Also known as an interlocking nail or intramedullary nail, an intramedullary rod is one of the most used orthopedic implants for the treatment of long bone fractures, for example, femur and tibia fractures. It is used by inserting into the medullary cavity of the bone to stabilize and align the fracture. These rods are known to be designed to stay in the body forever. One of the reasons why the use of IM rods is preferred rather than other methods of fixation is that they can share the load with the bone rather than only providing support.
History of Intramedullary Rods
Intramedullary rods are known to be used for the first time in World War II (1939) to fix femur fractures in soldiers. Gerhard Kuntscher, a German surgeon is the one who used intramedullary nailing for the first time. The use of IM nails for fracture fixation helps in quick recovery when compared to traditional ways like plaster application or traction. This became a huge advantage for soldiers during World War II.
Why are IM Nails known as Locking Nails?
The cross-sectional structure of IM nails was ‘V’ or triangular-shaped earlier and later, it was changed to the presently used clover-shape to make it more stable. Besides this, stainless steel was the choice of material for the manufacturing of IM nails but, with time, titanium became the preference for having better biocompatibility and lower mechanical failure rates.
The design of Intramedullary rods that were used earlier had some issues with preventing collapse or rotation in unstable fractures. This is where the concept of “locking” the nails came in. The use of bolts was introduced to lock the nails from each end to prevent rotation of the fragments. That is the type of intramedullary interlocking nails we are using these days.
Bone Healing and Intramedullary Rods
There is a misconception in some of our minds that the use of implants like IM rods speeds up the healing process. But this is not the case, implants do not impact the way our body heals bones though, they do provide the stability to broken bone fragments. Implants are designed to hold fractured bone fragments into their correct alignment.
If we talk about implants like IM nails, then they are designed to carry the load of the body along with stabilizing the fracture. This is why people having IM nails used to fix long bone fractures tend to easily place weight on the extremity sooner than to wait for complete healing of the bone.
Early mobilization prevents joint stiffness which is a common sequela after plaster. While on the other hand, early load-bearing improves the recovery of post-traumatic muscle atonia and also improves the proprioception of the limb involved.
Uses of Intramedullary Rods
Broken long bones are often treated with intramedullary nailing. The rod is inserted into the medullary cavity by making a small incision either at the knee or hip. Once inserted, the rod is locked at both ends using orthopedic screws to prevent any rotation of the fragments. Locking of the nail ensures its proper positioning until the bone heals. When compared to using a cast or external fixation, an IM rod ensures better positioning.
Femoral shaft fractures and shinbone fractures are the ones for which IM interlocking nails are used. Intramedullary nailing is found to be effective in the treatment of the above-mentioned fractures as the implant allows full-length fixation.
Intramedullary nails are most commonly made using titanium for being highly biocompatible and showing good biochemical inertness. Besides this, they are also available in different lengths and diameters. The size of the IM nail to be used is chosen according to the age and height of the patient.
Above all, the use of intramedullary nails is also there to fix and provide support to the bone after tumor removal in the case of metastatic bone disease. IM rods can also provide support to the bones that are at high risk for fractures. Intramedullary rods may also be used for preventing fractures and progressive deformity of long bones in people suffering from osteogenesis imperfecta (brittle bone disease), a genetic disorder.
Is There Any Damage to Bone Marrow After Inserting IM Rod?
Yes, of course! Insertion of rod or nail into the medullary cavity damages the bone marrow of that bone. But the point to be noticed here is that intramedullary nailing does not impact the ability of red blood cells and immune cells formation. Plus, if the rod is removed after complete healing of the bone, bone marrow present in that bone could regenerate itself. If the nail needs to be removed, it is generally done a year after the surgery or may depend upon the recovery speed of the patient.
