plating or intramedullary rod fixation. The union and complication rates were compared with a 12-months follow-up. From 50 cases treated by intramedullary rod and 56 who received plating 48 (96%) and 52 (92.9%) patients respectively achieved union. Non-union was observed in 4% of intramedullary rod and 7.8% of plate fixation cases. The infection rate in the plated tibias was significantly more than the intramedullary fixation cases (p=.034). The rodded cases had a shorter time to union than the plated ones (p=.006). Union of closed tibial fracture is similar whether fixed by intramedullary rod or plate. A higher infection rate and a slower time to union are however to be expected with plating.

Rotational deformity after intramedullary nailing is a well-known complication. Femoral malrotation is the most common form of malunion but it is underrecognized in part because of the difficulty in accurately assessing rotation as well as the variation that exists in normal anatomy. The aim of this study was to evaluate femoral malrotation following intramedullary nailing of the femur. We studied 70 patients who had referred to Imam Khomeini Hospital and had undergone antegrade intramedullary fixation for isolated femoral shaft fracture during 3-year period from 2008 to 2011. Inclusion criteria including isolated femoral shaft fracture that had undergone antegrade intramedullary nailing. Exclusion criteria including spontaneous ipsilateral tibial fracture or pelvic fracture، contralateral femoral fracture، femoral fracture that had fixed using plate or external fixator or retrograde intramedullary nailing. During operation، the patients were assessed clinically for rotational deformity and then in the postoperative follow-up period، degree of rotation was identified with CT scan. Postoperative computed tomography measurements of rotation were compared with the opposite side. There were 70 patients، 56 men and 14 women. The average age of the patients was 28. 21±14. 39 patients (55/7%) had external rotation and 31 patients (44/3%) had internal rotation. The mean of malrotation degree in physical examination was 4/67 and The mean of malrotation degree in CT scan was 7. Degree of malrotation deformity، less of 5º، 5 to 10º and 10 to 15º was less of 8. 6%، 75. 7% and 15. 7% respectively. Degree of malrotation didn’t relate to age، sex، fracture location and activity of the patients (P> 0. 05). Rotational deformity in 28% of the patients was equal to more 15º. This complication didn’t relate to fracture location. The patients with external rotation deformity had more symptoms than the patients with internal rotational deformity but there isn’t significant relation in this study.

The aim of the present study was to compare two methods of plating and intramedullary nailing in treatmant of closed noncomminuted tibia fractures with intact fibulae. Utimately 69 patients were followed for at least one year. The patients were randomly devided into two groups of plating and intramedullary nailing and operated on. One case of nonunion and one case of superficial infection occurred in the intramedullary group. One of the patients in the intramedullary group developed late deep infection in the screws location (in both cases p>.05). In both of the groups the tibia fractures reached union in about 4 months, though the intramedulary group had underwent more operations for union achievement (dynamization in 4, 12.1%, p≥.05). The need for implant removal was not statistically significant in the two groups (p≥.05). Of the other variables, the diffence between the two groups was statistically significant only with regard to their complaints of the limb and the number of individuals with knee pain (p<.001). It seems that both methods are suitable for closed noncomminuted isolated tibia fractures, but the patients with intramedullary nails, probably will need more operations to achieve union and probably will have more complaint of limb pain.

Abstract Non-union or delayed union after long bone fracture surgery is very common. This study aimed at evaluating the healing time of closed femoral shaft fractures in smokers and non-smokers following open reduction and internal fixation with plate and intramedullary nailing. In a cohort study, patients were divided into two groups of smokers and non-smokers with closed transverse fracture of the femoral shaft bone. The patients who smoked 6 or more cigarettes per day were considered as smoker. Treatment method was based on the patient's preference and not based on being smoker or not. Patients were followed up for one year for clinical and radiological examinations on the status of the union. The collected data were analyzed using SPSS software version 19. In our study, 220 patients were studied (110 smokers and 110 non-smokers). Most of the patients with closed femoral shaft fractures were men (79.7%). Their mean age was 32.78± 16.93 years. There was a statistically significant relationship between the bone healing in treatment with plate and intramedullary nailing in smokers (P = 0.004). All non-smokers had union (100%), 74.1% in the group treated with plate had union and 78.8% in the group treated with intramedullary nailing had union, respectively (P = 0.234) 180 days after surgery. There was also a statistically significant association between delayed union in plate treatment and intramedullary nailing in patients who smoked (P = 0.04). The treatment and daily function of smokers is usually worse than non-smokers and needs longer follow-up. It seems that the intramedullary nailing in smokers with closed femoral shaft fracture leads to more delayed union.