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AbstractOne of the most challenging parts of
intramedullary nailing is finding the location of the distal holes
of the intramedullary nail following its insertion along the
medullary canal. The preferred method for locating the distal
holes involves the use of x-ray imaging. In order to reduce the
exposure of the medical personnel and patient to ionizing
radiation several alternative methods are being investigated and
their feasibility and accuracy are being assessed by performing
surgery on cadavers. Due to several issues associated with
cadavers, this paper introduces a phantom as an alternative tool
for the evaluation of such techniques. The features associated
with this phantom should allow researchers to assess the
performance of their distal locking systems at a reduced cost
and without the need for surgical skills.

Key words Intramedullary nailing, distal hole targeting
system, cadaver, phantom, ionizing radiation.
I. INTRODUCTION
Intramedullary nailing (IMN) is the preferred method of
choice for the treatment of fractures of the femoral shaft as it
is associated with very good stability, less soft tissue injury
and blood loss, less incidents of nonunion, delayed union,
and malunion, shorter hospitalization time, and earlier
mobilization of the patient compared to other methods [1].
According to orthopedic surgeon reports, the most
challenging part of IMN is locating and drilling the
interlocking screw holes [2]. IMN interlocking requires the
surgeon to locate the holes in the nail, center the drill, and
advance the bit through the bone to meet them. Interlocking
screws are then inserted.
Proximal locking is achieved using a mechanical guide,
which is fixed to the proximal portion of the nail. Usually,
the surgeon does not encounter any difficulties in inserting
the proximal screws. On the other hand, the mechanical
guide does not work well for the distal hole locking task. The
reason is that as the nail traverses along the medullary canal
it becomes deformed [3] due to the non-linearity in the shape
of the canal and adapts to the shape of the bone. This
deformation at the level of the distal holes may reach several
millimeters [2]-[4]. Failure to properly lock the distal holes
may lead to other complications such as poor stabilization,

* This paper was made possible by a UREP award [UREP12015-2-004]
from the Qatar National Research Fund (a member of The Qatar
Foundation). The statements made herein are solely the responsibility of the
authors.
Fadi T. Jaber is with the Department Of Electrical Engineering, Qatar
University, Doha, P.O. Box 2713, Qatar (phone: 00974-4403-4227; fax:
00974-4403-4201; e-mail: fjaber@qu.edu.qa).
Awni B. Al-Jayyousi, is with Amber House, Khalda, Amman, Jordan (e-
mail: info@amber-house.net).
distal fracture fragment rotation and bone weakening due to
large or multiple screw holes that the surgeon drills.
The challenge of distal hole locking is usually solved by
taking several x-ray images in order to locate the exact
position of distal holes [5], [6]. Nevertheless, the surgeons
direct radiation exposure varies from 3.1 min to 31.4 min per
operation, depending on his experience and skills, with
31%51% of the total exposure being from distal hole
locking only [7]-[10].
To minimize the requirement for x-ray images and reduce
the amount of ionizing irradiation for the patient and medical
staff, several alternative techniques have been reported in the
literature. These include improved mechanical guides for
distal hole locking [11], [12], self-locking nails [13],
reference metallic grids [14], computer-based navigation
systems [15], [16], laser guidance systems [17], robot-
assisted guides [18], optical targeting systems [19], [20], and
magnetic targeting systems [21], [22].
To evaluate the success of these distal targeting
techniques, researchers usually go through the process of
testing their systems in vitro where the nail is inserted into a
plastic femoral model in order to measure the accuracy of
the method [23]. Nevertheless, the use of plastic bone
models alone is not sufficient since it does not mimic the
actual IMN surgery. To overcome this problem in vitro
experiments are often performed on cadavers or cadaveric
parts before researchers can proceed with clinical trials [24],
[25]. The use of cadavers provides a fair representation of an
IMN surgery scenario and helps investigators to adjust their
system for clinical use.
In addition, the use of cadavers for in vitro experiments
provides researchers with a three-dimensional view of the
required anatomy [26], nonetheless, it does not always
deliver an accurate impression of the living body [27].
Furthermore, cadavers are expensive, in short supply, their
dissection is time-consuming and requires the presence of a
skillful surgeon. Furthermore, their use is associated with
several moral and ethical issues.
Considering the aforementioned, the work described here
introduces a phantom comprising leg tissue, a femur bone
and an IM nail that can be used for evaluating the accuracy
of distal hole targeting systems and that may overcome
several issues related to cadavers and cadaveric parts.
In the remainder of this paper section II describes the
different parts that constitute the proposed phantom and
section III discusses the potential advantages and limitations
of such a model. Finally, section IV concludes the work and
reveals future plans.
A Phantom for Cadaverless Evaluation of Targeting Systems for
Distal Locking of Intramedullary Nails*
Fadi T. Jaber , Member, IEEE and Awni B. Al-Jayyousi
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II. PHANTOM DESCRIPTION
The main aim of the phantom introduced here is to
provide a test platform for engineers to evaluate their distal
locking systems without going through all the intensive
surgical work that is required for IMN when performed on
cadavers. This, however, does not mean that it cannot be
used for training surgeons or as a demonstration model for
students. It consists of a leg-tissue part, a fractured femur
bone model and an IM nail. All parts are introduced in the
following subsections.
A. Leg-Tissue Model
To emulate IMN surgery conditions as much as possible,
it was decided that the part of the phantom, which represents
the leg tissue should be in the supine position since it is
preferred by several surgeon [28]. The tissue model
(SYNBONE AG, Switzerland) is that of an entire right leg
with pelvis, sacrum, fractured femur and tibia with a foam
coating (Fig. 1).