Siora Surgicals Pvt. Ltd. is crowned as one of the best manufacturers of a huge range of orthopedic devices including Intramedullary Nails. The company uses ISO standard titanium and stainless steel for the manufacturing of implants to meet the international guidelines. Siora is an ISO 13485:2016 and ISO 9001:2015 certified company having an FDA-India approved manufacturing unit established in Sonipat, Haryana. The quality and effectiveness of implants produced by Siora are praised by the top orthopedic surgeons across the globe. To avoid any biological contamination and maintain the highest quality standards, the packaging of implants by Siora is done in an ISO class 7 (10,000) cleanroom environment. Siora Surgicals is also open to providing quality OEM/contract manufacturing services.
The use of orthopedic devices for the fixation of fractures is new as it is being practiced for ages. The things that have changed are the quality and effectiveness along with the materials they are made from. One of the oldest orthopedic implants that are being used is the bone screw.
Archimedes of Syracuse is known to be the father of the screw who invented it in the third century BCE. If we talk about the use of orthopedic screws, then they were used for the first time in the 19th century (1850) by the French surgeons Cucel and Rigaud. The surgery was performed to reduce the olecranon fracture by internal fixation. This was the first-ever internal fixation procedure. During this surgery, the French surgeons used 2 transcutaneous screws.
Advancements in the field of orthopedics have led to the development of different types of orthopedic screws that are being used depending upon the type of orthopedic condition to be fixed. In this post, we will see different types of bone screws that are being used during orthopedic surgeries along with their other details.
What Are Orthopedic Bone Screws?
Orthopedic bone screws are metal-made hardware devices that are specially manufactured to be used inside a human body for the fixation of fractures. They are most commonly made of stainless steel and titanium as these metal alloys show better biochemical compatibility and inertness.
Screws used in orthopedic surgeries play a vital role in ensuring better healing of the fractured bone as the screws provide enough compression while reducing the gap between bone fragments. They are also known to reduce stress on the implants thus, helping them do their job properly. Depending upon the location and seriousness of the fracture, screws can either be used alone or in synchronization with other orthopedic implants.
Parts of Orthopedic Bone Screws
Before we move on to the different types of screws during orthopedic surgeries, let us have a look at the parts of bone screws:
The top flattened part of the screw is known as the head and it is mainly used to insert the screw inside the bone. The head configuration could be different and based on that, the screwdriver is used.
It is the distance between the head of the screw to its tip. Different screw lengths are used for the fixation of different types of fractures.
When it comes to measuring the diameter of an orthopedic screw, special care must be taken. This is because there are two types of diameters in orthopedic screws:
- The outer diameter is measured as a total thickness from one end of the thread to other
- The inner or the root diameter is the narrowest diameter which is measured from across the base of the thread.
Note – It is important to make sure that the diameter of the pilot hole must be the same as the inner diameter before screw insertion.
Pitch is the distance an orthopedic screw travels with each 360-degree turn.
The tip is the end of the screw present opposite to the head. The tip of the orthopedic screw can be of three types including non-tapping, self-tapping, and self-drilling.
Different Types of Orthopedic Bone Screws
The orthopedic bone screws can be classified based on the type of bone in which they will be used and also the location. Let us have a look at common types of bone screws used during orthopedic surgeries:
Cortical bones account for more than 80% of bone mass in the human body. These types of orthopedic screws are designed specifically to be used for hard bone tissues/cortical bones. Cortical screws are designed to have threads and this means that their pitch will be small. They are fully threaded screws but can also be availed in partially threaded configuration.
Cancellous screws are made to be used in spongy bones that are a bit softer. So, it is important to use screws that deliver better results during orthopedic surgeries. When compared to cortex screws, they are longer and have a larger pitch. Another factor that differentiates cancellous orthopedic screws from cortex screws is that the former ones have deep threads. They can be availed in both partially and completely threaded configurations.
Pedicle screws are designed to be used for spinal fusion or spinal fractures. These types of bone screws are threaded and have a mobile head. Just like other types of screws, pedicle bone screws can also be availed in different sizes. They are used to treat trauma or deformity occurring in the spine. These screws can be placed in the lumbar spine, thoracic vertebra, and sacral vertebra.
