The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented.

Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed.

77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points.

The XXS nails allow a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low.

Distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. Thus implant fixation is more difficult. Dorsal and radial comminution are frequent in these patients and so reduction and angle stable osteosynthesis needed. The angle stable plate, often also multidirectional is today the most common stabilisation device. Because of the introduction of bulky and bended implants as the Micronail or Targon DR wich require difficult opening of the bone with awles we decided to test the XS radius nail witch is a 4,5mm or 3,5mm straight nail and witch is introduced after guide wire placement and over drilling with a canulated drill of the same diameter. It is locked parallel to the joint in 3 different directions with angular stability with threaded wires.

Methods 16 radius sawbones were osteotomised corresponding to a A3 Fracture and stabilised with a angle stable plate (8) and XS nail (8). 1000 alternating load cycles from 20–200N were performed and the deformation was registered. Also a FE analysis with the MSC Patran/Marc softwere were performed.

Also the calculated deformation in the FE study was 20% lower. Also deformation amplitude was lower with 0.31mm compared to 0.42mm in the plate group. The differences however were not significant.

Both devices show good biomechanical results. The XS nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. Styloideus radii and over drilling with a canulated drill of the same size. The exposure of the N rad. superf. must be performed. First clinical evaluation is presented.

Due to the results we developed a anatomically adapted XS radius nail. The results of the first 100 patients are presented.

Clinical Problem

Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems.

We started to use the XS and XS nail as minimal invasive procedure for the management of these fractures in July 2000 first for the fibula and since for the fibula and pilon itself but extended metaphseal comminution are contraindication for the XS nail.

Because of soft tissue problems and higher loading capacity of intramedullary implants the XS Nail was also used for ankle fracture osteosynthesis but as in all articular fractures with open reduction,

The olecranon is exposed to high tension and bending forces. In 2/3 multifragment fractures occur. Tension belt and plate fixation in these not only transverse but also sagital and frontal plane fractures is often not possible. As a central weight bearing device the XS 4,5mm nail is exposed to a lower bending moment and a angle stable transverse fixation with 2,4mm threaded wires every 9mm is possible. Also a soft tissue independent fracture compression with a set screw (proximal longitudinal holes) is possible. Additional frontal and sagital plane fragments can be fixed to the system with fibre wire hemicerclages.

From 5.1999 to 12.2002 80 consecutive cases with XS nail osteosynthesis of a olecranon fracture were treated and 73 (91%) could be re-examined clinically and radiological 15 months after surgery. 13,7% were open fractures 67% were 3 or more part fractures. For evaluation the Murphy score was used.

The mean time for surgery was 37min for two part and 56 min. for more part fractures. The Murphy score showed in 64% very good and in 29% good results. Only in 4 patients with more part fractures with additional radius head fractures and previous surgery had fair or unsatisfactory results.

The XS nail is a new concept for stabilisation of all but specially of complex and very comminuted olecranon fractures with a very low complication rate and good functional results.

The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented.

Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed.

77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points

The XXS nails allows a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low.

Clinical Problem: fractures under tension are common injuries and occur when patients are falling on partial flexed limbs under maximal contraction of the extensor muscles. Typical injuries are patella and olecranon. For these fractures the tension belt osteosyntheses is the mainly used procedure. A high complication rate regarding dislocation, bone healing, pain and functional outcome are reported. This is due to the unstable fixation with the tension belt because of the tendon insertion around the bone fragment witch allow secondary loosening of the tension belt under alternating load. This was found allready 1987 by Brill and Hopf in an experimental study.

Materials and Methods: To improve stabilisation a new device was developed: the XS (4,5mm diameter) and the XXS nail (3,5mm) witch is locked with threaded wires and a set screw allows fracture compression inside the nail independend from the soft tissues around. Fiber Wire cerclage transversal around the threaded wire ends allow the fixation of additional frontal plane fragments or marginal fragments.

Experimental test were performed in a patella sow-bone models and showed superior to tension bel (patella) and Plate fixation/fibula). On the other side the locked nail system allows percutaaneous osteosynthesis of the whole ulna also in shaft, distal fractures and shortening osteotomies.

All clinical cases treated with the XS/XXS nail where recorded prospectively and re-examined after 6–12 months. From may 2000 to march 2002 76 patients with olecranon fractures were evaluated. 85% of the olecranon fracture patients could be re-examined. Most patients where treated immediately or after wound healing without splint.

Results: the experimental results shows in all XS nail group no gap after alternating load of 250 and 500N and a rigidity a little higher than that of the not osteotomised patellae. In the tension belt groups in all tested patellae visible gaps of 1 to 3 mm occurred. There was no difference between the single and double XS nail Osteosynthesis.

71.7% of all patients with olecranon fractures showed a very good result according to the Murphy score. In 2 part fractures the rate was even 94.7%. Only in the group of more part fractures in 5.9% fair results were found. No patient showed a poor result.

The technical possibilities of XS nail osteosynthesis in ulna shaft, distal fractures and shortening osteotomies are presented.

Conclusions: the XS nail is a new device witch allows good anatomical reconstruction and stable fixation with immediate functional therapy in all olecranon and ulna fractures.

Clinical Problen: the avulsion fracture of the MT V bone and the Jones fractures are typical fractures under tenssion and therefore often require osteosynthesis.

