Date: Sun, 30 Dec 2001 12:09:36 +0500

From: Alexander Chelnokov

Subject: Awl or cannulated cutter?

Hello All,

Merry XMas and HNY!

I've got a cannulated cutter with a protective sleeve in a closed nailing set. But since my first case of the nailing 9 months ago i've been using an awl to make the entry. So the question is maybe i am wrong and the cutter should be preferred? What benefits does it offer? As i realize at the moment the sleeve is more thick than awl so requires more long incision.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia

Date: Sun, 30 Dec 2001 10:09:10 -0600

From: Adam Starr

Hi Alex,

If you're already making a small incision with the awl, then I think any benefit of the cannulated cutter will be minimal.

Percutaneuous technique is nice - the patients like small scars, and I think it may lead to less abductor weakness and less pain after surgery.

If you can do a small incision and get your piriformis fossa start using the awl, I think I'd keep using the awl.

We're making smaller and smaller incisions to place femoral nails here in Dallas. The limiting factor is really the jig attached to the nail. The jigs are old designs, not really made for percutaneous use. You can get your staring hole, ream, and even place the nail part way into the bone thru an incision that's about 1.5cm long...but then the jig usually gets hung up on the skin as you drive the nail down, and you wind up having to make a bigger incision.

What I need is a nail system designed for percutaneous use.

I'm glad you got a nail set. Have fun, and Happy New Year.

Adam Starr
Dallas, Texas

Date: Sun, 30 Dec 2001 08:59:26 -0800

From: Chip Routt

Both Synthes and Zimmer systems have percutaneous insertion devices for their femoral nails. Others may as well.

The Synthes percutaneous system for their Universal Femoral Nail has been available for at least 8 years here. We've enjoyed it. This has been an excellent device/system for treatment and teaching.

You can also use the terminally threaded guidepin and center drill portion of the triple reamer from the Dynamic Hip Screw (DHS) system to "percutaneously" create a perfect proximal femoral (or other) medullary starting point. Any narrow diameter, sharp tipped device with a handle remote from the imaging field is functional for this purpose.

Try this - use the same technique that you would prefer to have if you (or a family member) were a patient.

Chip

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
University of Washington
Harborview Medical Center
Seattle, WA

Date: Mon, 31 Dec 2001 18:43:16 EST

From: OTS1

To Adam Starr,

i read your email about the problem with old nail systems. TRIGEN offers all of the things you want, 1 inch incision, protective sleeves, easy channel opening, simple insertion, and jigs designed for surgeons so that you don't have to increase your incision just to get the nail in. It is true that i am biased, however we designed this system for surgeons, because of our frustration with the many instrument sets and archaic instruments we are all forced to use. In fact if you are still using a 3 mm ball tip guide wire and need to exchange over a chest tube, you are using techniques that Kuntcher and his boys developed during the " big one". I got tired of jury rigging everything so this system goes the next step. Percutaneous extraction is also easy using the instruments so you don't have to make a bigger incision just to get the nail out. And of course, the same instruments are used ( 1 set) for antegrade femur piriformis and trochanteric insertion, recon nail, retrograde femur, tibia, and supracondylar nail. Should solve alot of problems. However this is the last thing I will say on the subject as I am certain some readers will think I am using this forum inappropriately. I am not, I just think there is a need to know what is out there. Have a good new year.

Roy Sanders, MD,
Tampa, Florida

Date: Mon, 31 Dec 2001 18:52:40 -0500

From: Charles Blitzer

I like the system but do you plan to have it available in stainless?

Charles Blitzer

Date: Tue, 1 Jan 2002 09:03:28 +0530

From: Dr. T I George

Dear all,

May I take the freedom to share some of my problems in interlocking. I really do not know how many of you face similar problems. May be some of it could be secondary to limitation of instrumentation availability in the part where I work. May be some of them due to design problems in the implants.

INSERTION: This usually requires a fairly large incision for antegrade femoral nailing. Getting into the pyriformis fossa is not difficult in a thin patient. But in those who are generously built in the hip region this has been difficult. One trick has been to adduct the affected limb. When the tensor fascia lata is tight this again becomes problematic on a fracture table or even in the ordinary table top.

LOCKING BOLT DESIGN PROBLEMS: I have been using freehand technique for locking the distal holes. I have been particularly finding it difficult to use the bolts supplied by Smith and Nephew for RT and Recon nails.At the same time Synthes locking bolts were found easier to use. On comparison I find that the Smith and Nephew bolts were blunter at the tip and the threads were found to be more difficult to negotiate the cortical bone. Both were self tapping but Synthes was definetely user friendly.Is it my faulty technique or something else. I had e-mailed Smith and Nephew recently about this problem but am yet to get their response.

Anybody with similar problem and solutions for the same?

Dr. T. I. George,
Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital,
Trichur, S. India

Date: Tue, 1 Jan 2002 16:01:35 +0500

From: Alexander Chelnokov

Hello Roy,

Oac> To Adam Starr,

i read your email about the problem with old nail systems. TRIGEN offers all of the things you want, 1 inch incision, protective sleeves, easy channel opening, simple insertion, and jigs designed for surgeons

It seems to me that i already posted the question when ped/adolescent fractures were discussed but it was either lost or ignored. Could you pls provide more details about the system? What nails are used? How much is the set and implants? If the commercial information is not relevant to the list pls reply directly to my e-mail.