Figure 1. Right-thigh tissue model in the supine position. (a) lateral view,
(b) medial view.

The length of the leg is 850 mm. A wooden stand
attached to the sacrum (Fig. 1-b) can be used for stabilizing
the leg on a bench as if a patient is in the supine position
prior to surgery. The foam coating at the posterior of the leg
is cut open and the two ends are held together by hook and
loop fasteners (Fig. 2). This provides easy-access to the
inside of the leg, which houses the femur and tibia bones.
B. Femur Bone Model
The femur model (SYNBONE AG, Switzerland) housed
in the leg model (Fig. 2) has a cortical layer and an inner
foam layer that resembles cancellous bone. This type of
model has been developed for orthopedic surgical education
and is designed to provide the 'feel' of working with real
bones with similar forces being required to drill holes. The
femur has an oblique femoral mid-shaft fracture and is
450 mm in length. In addition, it has a medullary canal
opening with a diameter of 9.5 mm for inserting IM nails.
Following a distal hole targeting experiment, the used femur
can be easily replaced.

Figure 2. Posterior view of leg. The hook and loop fasteners provide easy
access to the inside of the leg tissue, which houses a fractured femur shaft
made from foam.
C. Intramedullary Nail
Two different IM nails were used as part of the phantom.
These are illustrated in Fig. 3. The first nail was fabricated at
the mechanical workshop of Qatar University from a
stainless steel rod with a diameter of 8 mm and a length of
400 mm. The two distal holes have a diameter of 5 mm and
are 40 mm apart. The second nail used is a commercial
titanium alloy nail (Kanghui Medical, China). The diameter
of the nail is 9 mm and its length is 340 mm. The two distal
holes have diameters of 5 mm and 7 mm for the most distal
one.
Fig. 4 shows the two fractured parts of the femur after
alignment with the stainless steel nail inserted through them
via the medullary canal opening at the greater trochanter.

Figure 3. The two IM nails that are used with the phantom. A custom-made
stainless steel nail (top) and a titanium alloy commercial nail (bottom).


Figure 4. Alignment of fractured femur model and insertion of nail.
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III. DISCUSSION
As mentioned in the earlier section, such phantom may
have a twofold purpose. First it can be used by investigators
as a test platform for assessing the accuracy and clinical
applicability of distal hole targeting systems that are being
developed, and second, it can have an educational role as a
training tool for surgeons and a demonstration model for
medicine and engineering students.
The drawback of the phantom is that it does not represent
the anatomy of the leg as accurately as a cadaveric leg.
Nevertheless, scandals related to cadaver trafficking indicate
the existence of a profit-making industry [29]. This raises
ethical and moral questions regarding their use.
Apart from the ethical portion of the problem, factors that
were considered prior to the development of the phantom
were cost, usability (i.e. ease-of-use), reusability, and
storage.
The cost of a cadaver ranges between $1,000 and $1,500,
nevertheless, specific pieces of anatomy (e.g. a leg) may cost
much more [29], [30]. In contrast, the prices of all the parts
used in this work are shown in Table I.
TABLE I. PRICE OF PHANTOM PARTS
Part Price ($)
Leg-tissue model (includes one
fractured femur)
850
Commercial nail 1,265
Custom-made nail 10
Femur bone replacements 32

When comparing the price of the model proposed here
with that of cadavers the cost of the IM nail is not included
since the price of a cadaver or cadaveric part also does not
include it. Nevertheless, Table I shows that using a custom-
made nail adds only $10 to the total cost. Since the leg-tissue
model includes one broken femur, $850 are sufficient for
performing a single distal locking experiment. This is at least
$150 less than using a cadaver or cadaveric part.
The fact that the phantom is reusable reduces the cost
even more. This is so because only $32 are required for each
additional experiment since the femur can be easily replaced.
The cost is also reduced as no special storage facilities are
required for the phantom.
Finally, it should be pointed out that the use of cadavers
requires the presence of an orthopedic surgeon for inserting
the IM nail. In contrast, this task is easily performed on the
phantom by simple hook-and-loop fasteners that provide
access to the interior of the thigh and the femur. A pre-
drilled medullary canal in the femur also saves time and
work since the nail can be inserted straight away.
IV. CONCLUSION & FUTURE WORK
The phantom presented in this paper has the potential of
replacing cadavers for the purpose of evaluating the accuracy
of distal locking techniques as well as for educational and
training purposes. It offers several advantages in relation to
the use of cadavers. These include lower cost, easy storage,
ease-of-use, and reusability. In addition, there are no moral
or ethical dilemmas associated with using such a model.
The development of this phantom is part of a larger
project that involves the implementation of a radiation-free
distal locking system and will serve as a testing platform for
it.
ACKNOWLEDGMENT
The authors would like to thank Dr. Rashid Mazhar
(Hamad Medical Corporation, Qatar) for the commercial
nail, Dr. Sumukh Khandekar (Al-Ahli Hospital, Qatar) for
his invaluable advice and expertise, and the Qatar National
Research Fund (QNRF) for supporting this work.
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