Cannulated screws are used for the fixation of different types of fracture patterns and also to pass a guidewire for the correct placement of the screws. They are designed to have a hollow shaft to facilitate guidewire for better alignment before drilling. Cannulated screws help surgeons avoid drilling multiple holes during fracture fixation. These types of orthopedic screws can be availed in cancellous and cortical configurations.
They are headless screws and are most commonly used for the internal fixation of bones involving joint cartilages. Some of the most common uses of these types of screws are scaphoid, radial head, capitellum, and osteochondral fractures.
These types of screws are most commonly used for the fixation of small fragments in the cancellous bone. Interfragmental compression of bone plates is what malleolar screws are best applied for. They are known for having a smooth shaft and are available in the partially threaded configuration. Malleolar screws are used for the fixation of ankle fractures.
Materials Used for the Manufacturing of Orthopedic Bone Screws
Orthopedic bone screws are made using materials that are biocompatible and biochemically inert. Below-mentioned is the materials used for the manufacturing of bone screws:
Stainless steel is the most commonly used metal alloy for the manufacturing of bone screws. Screws made from this metal can be used for both cancellous and cortex bones.
The chances of infection caused by titanium screws are lesser when compared to the ones made from stainless steel. Titanium-made orthopedic screws are known to be best for the treatment of mandibular fractures.
Besides metal alloys, orthopedic screws are also made using bio-absorbable materials including polylactic acid, polyglycolic acid, and poly-L-lactic acid. These types of bone screws need not be removed later on as they are absorbed by the body.
Siora Surgicals Pvt. Ltd. is an experienced manufacturer of all types of orthopedic bone screws that are used for the fixation of different types of fractures. The company uses ISO-grade titanium and stainless steel for the manufacturing of its implants. Siora is an ISO 9001:2015 and ISO 13485:2016 certified company having an FDA-approved manufacturing unit in the RAI District, Sonipat, Haryana (India). The company is also open to providing OEM/contract manufacturing services.
Clavicle fractures are very common and comprise 2.6% to 5% of all fractures in adults, with midshaft injuries accounting for almost 75% of all fracture types. Clavicle fractures typically occur when an axial load is applied to the bone, generally in the form of a sudden point load to the apex of the shoulder. When these fractures displace, the proximal fragment is usually pulled superiorly by the sternocleidomastoid muscle while the distal fragment is pulled laterally by the weight of the arm. Most minimally displaced clavicular or nondisplaced fractures can be managed non-surgically simply by placing the arm in a sling. In these instances, the malunion and nonunion rates are very low.
However, when midshaft clavicular fractures present with complete displacement or significant shortening, the risk of nonunion is significantly higher with conservative management. Surgical decision making is a matter of debate. Currently, the only absolute indications for surgical treatment of clavicular fractures include open fractures and injuries associated with evolving skin compromise. Relative indications for internal fixation and open reduction of midshaft clavicular fractures include injuries with 15 to 20 mm of shortening, fractures with significant comminution, completely displaced fractures, floating shoulder injuries that involve a concomitant glenoid neck fracture, painful non-unions, and midshaft clavicular fractures in some multisystem trauma cases.
Depending on fracture morphology, either open or closed reduction and intramedullary orthopedic pin fixation or open reduction and bone plate fixation can be performed and these quality implants can be supplied by Orthopedic implants Manufacturers. Biochemically, both methods provide similar repair strength for middle-third clavicle fractures. After hardware removal, clavicles previously treated with intramedullary fixation were shown to be stronger than those treated with bone plate fixation. Clinically, internal fixation and open reduction of clavicular fractures have shown marked success for the union in a relatively expected time frame with low complications.