THX in advance and HNY.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia

Date: Tue, 1 Jan 2002 16:33:03 +0500

From: Alexander Chelnokov

Hello Dr. George,

DTIG> been difficult. One trick has been to adduct the affected limb. When the tensor fascia lata is tight this again becomes problematic on a fracture table or even in the ordinary table top.

It seems to me that the problem can be solved by using a distractor instead of the fracture table.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia

Date: Tue, 1 Jan 2002 18:13:54 EST

From: OTS1

no the system is only available in titanium alloy, as are most newer systems. Among other things it has an advantage in that you can MRI around the implants without a problem.

the question of distal locking bolts is addressed in the TRIGEN system by having the screw actually locked (screwed in - captured) to the screwdriver using an internal thread akin to the threaded system used in a hip screw insertion device. The screw can't fall off and the screw can be used as a drill, since the tip is self drilling and self tapping, even though it is a bi-cortical screw. Although it is ridiculously easy to insert, the best application is in proximal; locking of the retrograde nail, because you can't lose the screw in the soft tissue, if you miss the hole or skive off the screw driver just pulls the screw out with it.

Roy Sanders, MD,
Tampa, Florida

From: Adam Starr

Hi Chip.

Cliff Jones was down here in Dallas and presented some of the cases he's done with the Zimmer perc nailing system, but I've never seen the Synthes one. I'll have to see if I can get our rep to bring one over.

What we're doing now is place a 3.2 threaded tip guide wire into the fossa, then run a reamer over it to make a hole. THen we stick the ball-tip wire down there, ream and place the nail.

Everything goes great until we try to place the nail. The dang jig hits the skin, and we wind up needing a bigger incision. You can do every step up to the nailing thru an incision not much bigger than the nail itself.

Our incisions are still a lot smaller than they used to be, but they could be smaller still. I'll have to check out those other systems.

Adam Starr

Date: Wed, 02 Jan 2002 06:59:36 -0800

From: Chip Routt

Hi Roy-

Will Trigen help fibromyalgia too?

Some readers may not understand this detail - if the screw functions as the drill also, how do you accurately determine the bicortical screw/drill's length prior to drilling/screw insertion?

Some readers may not know that an absorbable suture tied to the neck of the potential locking screw functions well to retrieve an errant screw insertion. Once the surgeon inserts the locking screw correctly, the suture is trimmed beneath the skin.

Happy New Year to you and your group-

Chip

Date: Wed, 2 Jan 2002 15:24:15 -0000

From: Chris Oliver

HI Chip

We wrote up this suture technique, several years ago, it works for end caps too!

Injury 1997 Nov-Dec;28(9-10):715-6
A fail-safe method of inserting end caps into intramedullary nails.
Chapman-Sheath PJ, Clasper J, Oliver CW

Chris Oliver DM, FRCS (Tr & Orth), FRCP
Consultant Trauma & Orthopaedic Surgeon
Edinburgh Orthopaedic Trauma Unit

Date: Wed, 02 Jan 2002 08:33:46 -0800

From: Chip Routt P>Good job.

Cheers-

Chip

Date: Wed, 2 Jan 2002 21:44:40 +0530

From: Dr H K Bachani

Dear Dr George

After making incision you feel for pyriformis fossa , how do you identify it before putting awl ?

h k bachani

Date: Thu, 3 Jan 2002 20:45:59 +0530

From: Dr. T I George

Dear Dr H K Bachani ,

I usually go by the image along with the feel of the awl. I probably has been erring more on the lateral entry after I detected a basal fracture neck once after nailing femur using a GK type nail. Of course latest was a small split on the lateral part of greater trochanter two weeks ago where I was using a RT nail. Here proximal end I had reamed to 15mm as recommended. I suppose one should evetually face all sorts of complications during the carrer in trauma management.

Dr. T. I. George,
Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital,
Trichur, S. India

Sent: Wednesday, January 02, 2002 9:27 PM

From: Dr. Sunil Kulkarni

dear Dr.george,

cannulated cutter is a very ease to insert. the blade is very sharp, the sleeve protects the soft tissue, the steinman pin supplied is very long so easy to manipulate with the help of T handle gripper. We do all interlockings in lat. position. so no difficulty in finding the correct entry hole on fracture table. I recommend cutter to awl. regarding the bolts. the bolts are to prevent rotation. the S&N are of 5mm with 5 mm diff. synthes are 4.9 mm. with course threads & 2mm diff. somehow synthes are better bolts but very expensive. S&N requires special drill bit to insert these bolts.

dr. sunil kulkarni, miraj

Date: Thu, 3 Jan 2002 20:50:48 +0530

From: Dr. T I George

Dear Dr Sunil,

I am yet to see the cannulated cutter in the sets available locally. Regarding cost of locking bolts, The Smith and Nephew ones are locally priced much higher than the Synthes ones. That is the patient pays much higher amount for less surgeon friendly locking bolts.

Dr. T. I. George,
Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital,
Trichur, S. India