Patent Publication Number: US-2023149060-A1

Title: Flexible intramedullary nail

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
     The present application claims priority to U.S. Non-Provisional patent application Ser. No. 17/525,075, filed on Nov. 12, 2021, which is incorporated in its entirety herein. 
    
    
     TECHNICAL FIELD 
     The present teachings relate to intramedullary (IM) fixation. More particularly, the present teachings relate to an implant and a method for implanting an implant in a medullary canal in performing intramedullary fixation. 
     BACKGROUND 
     Surgical procedures to repair bone fractures can include the use of implants, such as plate fixation, IM nails, and interfragmentary screws, that are commonly associated with complications such as infection, wound breakdown, nonunion, implant failures, poor cosmetic outcome, and local numbness, etc. The term “intramedullary” means that the nail resides at least partly in the medullary canal of a bone. IM fixation involves the treatment of unstable fractures with an intramedullary nail as a treatment option for bone fractures and other injuries. Generally, intramedullary fixation devices for bone fractures are complicated by the need to perform reliable fixation of the bone while providing some flexibility supporting anchoring and/or improving fixation of the device. Additionally, “interfragmentary” screws are used to provide compression between the fracture fragments to stabilize the fracture. 
     In one example, U.S. Pat. No. 7,625,395 to Helmut Muckter (“Muckter”) discloses an interfragmentary screw that is required to be implemented in separate pieces during implantation. For example, Muckter discloses that a threaded part with a bone thread must be screwed into the bone utilizing a cannulated wrench that is pushed over a wire cable before a hexagon socket head nut is subsequently attached with a metal thread. Additionally, Muckter&#39;s interfragmentary screw may not be utilizable in procedures that require minimizing bone compression. Improvements in IM fixation are therefore desired. 
     BRIEF SUMMARY OF THE DISCLOSED EMBODIMENTS 
     During the preparation and placement of existing intramedullary nails and associated syndesmotic fixation, there is the potential for the placement of those syndesmotic members to be overly rigid and inflexible, complicating the healing process and introducing instability to the fixation members. Additionally, some known syndesmotic members can be configured in a way that introduces undesirable bone compression in certain injuries. This is solved in the presently disclosed embodiments by providing a surgical nail that limits bone compression yet imparts flexibility to an implant and therefore the healing bone, according to some embodiments. 
     According to embodiments, a surgical nail can include a nail body having a proximal end, an elongate intermediate portion comprising an intermediate flexible portion, and a distal end. In some embodiments, the proximal end and the distal end are coupled and offset from one another by the elongate intermediate portion. The intermediate flexible portion can include two or more cables that are bonded together (e.g., by welding, adhesive bonding, fusing, and/or the like) to maintain a fixed length. 
     According to some embodiments, the cable can include two or more cables twisted around one another in a helical arrangement and bonded together. In some embodiments, the proximal portion can include a threaded proximal portion coupled to the threaded portion by the intermediate flexible portion. According to some embodiments, the distal end portion can include a threaded end portion. 
     According to some embodiments, the proximal portion can include a threaded proximal portion coupled to the threaded end portion by the intermediate flexible portion. In some embodiments, the proximal end portion can include a cylinder having an outer surface defining a perimeter of the surgical nail. 
     According to some embodiments, the one or more cables is configured in one or more arrangements consisting of a Helical Hollow Strand (HHS) arrangement, and/or a simple stranded cable arrangement. In some embodiments, the proximal portion and the threaded end portion are coupled together by the intermediate flexible portion as a unitary, integrated element prior to any use of the surgical nail in an implant procedure. According to some embodiments, the cylinder can include at least one through hole for receiving a fixation element configured to anchor the surgical nail into a bone fragment. 
     According to some embodiments, the intermediate flexible portion is configured to permit the proximal portion to bend at an angle relative to the distal portion such that a health practitioner is enabled to implant the surgical nail in a medullary canal as a unitary, integrated element. Also, in some embodiments, the intermediate flexible portion is configured to be flexible when implanted in the medullary canal and is further configured to minimize compression of the surgical nail. 
     According to some embodiments, the proximal end of the surgical nail is configured to couple the proximal head portion to a washer, wherein an outer perimeter of the washer has a greater diameter than the second perimeter. In some embodiments, the proximal end comprises a washer configured to increase an area of compression of the surgical nail to an adjoining body. 