Intramedullary fixation offers the benefit of smaller scars and lower refracture potential but also bears the potential risk of hardware prominence and a little higher incidence of nonunion. General principles for a successful surgical outcome involve minimizing soft tissue disruption and periosteal stripping as much as possible during exposure, achieving an anatomic reduction, and preventing wound complications and hardware irritation as much as possible with suitable soft tissue hardware coverage. Either dynamic compression plates (DCP) or locked plating constructs can be used, depending on bone quality and fracture type. In general, the orthopedic bone plate is placed on the anteroposterior, or tension side, of the clavicle to result in the most biochemically sound construct.
A fibula fracture refers to a break in the fibula bone. A forceful impact, such as landing after a high jump or any impact to the outer part of the leg, can cause a fracture. Even spraining or rolling an ankle puts stress on the fibula bone, which can lead to a fracture.
Types of Fibula Fracture
Fractures in Fibula can happen at any point on the bone and can differ in type and severity. Types of fibula fracture include:
- Lateral malleolus fractures occur when the fibula is fractured at the ankle
- Fibular head fractures occur at the upper end of the fibula at the knee
- Avulsion fractures happen when a small chunk of bone that is attached to a ligament or tendon is pulled away from the main part of the bone
- Stress fractures describe a condition where the fibula is injured as the result of repetitive stress, such as hiking or running
- Fibular shaft fractures occur in the mid-portion of the fibula after an injury such as a direct blow to the area
- Fibular shaft fractures occur in the mid-portion of the fibula after an injury like a direct blow to the area
- A fibula fracture can be because of several tough injuries. It is commonly associated with a rolled ankle but can also be because of a fall, awkward landing, or a direct blow to the outer ankle or lower leg.
Fibula fractures are most common in sports, especially those that involve jumping, running, or quick changes of direction such as football, basketball, and soccer.
Swelling, pain, and tenderness are some of the most common signs and symptoms of a fractured fibula. Other signs and symptoms include:
- Incapability to bear weight on the injured leg
- Bruising or bleeding in the leg
- Visible deformity
- Coldness and numbness in the foot
- Tender to the touch
People who have injured their leg and are facing any of the symptoms should consult a doctor for diagnosis. The following steps occur during the process of diagnosis:
- Physical examination: A thorough examination will be conducted, and the doctor will look if there are any deformities
- X-ray: These are used to see the fracture and know if a bone has been displaced
- Magnetic resonance imaging (MRI): This type of test provides a more detailed scan and can generate detailed pictures of the soft tissues and interior bones
Computerized tomography (CT), bone scans, and other tests may be ordered to make a more precise diagnosis and judge the severity of the fibula fracture.
Treatment for a fibula fracture can differ and depends greatly on how severe the break is. A fracture is classified as closed or open.
Open fracture (compound fracture)
In an open fracture, either a deep wound exposes the bone through the skin or the bone pokes through the skin and can be seen.
An open fracture is mostly the result of a high-energy trauma or direct blow, such as a motor vehicle collision or fall. This kind of fracture can also occur indirectly such as with a high-energy twisting type of injury.
The force needed to cause these types of fractures means that patients will often receive additional injuries. Some injuries could be potentially life-threatening.
According to the American Academy of Orthopedic Surgeons, there is 40% to 70% rate of associated trauma elsewhere within the body.
Doctors will treat open fibula fractures immediately and look for any other injuries. Antibiotics will be administered to avoid infection. A tetanus shot will also be given if it is essential.
The wound will be cleaned thoroughly, examined, stabilized, and then covered so that it can heal properly. An open reduction and internal fixation with bone screws and bone plates may be essential to stabilize the fracture. If the bones are not uniting, a bone graft may be essential to promote healing. Orthopedic implants such as Bone plates and bone screws can be accessible from orthopedic instruments suppliers.
Closed fracture (simple fracture)
In a closed fracture, the bone is broken, but the skin is left intact
The goal of treating closed fractures is to put the bone back in place, control the pain, give the fracture time to heal, prevent complications, and return to the normal function. Treatment begins with the elevation of the leg. Ice is used to relieve the pain and lessen the swelling.
