Complications of Intramedullary Nailing & Ex Fix
JEFFREY MANWAY, DPM
PROGRAM DIRECTOR
UPMC MERCY PODIATRIC SURGICAL RESIDENCY
UPP DEPT OF ORTHOPAEDICS IM Nailing Overview of Complications
• Infection
• Iatrogenic fracture
• Hardware failure (nail fracture)
• Non-union
• Embolus? History of IM Nails
Initial IM concept ◦ Prof Gerhard Kuntscher ◦ IM nailing WWII1940s ◦ GI returning home
Limited soft tissue damage
Rigid fixation
Early return for certain applications Goal
Eliminate complications
- Lower infection rate
- Increase stiffness/stability
- Return patients to weightbearing Contraindications
Acute infection Proximal IM nail placement
Previous pathology of the heel Peripheral Arterial Disease? ◦ OM Non-neuropathic patients? ◦ Previous hardware ◦ Bone loss Severe frontal deformity? ◦ Bayonet of the tibia Heel ulceration or history of ulcer? Previous trauma ◦ Sclerosis? Advantages
Super Constructs ◦ Largest/most powerful device soft tissue will allow ◦ Truncation of foot/ankle for correction of deformity ◦ Application of a device in position of mechanical advantage ◦ Span outside zone of deformity Other Advantages
•Speed of application
•Permits substantial deformity correction
•Large surface area • Increased stability
•Load sharing device • Decreases stress shielding Infection
Intramedullary nail versus external fixator • IM nail compared to ring fixation for ankle arthrodesis in Charcot • 2x fusion rate in the nail group neuroarthropathy: A meta-analysis of • Significant increased infection rate in Ex fix comparative studies group ◦ J. Orthopedic Surg 2019 • Hardware and wound infection Infection/Non-union
Uncontrolled diabetes as a potential risk 82% Union rate factor in tibiotalocalcaneal fusion using a ◦ 5 non-unions and 2 BKAs attributed to retrograde intramedullary nail uncontrolled DM ◦ Foot Ankle Surg 2018 ◦ Increased failure rate with odds ration of 10 Infection/Non-Union
Tibiotalocalcaneal Arthrodesis With the 20 Patients Hindfoot Arthrodesis Nail: A Prospective Consecutive Series From a Single Institution • 95% “favorable outcomes” • J. Foot Ankle Surg 2018 • Superficial wound infection 20% • Deep wound infection 15% • Below the knee amputation 5% • Non-union • 20% ankle fusion • 20% STJ fusion • 80% Tib-calc fusion Non-union
[Ankle arthrodesis with intramedullary 137 Fusions compression nailing] • Initial 10% nonunion rate • Unfallchurig 2003 • Secondary portion responded to “re- compression and bone grafting”
• 1 Tibia shaft fracture
• Infections (3 superficial/8 deep) Non-union?
Re-arthrodesis after primary ankle fusion: 134/1,716 patients required revision after 134/1,716 cases from the Swedish Ankle ankle fusion Registry ◦ Compared IM Nail, Screw and arthroscopic ◦ Acta Orthop 2018 ◦ Arthroscopic significantly higher rate of re- operation rate Non-union
Locking plate versus retrograde Compared locked plate vs. IMN intramedullary nail fixation for • Union rate 90.6 vs. 95.4 tibiotalocalcaneal arthrodesis: A retrospective analysis • Trend toward lower complication rate in locked plate group • Indian J Orthop 2015 INFECTION
Deceased 2 years from ankle surgery Simpler Great! Oooh… Don’t freak out Worse
Cutout Positioning Your Incisions/Pins
Joint Prep is the easy part ◦ Ankle prep is possible anterior, posterial, medial, lateral or arthroscopic ◦ Plantar incision ◦ Make it long enough ◦ Make it lateral enough ◦ Lateral 1/3 rd of the heel ◦ Posterior heel incision ◦ Vertical vs. Horizontal?
Revision
Underwent Revision
• Still a problem
• Calcaneus is now insufficient
• BKA vs. Hail Mary Screw Application
Pay Attention to your insertion points ◦ Skin and Xrays ◦ Calcaneus and Talus
Cross-locks ◦ 1 or 2? ◦ Dynamic or Static ◦ Be careful and don’t be anterior ◦ Don’t risk it – go higher or lower ◦ Tap it in!
