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Journal of case reviews from the SIGN Surgical Database.

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Proximal Tibia Fractures – Reduction and Stabilization

Posted by on Nov 5, 2014 in Journal of Database Reviews | 3 comments

The literature has many articles about reduction of proximal tibia fractures. These include using blocking screws, provisional plating and suprapatella approach( the fracture is reamed and the nail is introduced above the patella to enter the bone entrance of the tibia)

SIGN surgeons have solved the problem of reduction of the proximal tibia by using the figure 4 position as shown in the technique manual. Please put your own leg in the figure 4 position and you can see why a valgus malreduction is unlikely.

The proximal fragment above the fracture should be pressed into flexion by the surgical assistant. Using this position of figure 4 and pressing the proximal fragment will reduce the fracture. During this technique of flexion of both the knee and the fragment, the reamer and nail does not strike the patella as they are inserted. The fracture site therefore is reduced.

We have not found it necessary to place the incision more lateral which also decreases the possibility of valgus malreduction.

Complications Resulting In Instrument Damage

Posted by on Jan 31, 2014 in Journal of Database Reviews | Comments Off on Complications Resulting In Instrument Damage

Complications resulting in instrument damage:

  • striking the cutting edges of instruments such as reamers, step drills and drill bits. These nicks cause the cutting edges to heat up during use and become dull. All of us have felt a hot drillbit after we remove it.
  • Allowing the drillbit to spin rapidly without advancing in the bone. The drillbit will heat up and become dull
  • not removing the bone from the flutes of the drill bit will also result in slow cutting progress, heating up of the drill with subsequent dulling
  • using an electric drill or a drill with improper drilling speeds. Technique of drilling is on the SIGN webpage
  • Allowing the cutting edges of instruments to be hit by other instruments during cleaning and sterilizing
  • rotating a cutting instrument in a reversed direction as the cutting-edge. Reamers, drill bits and step drills should be used clockwise both in insertion and withdraw
  • hitting the L-Handle will damage it which will affect the distal interlock.
  • Bending the cannulated slot finder which is not as strong as the solid slot finder. Once this is bent, it will not enter the slot in the nail nor will the depth gauge go through the slot Finder
  • bending the depth gauge during use may create a permanent curve. This curve may prevent the depth gauge from passing completely through the cannulated slot finder.
  • Using heavy mallet blows during insertion of the nail will bend the nail. The distal interlock must then be found using the curved slot Finder after removing the target arm
  • forcing the cap screws and shoulder bolt into the recipient threads ruins the threads. If the shoulder bolt does not progressed easily, look at the junction between shoulder bolt and target arm. If the second cap screw does not enter the proximal and distal target arms easily, perhaps the first screw is too tight
  • bending the target arm if the cannula does not rest on femur bone. The Screws may be loosened to allow the target arm to be in a position so the cannula will enter the bone

Aspects of the SIGN Technique

Posted by on Jan 20, 2014 in Journal of Database Reviews | Comments Off on Aspects of the SIGN Technique

During travel I have a chance to think about different aspects of SIGN technique. We are grateful to our friends in Vietnam and Laos for their hospitality during recent trip.

Points to ponder

  • During reaming, sometimes the reamer does not advance. Reason – the canal is oval and the reamer may be out of the track reamed by previous reamers. The surgeon should feel the reamer reaming the canal during most of the 360°. Regulate your pressure of reaming to allow the right speed of advancement. Sometimes the reamer must be removed approximately 4 cm and then restarted. Turn the reamer clockwise during removal as well as advancement.
  • When using the step drill, a similar mechanism occurs. The point of the step drill must follow the pilot hole from the small drill bit. Sometimes the step drill must be redirected. Look at the step drill and the reamer during use to be sure they remain on the proper course. Sometimes frequent changes of direction make reaming difficult.
  • If your program is short of nails, be sure reporting is up to date. Having a list of nail sizes available posted on the wall will make the surgery go faster. The nurses will not have to look through the nails that have been sterilized.
  • There are different ways to increase efficiency when choosing the proper size nail. These include sterilizing each nail separately so the surgeon can call for the proper size. Some programs have a cloth container for nails.
  • Care of instruments is important. When the cutting edges of the reamers, step drill and drill bit are struck against other metal, a small nick occurs. This leads to dullness of the instrument.
  • Use the technique of drilling recommended on our webpage. Pulse the drill and do not let it remain in the same area while trying to drill. The drill bit heats up and becomes dull.
  • Use a drill cover if you use a hardware drill for stability. We are looking for some enterprising group to make these drill covers from cloth in each country. We will be happy to supply the pattern.
  • If you have other points, please share them with us and we will place them on SIGNsurgeons.

Two Proximal Interlocking Screws vs. One

Posted by on Jul 8, 2013 in Journal of Database Reviews | Comments Off on Two Proximal Interlocking Screws vs. One

Fractures in the proximal femur if treated by antegrade approach should be stabilized by two interlocking screws in the proximal fragment.

Reason the gluteus medius and minimus cause the proximal fragment to abduct. The piriformis, gemellus  superior and inferior cause the proximal fragment to externally rotate. The psoas, which may be detached  by a fracture through the lesser trochanter, is a flexor and external rotator of the hip. The distal fragment is adducted by the adductor muscle group. These forces must be neutralized by the fixation. This is best accomplished by two proximal interlocking screws rather than one.

Reduction is different than other fractures because both proximal and distal fragments must be manipulated for reduction rather than reducing the distal shaft to the proximal shaft.

Experienced SIGN surgeons use two proximal interlocking screws. New SIGN surgeons must learn by experience.

That is a value of followup x-rays and reports.

Stop Smoking

Posted by on Jan 28, 2013 in Journal of Database Reviews | Comments Off on Stop Smoking

A paper presented at 2007 OTA meeting, a paper entitled “managing acute infectious after ORIF with hardware in place” stated that a 69% of fracture healed with hardware in place after soft tissue debridement and suppressive antibiotics.  A big subgroup of smokers should be noted. Smokers who had infection with retained hardware had high a risk of failure when the hardware was left in. They also had problems when the hardware was removed. Patients should be advised to stop smoking.

Peroneal Palsy

Posted by on Dec 21, 2012 in Journal of Database Reviews | Comments Off on Peroneal Palsy

I have not seen any reported cases of peroneal palsy due to the proximal interlocking screws after SIGN fixation of tibia fractures. The anatomy is recorded in Journal of Bone and Joint Surgery-British in 2007. We should look for damage to the peroneal nerve in SIGN nail fixation of tibia fractures.