If no surgery is required, crutches are used for mobility and a cast, brace, or walking boot is recommended while healing takes place. Once the area has healed, persons can stretch and strengthen weakened joints with the help of a physical therapist.
There are two main kinds of surgery if a patient requires them:
- Closed reduction involves realigning the bone back to its original position without the need to make an incision at the site of fracture
- Open reduction and internal fixation realign the fractured bone to its original position using hardware such as bone screws, orthopedic plates, and rods
The ankle will be placed into a cast or fracture boot until the process of healing is complete.
Clavicle (collarbone) fractures make up 44% to 66% of all fractures of shoulder. A doctor can often diagnose a clavicle fracture during a physical evaluation, but X-rays and other tests are often recommended. The fracture may also require surgical intervention when Orthopaedic or trauma Implant may be used to fix the fracture.
Diagnosing Clavicle Fractures
X-rays can help determine the extent and location of the injury. At times it is essential to distinguish between a clavicle fracture and an injury to the joint at the top of the shoulder, called the acromioclavicular joint. A CT scan may also be required for more detailed images.
During the physical examination, the physician may do the following tasks:
- Note areas of tenderness
- Observe skin discoloration
- Look for deformities
- Address any open wounds
- Palpate or touch the shoulder blade and ribs to determine if there is an accompanying injury
- Listen to the lungs with a stethoscope, and observe differences in breathing
- Evaluate the shoulder’s range of motion
A doctor may conduct a neurological examination to make sure that motor functions and sensation are normal. The clavicle is located near a series of nerves found based in the shoulder and neck called the brachial plexus. Injury to the brachial plexus is uncommon but can happen with a clavicle break.
The physician will also ask about the medical history of patient, how the injury occurred, and any symptoms associated with it.
Common Causes and Risk Factors of Clavicle Breaks
They may be caused by:
- An athletic event resulting in a fall or direct hit. Clavicle fractures related to sports are commonly seen in children and young adults. Caution is advised when playing contact sports- including rugby, football, and hockey- and when participating in “extreme” sports where falls can happen- such as skateboarding and biking.
- A fall on the shoulder or an extended arm.
- A direct hit to the shoulder in a collision of motor vehicle.
Falling on the shoulder is the common cause of clavicle fractures.
Risk factors for clavicle breaks include:
- Young age, reaching a high point between the ages of 10 and 19. The clavicle is not entirely developed until about 20 years of age.
- Advanced age in both females and males over the age of 70.
- The onset of osteopenia, which is the early stage of reduced bone maps that can eventually lead to osteoporosis.
While certain people are at greater risk for a clavicle fracture, they can affect any person.
Nonsurgical Treatment for a Clavicle Fracture
Nonsurgical treatment for a broken clavicle can include the following:
- A wrap or arm sling is typically worn after the break occurs. This helps to prevent arm movement as the collarbone recovers.
- Pain medication, typically nonsteroidal anti-inti-inflammatory drugs such as ibuprofen or naproxen, can be taken to reduce pain.
- Physical therapy exercises will be recommended once the collarbone starts to mend. The patient will start with mild movements to ease stiffness. More intense exercises will be added after the recovery of bone.
Surgical Treatment for a Clavicle Fracture
Clavicle surgery may be required if the fractured pieces of bone are not in their anatomical and correct location. (The medical term for this is a displaced fracture). In these cases, the bones need to be secured and moved to heal properly. Bone plates, bone screws, and pins are often used during the surgical process. Rehabilitation after surgery includes exercises that can be done at home or with a physical therapist.
Cervical or spine implants are orthopedic devices orthopedic surgeons use to decompress and stabilize the spine. These devices are implanted either from the front (anterior) of the spine or from the back (posterior). Information about anterior implants starts below.
The Aims Of Cervical Spine Surgery Include:
- Reduce pressure on the nerve(s) by decompression (for instance, surgically removing tissues pushing on a nerve).
- Stabilize the cervical spine by fusing 2 or more cervical vertebrae together.
