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Third Generation Nailing

Russell, Thomas A MD

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Journal of Orthopaedic Trauma: March 2008 - Volume 22 - Issue - p S1
doi: 10.1097/BOT.0b013e31816bf82d
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The surgical treatment of fractures with internal fixation is a dynamic and evolutionary discipline. The advances in surgical implant and instrumentation design during the past 30 years coupled with advances in preoperative analysis such as computed tomography (CT) and magnetic resonance imaging (MRI) and the advances of intraoperative fluoroscopic imaging have revolutionized orthopaedic trauma surgery. The old adage that a nail is a nail and a plate is a plate has been proven patently false through rigorous biomechanical and controlled study paradigms. The combination of minimally invasive surgical techniques with biomechanical design parameters to optimize bone regeneration after injury is a highly implant- and instrument-dependent process.

The TriGen intramedullary nail system, introduced in 1998 as an outgrowth of the Russell-Taylor nail system, was a radical redesign of intramedullary surgical technique, advanced biomechanical design, and manufacturing. Humeral nailing, essentially thought to be relegated to pathologic fractures, has returned with major redesigns in surgical approach, technique, and instrumentation and now rivals other treatment options as described by Linhart et al.1 Antegrade femoral nailing with a Piriformis portal, long the standard for femoral nailing, is being replaced with the modified medial trochanteric entry portal and custom-designed trochanteric antegrade femoral nails, with the TriGen TAN serving as the first of its kind for this new generation.2 The basis for this change is clinically proven surgical efficiency with shorter operative times and lower radiation exposure to the patient and surgical team when compared to conventional Piriformis portal nail techniques as reported by multiple study centers in North America and Europe. Retrograde femoral nailing has now obtained union and complication rates rivaling antegrade nailing with improved mechanical designs and multiplanar screw options as reported by Seifert et al.3

Tibial nailing has also evolved for the treatment of metaphyseal-diaphyseal fractures with the addition of Poller or Blocking screw techniques as originally reported by Krettek et al4 and subsequently by Ricci et al.5 Modification of surgical techniques with the use of the TriGen reducer has increased precision for these procedures and has led the way in development of new targeting systems for blocking screws. The addition of multiplanar interlocking configurations with threaded screw holes to enhance nail stability in combination with fibular plating for enhanced distal tibial constructs increases the utility of the nail technique for these difficult fractures.

Finally, the segmental defect problem is now being studied, with new concepts to augment intramedullary fixation and minimize the prolonged treatment normally required in these injuries as describe by Ostermann et al.6 With all the advances in recent years, intramedullary nail techniques and designs will continue to evolve with the goal and hope of improved functional recovery for our patients.


1. Linhart W, Ueblacker P, Großterlinden L, et al. Antegrade nailing of humeral head fractures with captured interlocking screws. J Orthop Trauma. 2007;21:285-294.
2. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma. 2005;19:681-686.
3. Seifert J, Stengel D, Matthes G, et al. Retrograde fixation of distal femoral fractures: results using a new nail system. J Orthop Trauma. 2003;17:488-495.
4. Krettek C, Miclau T, Schandelmaier P, et al. The mechanical effect of blocking screws (“Poller screws”) in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma. 1999;13:550-553.
5. Ricci WM, O'Boyle M, Borrelli J, et al. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma. 2001;15:264-270.
6. Ostermann PA, Haase N, Rübberdt A, et al. Management of a long segmental defect at the proximal meta-diaphyseal junction of the tibia using a cylindrical titanium mesh cage. J Orthop Trauma. 2002;16:597-601.
© 2008 Lippincott Williams & Wilkins, Inc.