Distal aiming device versus free hand technique for distal locking screw insertion time in femoral nail: A prospective cohort study
Keywords:
fracture femoral, femoral diaphysis, nailing, distal locking screw, aiming deviceAbstract
Background: Distal locking screw placement is a challenging procedure for intramedullary nail of femoral shaft fracture. Assisting by aiming device may decrease operative time and reduce radiation exposure time compared to free hand technique.
Objectives: To compare the operative time for locking distal screw, fluoroscopic time and numbers of fluoroscopic shot for locking distal screw in two different techniques which were aiming device and free hand techniques.
Research Methodology: A prospective cohort study conducted in patients with femoral shaft fractures were treated using intramedullary nails, with two different techniques for distal locking screw insertion: the freehand technique and the aiming device technique. This study was conducted between July 1, 2020, and April 1, 2022, at Nakornping Hospital in Chiang Mai, Thailand. The primary outcome measured was the distal screw insertion time. Secondary outcomes included fluoroscopic time and the number of fluoroscopic shots during distal screw insertion. According to data analyses, intention-to-treat strategies were applied. T-tests, the rank-sum test, and Fisher's exact probability test were performed to compare the differences.
Results: Thirty patients underwent the aiming device technique, while 28 patients received the freehand technique. Although there was no significant difference in distal screw insertion time between the two methods, the aiming device technique significantly reduced fluoroscopic time, with median values of 19 seconds (range: 24.3-224 seconds) compared to 52.5 seconds (range: 35.5-103 seconds), p-value < 0.001. In the aiming device group, eight patients (26.67%) were switched to the freehand technique, primarily due to infra-isthmal femoral fractures, with a conversion rate of 62.5% in these cases (p-value < 0.05).
Conclusion: The study found no statistically significant difference in screw insertion time between the group using an aiming device and the group using freehand technique. However, the group using the aiming device required significantly less fluoroscopic assistance during surgery. Nonetheless, there was a higher likelihood of switching to the freehand technique, particularly in cases of infra-isthmal femoral fractures.
Thai Clinical Trial Registry: TCTR20230221005
References
Arneson TJ, Melton LJ 3rd, Lewallen DG, O'Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res. 1988;(234):188-94.
Bengnér U, Ekbom T, Johnell O, Nilsson BE. Incidence of femoral and tibial shaft fractures. Epidemiology 1950-1983 in Malmö, Sweden. Acta Orthop Scand. 1990;61(3):251-4. doi: 10.3109/17453679008993511.
Enninghorst N, McDougall D, Evans JA, Sisak K, Balogh ZJ. Population-based epidemiology of femur shaft fractures. J Trauma Acute Care Surg. 2013;74(6):1516-20. doi: 10.1097/TA.0b013e31828c3dc9.
Salminen S, Pihlajamäki H, Avikainen V, Kyrö A, Böstman O. Specific features associated with femoral shaft fractures caused by low-energy trauma. J Trauma. 1997;43(1):117-22. doi: 10.1097/00005373-199707000-00027.
Salminen ST, Pihlajamäki HK, Avikainen VJ, Böstman OM. Population based epidemiologic and morphologic study of femoral shaft fractures. Clin Orthop Relat Res. 2000;(372):241-9. doi: 10.1097/00003086-200003000-00026.
Wolinsky PR, McCarty E, Shyr Y, Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma. 1999;46(3):392-9. doi: 10.1097/00005373-199903000-00007.
Bezabeh B, Wamisho BL, Coles MJ. Treatment of adult femoral shaft fractures using the Perkins traction at addis Ababa Tikur Anbessa University Hospital: the Ethiopian experience. Int Surg. 2012;97(1):78-85. doi: 10.9738/CC48.1.
Gosselin R, Lavaly D. Perkins traction for adult femoral shaft fractures: a report on 53 patients in Sierra Leone. Int Orthop. 2007;31(5):697-702. doi: 10.1007/s00264-006-0233-5.
Alonso J, Geissler W, Hughes JL. External fixation of femoral fractures. Indications and limitations. Clin Orthop Relat Res. 1989;(241):83-8.
Broos PL, Miserez MJ, Rommens PM. The monofixator in the primary stabilization of femoral shaft fractures in multiply-injured patients. Injury. 1992;23(8):525-8. doi: 10.1016/0020-1383(92)90151-h.
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48(4):613-21. doi: 10.1097/00005373-200004000-00006.
Geissler WB, Powell TE, Blickenstaff KR, Savoie FH. Compression plating of acute femoral shaft fractures. Orthopedics. 1995;18(7):655-60. doi: 10.3928/0147-7447-19950701-13.
Loomer RL, Meek R, De Sommer F. Plating of femoral shaft fractures: the Vancouver experience. J Trauma. 1980;20(12):1038-42. doi: 10.1097/00005373-198012000-00005.
Riemer BL, Butterfield SL, Burke CJ 3rd, Mathews D. Immediate plate fixation of highly comminuted femoral diaphyseal fractures in blunt polytrauma patients. Orthopedics. 1992;15(8):907-16. doi: 10.3928/0147-7447-19920801-07.
Rüedi TP, Lüscher JN. Results after internal fixation of comminuted fractures of the femoral shaft with DC plates. Clin Orthop Relat Res. 1979;(138):74-6.