Anterior Cervical Approach Implants
Interbody Cage or Spacers: Cages and spacers are placed between 2 vertebrae. Their purpose is to:
- Keep space between vertebrae (if space gets so narrow, nerve roots may be pinched).
- Preserve spinal alignment (for instance, a healthy neck has a specific curve; a spacer can facilitate restoring this curve).
- Promote spinal fusion (for instance, join (fuse) 2 or more vertebrae together).
Cages are available in various sizes and shapes; some are cylinder-shaped, and others are box-shaped. Cages are placed or fit into the spine between vertebrae. Usually, cages are made from bone, metal, plastic, or carbon fiber. Bone chips (autograft, allograft, other bone graft alternatives, or other bone growth stimulating materials (for instance, demineralized bone matrix) can be packed into the cage. During the months after surgery, the hope is the cage will allow and improve fusion between the vertebrae above and below. Fusion increases spine stability.
Spacers are solid devices and bone cannot be packed inside. A spacer is utilized to facilitate restoring or correct spine alignment.
Anterior cervical plates are attached to the front of 2 or more vertebrae. Bone plates help to:
- Increase the stability of the cervical spine immediately after surgery.
- Increase the chances for a successful solid fusion.
- Stabilize the cervical spine while healing.
- Help to reduce the time the patient can need wearing a cervical collar after surgery.
Plates are made with screw holes through which bone screws are positioned into the adjacent (to be fused) vertebral bodies to anchor the plates into an accurate place. Both plates and screws are available in various sizes and designs. Most plates are made from metal (mostly titanium); some are produced from plastics. Certain newer plates are manufactured from composite substances that dissolve after fusion happens. Some designs of the plate are self-compressing to help promote spinal fusion.
Artificial Cervical Discs
Spine surgeons of the world have an interest in cervical artificial discs to treat degenerative disease. It’s believed keeping movement between vertebrae is better than spinal fusion. Early studies report cervical artificial discs can help slow down the process or prevent adjacent level disc degeneration. The process is called disc arthroplasty. Artificial discs are produced from various materials. Some designs are all plastics and metal composites and other metal. There are numerous ongoing, and some finished, FDA trials of artificial discs underway in the United States. Devices are being cleared for sale and implantation as the studies show safety and efficacy compared to fusion in selected cases.
If your surgeon suggests cervical surgery, you may be encouraged that cervical decompression and stabilization processes are some of the most successful operations spine surgeons perform presently. Patients often have a rapid recovery and quickly return to activities of everyday living with marked improvement of their symptoms.
Siora Surgicals has launched its new orthopedic product range of spine surgery implants or cervical implants which includes Variable Angle Cervical Locking Plate and Cervical Locking Screws in titanium.
A fibula fracture occurs when there is an injury in the leg to one of the two bones of the leg. The leg (the segment between the ankle and knee) is made up of two bones. The larger bone, the tibia, carries most of the weight of the body). The smaller bone, the fibula, is located on the outside part of the leg.
The fibular bone starts just below the knee joint on the outside of the leg and extends all the way down to the ankle joint. The bone is a thin, long bone, hollow in its center. While the bone does little to support the body weight, it is a critical site of attachment for ligaments at both the ankle and knee joint and is also connected to the tibia by a thick ligament called the syndesmosis.
While the fibula is a significant bone, it is possible to extract much of the bone for surgical procedures where the bone is needed elsewhere in the body. When these grafting procedures are performed, people can function very normally, despite missing a large part of the fibula bone.
Types of Fibula Fractures
There are several types of injury to the fibula bone. For this discussion, I will divide them into more manageable topics:
- Fibula fractures that occur due to injury to the ankle joint
- Fibula fractures that occur in conjunction with tibia fractures
- Stress fractures of the fibula
These are not the only types of injury that can occur to the fibula but account for the majority of cases of injury to the fibula bone. By far the most common are injuries that occur when the ankle joint is damaged. Typically, the ankle buckles or is twisted and the fibula is injured as part of the injury.
