Intramedullary Nailing

Intramedullary nailing, in the current "locked" version, can be defined as a kind of "dynamic fixation" because, as for external fixation, its stiffness can be adjusted during the treatment. By removing the proximal or distal screws (called dynamization),the callus formation is stimulated.

Intramedullary nailing, distinguished in two categories (nails applied with or without reaming), has some advantages [30]: it allows early weight bearing thanks to its stability; and the nail can be inserted in most cases without opening the fracture site, minimizing the soft tissue damage and increasing the consolidation rate compared to plating. In particular, in treating long bone nonunions, the debris produced by the reaming procedure, with their osteoinductive and osteoconductive elements, seems to be very effective in reinitiating the healing cascade. In some cases, nevertheless, adjuvant bone grafting is required [5].

Disadvantages of this technique are: limitations of indications (nonunions with bone loss or periarticular nonunions are contraindications for the use of intramedullary nails); complications are difficult to treat (postoperative infections can infect the whole diaphysis); and it is often difficult or impossible to remove a broken nail (Figs. 4-6).

In the series reported by Galpin et al. [37] and by Wiss and Stetson [38] satisfactory results are reported in the management of noninfected nonunions.

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