Published online Jul 18, 2013. doi: 10.5312/wjo.v4.i3.130
Revised: April 15, 2013
Accepted: June 1, 2013
Published online: July 18, 2013
AIM: To define the optimum safe angle of use for an eccentrically aligned proximal interlocking screw (PIS) for intramedullary nailing (IMN).
METHODS: Thirty-six dry cadaver ulnas were split into two equal pieces sagitally. The following points were identified for each ulna: the deepest point of the incisura olecrani (A), the point where perpendicular lines from A and the ideal IMN entry point (D) are intersected (C) and a point at 3.5 mm (2 mm safety distance from articular surface + 1.5 mm radius of PIS) posterior from point A (B). We calculated the angle of screws inserted from point D through to point B in relation to D-C and B-C. In addition, an eccentrically aligned screw was inserted at a standard 20° through the anterior cortex of the ulna in each bone and the articular surface was observed macroscopically for any damage.
RESULTS: The mean A-C distance was 9.6 mm (mean ± SD, 9.600 ± 0.763 mm), A-B distance was 3.5 mm, C-D distance was 12.500 mm (12.500 ± 1.371 mm) and the mean angle was 25.9° (25.9°± 2.0°). Lack of articular damage was confirmed macroscopically in all bones after the 20.0° eccentrically aligned screws were inserted. Intramedullary nail fixation systems have well known biological and biomechanical advantages for osteosynthesis. However, as well as these well-known advantages, IMN fixation of the ulna has some limitations. Some important limitations are related to the proximal interlocking of the ulna nail. The location of the PIS itself limits the indications for which intramedullary systems can be selected as an implant for the ulna. The new PIS design, where the PIS is aligned 20°eccentrically to the nail body, allows fixing of fractures even at the level of the olecranon without disturbing the joint. It also allows the eccentrically aligned screw to be inserted in any direction except through the proximal radio-ulnar joint. Taking into consideration our results, we now use a 20° eccentrically aligned PIS for all ulnas. In our results, the angle required to insert the PIS was less than 20° for only one bone. However, 0.7° difference corresponds to placement of the screw only 0.2 mm closer to the articular surface. As we assume 2.0 mm to be a safe distance, a placement of the screw 0.2 mm closer to the articular surface may not produce any clinical symptoms.
CONCLUSION: The new PIS may give us the opportunity to interlock IMN without articular damage and confirmation by fluoroscopy if the nail is manufactured with a PIS aligned at a 20.0° fixed angle in relation to the IMN.
Core tip: Limitations of intramedullary nailing (IMN) of the ulna, which make IMN a secondary choice, include problems experienced at the proximal interlocking screw (PIS). A new PIS system may solve most common problems with an eccentrically aligned screw. This new PIS system may be very advantageous if the fluoroscopy time, operation time and the need for additional incision in other systems is considered. However, the screw must be designed at a safe angle to have these advantages. According to our results, a 20.0° is the optimum angle of alignment for this screw.