As mentioned, fibula fractures can occur in association with injuries to the ligaments, other bones, tendons, and tendons around the knee and ankle. The most common symptoms related to the fibula fracture include:
- Pain directly over the fibula bone (outside of the leg)
- Swelling in the fracture part
- Bruising over the injury site
Diagnosis of a fibular fracture can typically be done with an x-ray image. Other imaging studies such as CT scan or MRI are typically not necessary, but there are some situations where a fibular fracture may not show up on a regular x-ray. These conditions include injuries such as stress fractures. Your physician will examine the injury site, the ankle and knee joints for associated injuries which may impact the treatment of the fibular fracture.
Fibula fractures typically occur as part of an ankle injury. Whenever a fibula fracture is found, the ankle joint should be examined for an injury that can be possible.
The most common kind of fracture to occur to the fibula bone is an isolated injury to the end of the fibula bone at the level of the ankle joint. These injuries occur in a similar manner to a badly sprained ankle, and mostly the injury can be treated similarly to a badly sprained ankle.
Fracture Of The Greater Tuberosity: Mechanism Of Fracture
This type of fracture occurs in the following cases of direct and indirect injury.
In cases of a direct injury, the patient falls with the arm in an abducted position. Here, the force is transmitted in an upward direction along the humerus (the long bone in the upper arm). The greater tuberosity encroaches against the acromion process which further leads to the upper end of the humerus fracture.
In other cases, such fractures can occur due to an indirect injury which usually happens before the epiphyseal union. Sudden contraction of the supraspinatus muscle (supraspinatus is a relatively small muscle of the upper back) can produce separation of the greater tuberosity. In the adult age group, the same contracting force the supraspinatus muscle can lead to tearing of the supraspinatus tendon. Our company manufactures Locking Distal Humerus Plate Medial Side 2.7 / 3.5mm for distal humerus fracture.
Proper diagnosis is very important in all kinds of fractures. Some of the common symptoms that patients often complaints include pain and swelling around the shoulder area. Also, the abduction movement is painful, restricted, or absent X-ray diagnosis or Radiological evidence substantiates the fracture.
While going through the X-ray diagnosis, two views should be taken. Further, the amount of parting of the greater tuberosity must be considered cautiously.
The lesion in case of fracture of the upper end of the humerus can be of the following five types.
I. Fracture without displacement.
II. Nominal displacement of the fragment.
III. Comminuted fracture without displacement.
IV. Under the acromion process, a small piece of bone is pulled upwards
V. Fracture with a coarse displacement of a large piece of bone.
In the case of fracture of the upper end of humerus, it is very important to diagnose the condition early and properly. If the condition is not recognized and properly treated, a disability may appear like the abduction disability of the shoulder.
The treatment varies as per the diagnosis. In cases where there is no displacement, a reduction is not required. A simple cuff and collar sling which provides more mobility is useful. Doctors generally prescribe an early exercise of the joints of the limb.
In patients where displacement is there in fracture diagnosis, reduction, as well as maintenance of this reduction of the fracture, is fundamental.
Orthopedic implants experts also use conservative treatment in such cases. In this type of treatment, the affected limb is immobilized in an orthopedic implant like an abduction splint or a plaster spica. It is used to provide an abduction of 30, 60 & 90 degrees. Here, the shoulder is maintained at 90° abduction, 60° external rotation, and 40° forward fixed position. An X-ray of the joint is then done to confirm the reduction. Immobilization or restriction in movement is continued for a period of six weeks.
An operation may also be needed in some cases as discussed below.
In the first case, where there is a failure of closed reduction, fixation of the tuberosity by suture or screw may be required.
In some other cases where the fragment is small, it should be excised and the supraspinatus tendon which passes laterally beneath the cover of the acromion is sutured to the humerus.
Lastly, the after-treatment involves the immobilization of the arm in an abduction splint.