     A method for performing implantation of a surgical nail during a surgical procedure to repair a fracture of a bone is described. According to some embodiments the method can include identifying a starting point of a medullary canal of a patient&#39;s bone; providing an opening in the bone using a surgical device; inserting the surgical nail as a unitary element into the medullary canal; driving the surgical nail through a first bone fragment via a portion of the medullary canal; and fixing the intramedullary canal to a second bone fragment, wherein the intramedullary nail is flexibly fixed to the first and second bone fragments and is configured to minimize compression of the surgical nail. The intramedullary nail may also be configured to increase compression of the surgical nail and an adjoining body. The intermediate flexible portion can be configured to be flexible when implanted in the medullary canal and is further configured to minimize compression of the surgical nail. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG.  1    is an illustration of a surgical nail for use in syndesmotic fixation procedures, according to some embodiments. 
         FIG.  2    is an illustration of a surgical nail for use in syndesmotic fixation procedures, according to some embodiments. 
         FIG.  3    is an illustration of a surgical nail for use in syndesmotic fixation procedures, according to some embodiments. 
         FIG.  4    is an illustration of a surgical nail for use in syndesmotic fixation procedures, according to some embodiments. 
         FIG.  5 A  depicts a tool for implanting a surgical nail for use in syndesmotic fixation procedures, according to some embodiments. 
         FIG.  5 B  depicts a surgical nail implanting system for use in syndesmotic fixation procedures, according to some embodiments. 
         FIG.  6    depicts an exemplary surgical nail implantation in a surgical procedure to heal a clavicle, according to some embodiments. 
         FIG.  7    is a flow diagram of a method for performing an implantation procedure of an intramedullary nail having a flexible intermediate portion, according to some embodiments. 
         FIG.  8    is an illustration of a surgical nail for use in syndesmotic fixation procedures, according to some embodiments. 
     
    
    
     DETAILED DESCRIPTION OF THE DISCLOSED EMBODIMENTS 
     Intramedullary fixation can be performed utilizing surgical nails, such as intramedullary nails, to facilitate the healing of fractured bones. However, rigid intramedullary nails that do not sufficiently flex can impede anchoring to bone fractures and thwart the healing process. Further, conventional intramedullary nails having some degree of flexibility may compress and cause additional complications. The embodiments shown in the exemplary methods and devices are not exhaustive, and other operations can be performed in addition to the illustrated processes. In some embodiments of the present disclosure, the operations may vary and/or can be performed in a different order. 
     Surgical Nail with Flexible Portion 
       FIG.  1    illustrates a surgical nail  100 , which may be an intramedullary nail, that is configured to be flexible and support bone fragments during a bone healing process. Surgical nail  100  includes a nail body that can be elongate along a central axis  102 . The nail body can comprise a proximal end  110 , an elongate intermediate portion comprising an intermediate flexible portion  116 , wherein the intermediate flexible portion comprises two or more cables that are bonded together (e.g., by welding, adhesive bonding, fusing, and/or the like) to maintain a fixed length, and a distal end  120 . As shown, proximal end  110  and distal end  120  are coupled and offset from one another by the elongate intermediate portion  116 . 
     According to some embodiments, intermediate flexible portion  116  is configured to be bendable throughout its length. According to some embodiments, intermediate flexible portion  116  is configured to resist compression. In this regard, these embodiments differ substantially from concepts related to interfragmentary screws that may be configured to achieve compression. For example, in the embodiment illustrated in  FIG.  1   , intermediate flexible portion  116  is configured by bonded cables  116   a  and  116   b  to resist compression, which is distinct and different from Muckter&#39;s interfragmentary screw that is configured to provide bone compression. Instead, surgical nail  100  is configured using intermediate flexible portion  116  to be flexible without introducing bone compression. 
     In some embodiments, intermediate flexible portion  116  can comprise two or more cables  116   a  and  116   b  bonded together. For example, two or more cables  116   a  and  116   b  can be twisted and bonded together in a helical arrangement. In other embodiments, two or more cables  116   a  and  116   b  can be welded together in a braided arrangement. 