Materials and Methods: to avoid soft tissue problems due to the open reduction and implant on the bone surface on the lateral foot a percutaneus technique with a 3,5mm XXS locked compression nail was developed. The fracture is reduced with the gide wire witch is also used for the canulated 3,5mm drill wich prepares the canal for the nail. The locking is performed on both sides of the fracture with one 2mm threated wire and the dynamic compression of the Fracture of the fracture is performed with a set screw in the nail. All patients are allowed to walk free with normal foot wear

From Jul 1999 to Jan.2006 77 patients were treated according to the above technique.

Results: Tha OAFAS of the patients preoperativ was 22 and postoperative 96. No pseudarthrosis or implant failures occured but in 53 patients (69%) implant removal was necessary because patients had discomfort due to the implant.

Conclusion: the XXS nail is a new method for minimal invasive and stable fixation of MTV fractures with full weight bearing capacity in low complication rate. However in most cases implant removal is indicated.

Clinical Problem: The proximal femour ist he highest loaded part of the skeleton,on the other side the bone density is reduced in elderly patients. Therefore the cut out of the femour head and neck component is the most severe complication in the management of these farctures.

Material and Methods: To avoide cut out but also other complications a proximal femour nail with a I beam profile of the femur neck component was constructed: the gliding nail (GN) and small GN (SGNS).

Results: Experimental examination: an I beam plate (16x10mm) used in the Gliding nail, a single screw (12mm) fixation of the Gamma Nail and a double screw fixation (11 and 6mm) used in the Proximal Femour Nail were tested. For testing 9 sowbone femura and 3 pair of corps femura were used. A2 type of osteotomy and tests of 1000 cycles alternating load at 1000N and 1500N in the sowbons and 6000 cycles up to 3.500N were performed. Results: in the sowbones the I beam profile plate shows a total deformation of 1mm after 1000N and 2mm after 1500N test. For the 12mm screw the corresponding values were 2,5mm and 5.6mm. The double scew fixation showed a total cut out at 1000N in one femur and at 1500N in both others. In the corpse femura the differences were similar.

Clinical examination: Material and methods: in a five year period 03.1996-03.2001 501 patients all patients with trochanteric and subtrochanteric fractures were evaluated. Reexamination was performed at least 6 months after therapy. All patients with no additional injury of the same leg were allowed full weight bearing immediately(98%). 70% were female, mean age 76,2years,median 80 years.82% had risk factors, 11.2% were in a nursing home. 95% were treated in the first 36 houres by 23 surgeons.

Results: Eearly lokal complicationes occurred in 2,5%. Only wound revisiones for haematoma (11 cases with 5 times positive bacteriology) occurred but the general rate of complicationes was 28,5% especially urinary and pulmonary infections. Hospital mortality was 3.9%. Whereas the mortality in patients without risk factors the mortality was 2.4% when 4 risk factors were present mortality was 90%. Osteoporosis and Diabetes had no influence as risk factor. Late local complicationes were 3.3%. The 3 months mortality was 14.9%15.3% were in a nursing home.

Conclusion: The results show that the event of a trochanteric fracture is still a serious risk but local complicationes especially cut out of the implant and severe impaction of the fracture can be avoided by using the GN.

Proximal femur fractures are usually low-energy injuries of elderly patients, but they can also occur after highenergy trauma in young adults and children. The proximal femur shows very special biomechanical (high load) and biological (blood supply) characteristics. These factors, the patient’s age, and the implant characteristics (weight bearing capacity and cut out risk) are determinants for the surgical management of proximal femur fractures.

There are two main fracture groups that require a different approach because of the difference in blood supply: 1) medial femoral neck fractures and 2) lateral femoral neck, trochanteric, and subtrochanteric fractures.

Medial femoral neck fractures occur in about 90% of dislocated adduction fractures. Because of the high risk of pseudarthrosis and head necrosis (~30 %) in older patients, a hip joint prosthesis should be used. A total hip prosthesis is used (mainly cementless) for patients in good biological condition; in elderly patients (> 80 Y.) a hemiarthroplasty is performed. Because prospective studies have not shown any benefit for bipolar hemiarthroplasty, we use a unipolar hemiarthroplasty.

In non-dislocated fractures of the elderly and in all medial femoral neck fractures in younger patients, a joint-preserving osteosynthesis is used. The most used therapy is three canulated screws. Because of implantrelated complications (dislocation, cut out) particularly in steep fracture lines, comminution zones, and noncompliant patients, a stabler fixation with an intramedullary device should be used. We prefer the gliding nail because of the rotation stability and minimal cut out risk of the I-beam profile femoral neck component.

Lateral femoral neck, trochanteric, and subtrochanteric fractures have a minimal risk of femoral head necrosis. Intramedullary locked nail systems such as the gliding nail and gamma nail have a much lower bending movement and therefore allow full weight bearing in all types of fractures. The gliding nail also gives rotation stability to the head and neck fragment in unstable fractures because of the I-beam-profile of the femoral neck component, and has an over 50% reduced cut out risk as compared to screw profiles.

Extramedullary implants like the DHS do not allow full weight bearing in unstable trochanteric fractures and are unsatisfactory in subtrochanteric fractures. They can be safely used only in stable fractures. Prostheses should not be used in primary management of trochanteric fractures because of the very low re-operation rate in modern intramedullary implants (< 4 %). The operation time, possible late complication, blood loss, and costs are higher for a hip prosthesis.