Ankle Arthrodesis/fusion is the end-stage procedure for the treatment of ankle arthritis. Other options available for treating arthritis of the ankle is Joint Replacement Surgery. So, when selecting between arthrodesis and replacement as the optimum procedure for a patient the important considerations are-
1) Infrastructure: – Well equipped OT and Trained Staff
2) Availability of Implants: – Total Ankle still not available in India even in December 2019.
3) Patient’s expectations after surgery: – Total Ankle tolerated well in urban lifestyle.
4) The longevity of the Implant: – 85% survivorship at 10 years in the best of the series.
In low demand patients and financially sound Individuals, arthroplasty finds favor as the cost of the surgery is above 8000 US$.
On all the above counts’ Fusion/ Arthrodesis scores over Arthroplasty. It has been proven beyond doubt that ankle fusion does not produce a bad walking pattern, while it takes away the pain from an individual whose life is already severely compromised due to painful arthritis of the ankle.
Ankle Arthrodesis can be done by either open or arthroscopic techniques:
1) Open Technique: – For moderate to severe deformities. Healthy skin is mandatory for open procedures. Various approaches used are Anterior, Lateral, Lateral+medial, Medial & Posterior.
2) Arthroscopic Technique: – For mild deformities i.e. less than 15 degrees of varus or valgus tilt in the coronal plane. Preferred in the presence of compromised skin and diabetic patients.
Fixation Methods: – Screws, Anterior Plate, Lateral Plate
Plates are used to achieve more stiffness of arthrodesis especially in the presence of osteoporosis.
Fixation by 3 compression screws is biomechanically similar to that of plate
( Clifford C, Berg S, McCann K, Hutchinson B, A biomechanical comparison of internal fixation techniques for ankle Arthrodesis. The Journal of Foot Ankle Surgery 2013;54:188-191).
Dr. Kamal Dureja.
Head of Foot & Ankle Surgery Unit,
Max Smart Superspeciality Hospital, Saket
Dr. Shantanu Bhardwaj.
Fellow in Foot & Ankle Surgery,
Max Smart Superspeciality Hospital, Saket
Implants removal belongs to the foremost common elective orthopedic procedures in industrial countries. In an often-cited Finnish study, implant removal contributed to almost 30 percent of all planned orthopedic operations, and 15 percent of all operations of the department.
Controversy exists as to the necessity for routine orthopedic implant removal. In children, it can be essential to remove implants early to avoid disturbances to the growing skeleton, to avoid their bony confinement making later removal technically hard or impossible, and to enable for planned reconstructive surgery after skeletal maturation (for example, in case of hip dysplasia).
In adults, pain, the resumption of strenuous activities or contact sports after fracture healing, soft tissue irritation, as well as the demand of patient are typical indications for removal of the implant in clinical practice. Numerous surgeons will remember patients whose intractable, barely explainable local symptoms and complaints resolved rapidly after the procedure. Though, ortho implant removal needs a second surgical procedure in scarred tissue and poses a risk for re-fractures and nerve damage.
Pain can even get worse after implant removal. In a series of 109 femoral nail removals, a rise in pain and discomfort was noted in 4/58 (7 percent) of all patients with, and 10/51 (20 percent) of all patients without pre-operative signs. Similar observations were made in subjects who had experienced open reduction and internal fixation of ankle fractures.
Corrosion, systemic release of nickel, cobalt, and chromium, and it’s presumed allergic, toxic, and even carcinogenic potential have been related to stainless steel implants. Yet, none of these adverse effects had influentially been confirmed in the clinical setting. Orthopedic fixation devices made from titanium alloy are considered less vulnerable to degradation and safe to be retained in situ, but aluminum and titanium had been traced in serum and hair of 16 out of 46 patients after spinal instrumentation as well.
It is best to surmise that decision to remove an Orthopedic implant should be taken in consultation with the Surgeon who can help evaluate the need, effectiveness, and risks of this common procedure in different clinical settings.