     In some non-limiting examples, cable  116  can be a single- or multi-layered Helical Hollow Strand (HHS) tube. In another example, cable  116  can be a simple stranded cable arranged in various n×m cable classifications, in which n represents the number of strands in a cable and in represents the number of wires in each strand (e.g., 1×19, 1×7, 7×19, etc.). In some examples, cable  116  can be a multi-layered multi-directional cable. Additionally, cable  116  can be solid or cannulated. 
     In one non-limiting example, the component bodies such as proximal end  110 , intermediate flexible portion  116 , and distal end  120 , can be bonded together (e.g., by welding, adhesive bonding, or otherwise joining) at a fixed length prior to use. In this integrated implementation, surgical nail  100  is configured to be inserted in a medullary canal as a unitary structure, rather than as independent component bodies, as in prior art devices. According to some embodiments, the intermediate flexible portion is configured to permit the proximal end to bend at an angle relative to the distal end such that the health practitioner may implant the surgical nail in a medullary canal as a unitary, integrated element. For example, surgical nail  100  can be joined stably by bonding each component to another, such that the whole assembly rotates as one. 
     According to some embodiments, proximal end  110  includes one or more threaded portions. As shown, for example, in  FIG.  1   , proximal end  110  can include first proximal threaded portion  111  and second proximal threaded portion  112 . Also, as shown, distal end  120  of surgical nail  100  can include threaded end portion  118 . Each of the threaded portions  111 ,  112 , and  118  can be configured with cutting threads capable of being driven into one or more bone fragments. For example, threaded end portion  118  can be driven by a driving device (as described hereinbelow) such that threaded end portion  118  is fixed into a bone fragment. Likewise, threaded proximal portion  111  and threaded intermediate portion  112  can be driven to fix the cutting threads into corresponding portions of a bone fragment proximal to an opening lumen in the bone. Also, according to some embodiments (not shown), a surgical nail can be configured to perform proximal or distal end fixation, e.g., by an anchoring element. 
       FIG.  2    illustrates a surgical nail  200 , which may be an intramedullary nail, that is configured to be flexible and support bone fragments during a bone healing process. Surgical nail  200  includes a nail body that can be elongate along a central axis  202 . The nail body can comprise a proximal end  210  having a first proximal threaded portion  211 , a second proximal threaded portion  212 , an elongate intermediate portion comprising an intermediate flexible portion  216 , wherein the intermediate flexible portion comprises two or more cables that are bonded together (e.g., by welding, adhesive bonding, fusing, and/or the like) to maintain a fixed length, and a distal end  220 . Surgical nail  200 , which may be an embodiment of surgical nail  100 , can include proximal end  210  and distal end  220  coupled to and offset from one another by the elongate intermediate portion  216 . 
     As above, intermediate flexible portion  216  is configured to be bendable throughout its length. According to some embodiments, intermediate flexible portion  216  is configured to resist compression. In this regard, these embodiments differ substantially from concepts related to interfragmentary screws that may be configured to achieve compression. In one example, cables  216   a  and  216   b  may be formed of any flexible material, such as metal and/or metal alloy material in some embodiments. For example, cables  216   a  and  216   b  may be formed of steel, iron, aluminum, copper, nickel, any other suitable metal material, fiber, metal-fiber, polymer, and/or any other flexible material. Cables  216   a  and  216   b  may be welded (or otherwise bonded) to one another to avoid unraveling and to improve stability of the cables. Additionally, as described above, bonding cables  216   a  and  216   b  together configures intermediate flexible portion  216  to resist compression. 
     According to some embodiments, proximal end  210  includes one or more threaded portions. As shown, for example, proximal end  210  can include first proximal threaded portion  211  and second proximal threaded portion  212 . According to some embodiments, distal end  220  can include threaded end portion  218 . 
     According to additional embodiments, surgical nail  200  can include a cylindrical body portion  214  and at least one through hole  213  for receiving a fixation element configured to anchor the surgical nail into a bone fragment (not shown). Cylindrical body portion  214  defines an outer perimeter of surgical nail  200  and is disposed having at least one through hole  213  entering one side of the surgical nail outer perimeter and exiting through the other side of the outer perimeter. In this manner, surgical nail  200  is configured to accept transverse screws for fixation of surgical nail  200  to one or more bone fractures. 
     In some embodiments, intermediate flexible portion  216  comprises two or more cables  216   a  and  216   b  bonded together. For example, cables  216   a  and  216   b  can be twisted and bonded together in a helical arrangement. In other embodiments, cables  216   a  and  216   b  can be bonded together in a braided arrangement. 