Bad technique + bad decision + bad problem = … Bad Outcome Consider Long Nails
• Pass the Isthmus of the tibia • Less likely for stress fracture • Increases working length of nail and stress distribution ** Requires perfect circle technique in certain nails Perfect Circles Locking proximal tibia, free hand
47 2nd Chances
51 Infection
Deceased 6 months post Broken nail External Fixation Complications
Special Thanks To Patrick Burns, DPM
The picture can't be displayed. Indications
History of infection
Poor bone
Soft tissue compromise
Charcot
Fixation Augmentation
Bone transport
Dynamic Correction Fixation Types
• Pin & Bar Fixators • Uniplanar • Multiplanar
• Ring External Fixation Possible Complications
•Superficial Pin Infection •Pin Breakage
•Deep Pin Infection •Cage rage? • Cloaca •Loss of fixation • Brodie’s Abscess •Frame impingement •Tibia Fracture •Non-union •Skin tenting/Complications Why?
• Technique • Bad positioning • Too much heat • Not enough stability
• Host • DM w/ neuropathy • H/o infection • Non compliance • Swelling Ankle fusion
21 ex fix v 26 internal fixation
65 •26 internal fixation • 15 complications • Fusion 85% • 2 infections • 1 controlled with oral • 4 nonunion • 4 malunion • 5 soft tissue necrosis
66 •21 ex fix • 13 complications • Fusion 100% • 8 infected pins • 6 controlled by oral abx • 2 vascular injuries with repair • 3 soft tissue necrosis
67 •Pilon fx (AO/OTA 43) •133 fx •Ex pin location impact on infection
•Zone of injury
68 •22 deep infections (16.5%) • 81.8% of those were open 18/22
•Avg distance for all 62.2 +/-48.5 with 8/133 overlapping
•Infected 62.2mm v non infected 62.1mm • NOT sig
69 •159 pilon fx •Hybrid exfix •48 pt pin infx • All tx oral abx •2 hardware failure • 1 required revision fixation
•Pins in “zone?”
70 Post-op care of external fixation
•Want tight seal of skin to wires •Limit amount of “pin care” •Remove crust 1-2 times weekly • Soap/water • Saline • Alcohol • Chlorhexidine •No hydrogen peroxide
71 Super sized Fixation of the super super obese open acute ankle charcot neuroarthropathy Longest bars in the tray Spacing 2 in the Front, 3 in the Back
75 Pin site infection
•No specific definitions
•0-100%
•Reaction • Normal change in color, warmth, drainage resolves 72hrs
•Colonization • Erythema, warmth, drainage, pain
•Infection • Purulence, loosening
•Major v minor
76 Pin site infection risk factors
•Patient factors • Comorbidities • Application • Style of fixator • Stability • Muscle, skin, movement • Immunocompromised • Tension on skin • Smoking • Length of time • Static v dynamic frame
77 Infectious complications
•43 pts with external fixation •11 pts treated for Charcot reconstruction •51.2% major complication rate • Charcot not separated out
78 Infectious complications
•15 pts, 16 fixators •Complications • 5 major pin tract • 4 pin fractures • 9 wound dehiscence •10/16 operations had serious pin related complication (62.5%) •What are the associated variables? • Younger age 51 v. 63 • Pre-operative blood glucose 193 v. 141 • Long tourniquet times 119 v. 74 Infectious complications
•56 pts with external fixation •23 pts with DM vs 33 control •More complications in pts with DM 44 vs 14 • Minor ie. did not change treatment plan • 27 vs 10 • Major ie. required change • 17 vs. 4 •More complications in male pts • 40 vs 18 •Complications per pt • 1.3/DM vs 0.6/control Pin site infections
•NaCl v alcohol • No difference • Henry Pract Nurs 1996
•Any solution v nothing • No difference • Cannot promote any one alone
•Frequency • May cause infection
•Daily v weekly • No difference • W.Dahl Acta Orthop 2006
81 Pin site infections
•Weekly dressing v abx disks • No difference
•Dressings • No superiority • Xeroform, gauze, betadine gauze • Antibiotic ointment
•Showering • Once wound healed
•Antibioitics • 24 hr v 3 day • No difference
82 What seems to be accepted
•Preop abx and 24 post •Pre-drill •Use sharp pins •Use proper technique •No tension on skin •Make stable •Clean 1-2 times week • Soap, water, or alcohol •Dry gauze at pin sites •Shower when incisions, wounds healed
83 If concerned
•Increase frequency of cleaning •Oral antibiotic •Reduce activity if pertains •Elevate leg
•Remove loose pins •Revise fixator •Revision of frame
84 Skin-wire interface
85 86 87 Application Issues
Ex Fix Choices
Poor pin placement
99 Broken hardware
100 101 102
Chronic osteomyelitis but stable
104 Deep pin site, osteomyelitis
105 106
Thank you