Key Takeaways & Executive Findings
- •• The modified rectangular locking device achieved a 98% success rate in distal locking screw placement with an average of only 1.1 fluoroscopic exposures per case. • The device reduced distal locking screw placement time to an average of 7.0 minutes, significantly improving surgical efficiency. • Postoperative functional outcomes were excellent, with an average American Knee Society Score of 185 after fracture healing. • The device offers advantages over existing techniques by eliminating the need for specialized equipment and extensive surgical experience, while ensuring accuracy and repeatability.
Abstract
BACKGROUND: Conventional rectangular targeting devices are divided into two modules, one left and one right, which hinders flexible intraoperative use and is prone to deformation and error. Even after connection, repeated fluoroscopic confirmation is still required for screw drilling and placement. OBJECTIVE: To investigate the key technology development and clinical application of a modified rectangular locking device for precise distal locking screw placement in intramedullary nailing of femoral shaft fractures. METHODS: Medical records of patients with femoral shaft fractures admitted to Affiliated Suqian Hospital of Xuzhou Medical University and Suyu District People's Hospital from 2021 to 2023 were collected. Patients aged 18-65 years, diagnosed with femoral shaft fractures (AO classification: A, B, or C) by radiographic examination, who underwent closed reduction and intramedullary nailing with distal locking screw placement using the modified rectangular locking device, and whose clinical data (including medical history, radiographic findings, surgical records, and follow-up records) were selected. Forty-one cases met the criteria, including 30 males and 11 females, aged 20-62 years, with an average age of (41.17±8.14) years. Intraoperative fluoroscopy times, locking success rate, time for successful distal locking screw placement, American Knee Society Score at 1 month postoperatively and after fracture healing, and fracture healing time were collected. RESULTS AND CONCLUSION: (1) All 41 patients underwent distal locking screw placement using the modified rectangular locking device. Intraoperative fluoroscopy times ranged from 0 to 2 times, with an average of (1.1±0.5) times; the locking success rate was 98%; the time for successful distal locking screw placement ranged from 6 to 10 minutes, with an average of (7.0±1.5) minutes; the American Knee Society Score at 1 month postoperatively ranged from 140 to 190, with an average of (150±15) points. (2) Thirty-eight patients were followed up completely for 12-24 months. Fracture healing time ranged from 9 to 14 months, with an average of (10.5±2.5) months. After fracture healing, the American Knee Society Score ranged from 150 to 190, with an average of (185±8) points, with 35 excellent and 3 good results. (3) The results indicate that compared with freehand locking, oblique fluoroscopic placement, arthroscopic-assisted placement, and electromagnetic navigation locking of distal locking screws, the modified rectangular locking device offers advantages including no dependence on arthroscopic or electromagnetic navigation equipment, no requirement for extensive surgical experience, simple steps, accurate locking, high repeatability, and reduced radiation exposure.
1. Introduction
Femoral shaft fractures, defined as fractures occurring between 5.0 cm distal to the lesser trochanter and 5.0 cm proximal to the femoral condyles, are common adult fractures. Surgical treatment typically involves plate fixation or intramedullary nailing, with external fixation reserved for open fractures. In recent years, intramedullary nailing has become the recommended procedure for femoral shaft fractures due to its biomechanical advantages, including central fixation and uniform stress distribution, as well as its minimally invasive nature and soft tissue protection, which promote bone healing. However, the placement of distal locking screws during intramedullary nailing remains challenging, with issues such as complex targeting device operation and suboptimal accuracy.
Currently, several methods are used for distal locking screw placement, including the use of the intramedullary nail's own targeting device, freehand locking, oblique fluoroscopic placement, arthroscopic-assisted placement, and electromagnetic navigation. The built-in targeting device often fails due to deformation of the nail within the medullary canal, preventing accurate alignment. Freehand and oblique fluoroscopic methods require repeated fluoroscopy and rely heavily on surgeon experience. Arthroscopic-assisted placement requires specialized equipment and skills, while electromagnetic navigation is costly and not widely available. These limitations highlight the need for a more reliable and user-friendly device.
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ZHANG Ping, ZHOU Da-fang, CHEN Hui, ZHANG Ying, LIU Qing, SHI Ce (2026). Application of a modified rectangular locking device in the treatment of femoral shaft fractures with intramedullary nailing. Chinese Journal of Tissue Engineering Research. https://doi.org/10.12307/2026.21409
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Frequently Asked Questions
What is the modified rectangular locking device?
The modified rectangular locking device is an improved version of the rectangular frame-type aiming device, designed for precise placement of distal locking screws in intramedullary nailing of femoral shaft fractures. It integrates the left and right modules into one, adds locking screws to reduce displacement, and includes a stepped drill bit and graduated guide pin to enhance accuracy and reduce fluoroscopy.
How does the modified rectangular locking device reduce radiation exposure?
The device incorporates a graduated guide pin and a stepped drill bit, which allow for accurate placement without repeated fluoroscopic confirmation. In the study, the average number of fluoroscopic exposures was only 1.1, with some cases achieving zero fluoroscopy.
What are the advantages of the modified rectangular locking device over traditional methods?
Compared with freehand locking, oblique fluoroscopic placement, arthroscopic-assisted placement, and electromagnetic navigation, the modified rectangular locking device offers advantages such as no dependence on specialized equipment, no requirement for extensive surgical experience, simple steps, accurate locking, high repeatability, and reduced radiation exposure.
What were the clinical outcomes in the study?
In the study of 41 patients, the locking success rate was 98%, the average distal locking screw placement time was 7.0 minutes, and the average fluoroscopy times were 1.1. After fracture healing, the average American Knee Society Score was 185, with 35 excellent and 3 good results.
Is the modified rectangular locking device suitable for all femoral shaft fractures?
The device was evaluated in patients with AO type A, B, or C femoral shaft fractures treated with closed reduction and intramedullary nailing. It is designed for use with intramedullary nails and may be applicable to most femoral shaft fractures requiring distal locking, but its suitability should be assessed on a case-by-case basis.
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