Canadian Orthopaedic Trauma Society. Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am. 2003;85(11):2093-6.
Tornetta P 3rd, Tiburzi D. Reamed versus nonreamed anterograde femoral nailing. J Orthop Trauma. 2000;14(1):15-9. doi: 10.1097/00005131-200001000-00004.
Wiss DA, Fleming CH, Matta JM, Clark D. Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin Orthop Relat Res. 1986;(212):35-47.
Wattanakitkrileart S, Tangtrakulwanich B, Yuenyongviwat V. Comparing Results between New Aiming Device and Freehand Technique for Distal Locking of Intramedullary Implants. J Med Assoc Thai. 2016;99(11):1180-4.
Uruc V, Ozden R, Dogramacı Y, Kalacı A, Dikmen B, Yıldız OS, et al. The comparison of freehand fluoroscopic guidance and electromagnetic navigation for distal locking of intramedullary implants. Injury. 2013;44(6):863-6. doi: 10.1016/j.injury.2012.12.009.
Han B, Shi Z, Fu Y, Ye Y, Jing J, Li J. Comparison of free-hand fluoroscopic guidance and electromagnetic navigation in distal locking of femoral intramedullary nails. Medicine (Baltimore). 2017;96(29):e7450. doi: 10.1097/MD.0000000000007450.
Maqungo S, Horn A, Bernstein B, Keel M, Roche S. Distal interlocking screw placement in the femur: free-hand versus electromagnetic assisted technique (sureshot). J Orthop Trauma. 2014;28(12):e281-3. doi: 10.1097/BOT.0000000000000125.
Kanellopoulos AD, Yiannakopoulos CK, Vossinakis I, Badras LS. Distal locking of femoral nails under direct vision through a cortical window. J Orthop Trauma. 2003;17(8):574-7. doi: 10.1097/00005131-200309000-00006.
Barrick EF. Distal locking screw insertion using a cannulated drill bit: technical note. J Orthop Trauma. 1993;7(3):248-51. doi: 10.1097/00005131-199306000-00009.
Suhm N, Messmer P, Zuna I, Jacob LA, Regazzoni P. Fluoroscopic guidance versus surgical navigation for distal locking of intramedullary implants. A prospective, controlled clinical study. Injury. 2004;35(6):567-74. doi: 10.1016/S0020-1383(03)00312-7.
Chan DS, Burris RB, Erdogan M, Sagi HC. The insertion of intramedullary nail locking screws without fluoroscopy: a faster and safer technique. J Orthop Trauma. 2013;27(7):363-6. doi: 10.1097/BOT.0b013e3182828e10.
Krettek C, Könemann B, Miclau T, Kölbli R, Machreich T, Tscherne H. A mechanical distal aiming device for distal locking in femoral nails. Clin Orthop Relat Res. 1999;(364):267-75. doi: 10.1097/00003086-199907000-00033.
Rohilla R, Singh R, Magu N, Devgun A, Siwach R, Gulia A. Nail over nail technique for distal locking of femoral intramedullary nails. Int Orthop. 2009;33(4):1107-12. doi: 10.1007/s00264-008-0579-y.
Hashemi-Nejad A, Garlick N, Goddard NJ. A simple jig to ease the insertion of distal screws in intramedullary locking nails. Injury. 1994;25(6):407-8. doi: 10.1016/0020-1383(94)90139-2.
Cheng H, Chen BP, Soleas IM, Ferko NC, Cameron CG, Hinoul P. Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review. Surg Infect (Larchmt). 2017;18(6):722-35. doi: 10.1089/sur.2017.089.
Wills BW, Sheppard ED, Smith WR, Staggers JR, Li P, Shah A, et al. Impact of operative time on early joint infection and deep vein thrombosis in primary total hip arthroplasty. Orthop Traumatol Surg Res. 2018;104(4):445-8. doi: 10.1016/j.otsr.2018.02.008.
Wang Q, Goswami K, Shohat N, Aalirezaie A, Manrique J, Parvizi J. Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty. J Arthroplasty. 2019;34(5):947-53. doi: 10.1016/j.arth.2019.01.027.
Ko S, Kang S, Ha M, Kim J, Jun JK, Kong KA, et al. Health Effects from Occupational Radiation Exposure among Fluoroscopy-Guided Interventional Medical Workers: A Systematic Review. J Vasc Interv Radiol. 2018;29(3):353-66. doi: 10.1016/j.jvir.2017.10.008.
Balter S, Miller DL. Patient skin reactions from interventional fluoroscopy procedures. AJR Am J Roentgenol. 2014;202(4):W335-42. doi: 10.2214/AJR.13.12029.
Stahl CM, Meisinger QC, Andre MP, Kinney TB, Newton IG. Radiation Risk to the Fluoroscopy Operator and Staff. AJR Am J Roentgenol. 2016;207(4):737-44. doi: 10.2214/AJR.16.16555.
Shope TB. Radiation-induced skin injuries from fluoroscopy. Radiographics. 1996;16(5):1195-9. doi: 10.1148/radiographics.16.5.8888398.
Patra SK, Patro BP, Samal S, Sahu MC, Mohanty BB. Distal locking of femoral nails:a prospective comparative study of two different fluoroscopy assisted techniques. Int Surg J. 2016;3(1):237-40.
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