     In some non-limiting examples, cable  216  may be a single or multi-layered HHS tube; a simple stranded cable arranged in various n×m cable classifications, in which n represents the number of strands in a cable and in represents the number of wires in each strand as described in detail above; a multi-layered multi-directional cable; and/or any other arrangement of a cable. Additionally, cable  216  may be solid or cannulated. 
     As noted above, surgical nail  200  can include one or more threaded portions, such as threaded proximal portion  211 , threaded intermediate portion  212 , and threaded end portion  218 . Each of the threaded portions,  211 ,  212 , and  218  may be configured with cutting threads to facilitate driving surgical nail  200  into one or more bone fragments. For example, following insertion through a medullary canal, threaded end portion  218  may be driven by a driving device (as discussed hereinbelow) such that threaded end portion  218  is fixed into a bone fragment. Likewise, threaded proximal portion  211  and threaded intermediate portion  212  may be driven to fix the cutting threads into corresponding portions of a bone fragment proximal to an opening lumen in the bone. 
       FIG.  3    illustrates a surgical nail  300 , which may be an intramedullary nail, that is configured to be flexible and support bone fragments during a bone healing process. Surgical nail  300  may be an embodiment of surgical nail  100  and/or  200 . Surgical nail  300  may include a nail body that can be elongate along a central axis  302 . The nail body may comprise a proximal end  310 , an elongate intermediate portion comprising an intermediate flexible portion  316 , wherein the intermediate flexible portion comprises two or more cables that are bonded together (e.g., by welding, adhesive bonding, fusing, or the like) to maintain a fixed length, and a distal end  320 . As shown, proximal end  310  and distal end  320  are coupled and offset from one another by the elongate intermediate portion  316 . 
     According to some embodiments, the intermediate flexible portion  316  is configured to be bendable throughout its length. As above, intermediate flexible portion  316  is configured to resist compression as opposed to interfragmentary screws that may be configured to achieve compression. 
     According to some embodiments, surgical nail  300  may include a cylindrical body portion  314  and at least one through hole  313  for receiving a fixation element configured to anchor the surgical nail into a bone fragment. For example, after implantation of surgical nail  300  in a surgical procedure, a health practitioner may drive one or more screws into through holes  313  to fix and anchor a first fragment of the bone to surgical nail  300 , such that the first fragment of the bone is retained sufficiently to heal together with a second fragment of the bone. 
     As above, intermediate flexible portion  316  is flexible and configured by two or more cables  316   a  and  316   b  to be bendable without producing compression. By permitting flexibility without compression, intermediate flexible portion  316  allows the surgical nail to stay stably fixed to each bone fragment, thereby minimizing risks of nonunion or aggravation to the healing process. Cables  316   a  and  316   b  may be formed of any flexible material, such as one or more metal, polymer, and/or metal alloy materials. Cables  316   a  and  316   b  may be bonded (such as by welding, adhesives, or any other suitable bonding process or device) one cable to another to another to avoid unraveling and to improve stability of the cables. In some embodiments, a ratio of length l c  of cylindrical body portion  314  to length of l i  flexible intermediate portion  316  may be large relative to a corresponding ratio in the embodiment of  FIG.  2   . Such an implementation may be suitable in cases when a greater degree of flexibility is desired while maintaining resistance to bone compression. 
     As described in detail above, cable  316  may be a single or multi-layered HHS tube; a simple stranded cable arranged in various n×m cable classifications, in which n represents the number of strands in a cable and in represents the number of wires in each strand; a multi-layered multi-directional cable; and/or any other arrangement of a cable. Additionally, cable  316  may be solid or cannulated. 
       FIG.  4    illustrates a surgical nail  400 , which may be an intramedullary nail, that is configured to be flexible and support bone fragments during a bone healing process. Surgical nail  400  includes a nail body that may be elongate along a central axis  402 . The nail body may comprise a proximal end  410 , an elongate intermediate portion comprising an intermediate flexible portion  416 , wherein the intermediate flexible portion comprises two or more cables that are bonded together (e.g., by welding, adhesive bonding, fusing, or the like) to maintain a fixed length, and a distal end  420 . As shown, proximal end  410  and distal end  420  are coupled and offset from one another by the elongate intermediate portion  416 . 
     According to some embodiments, proximal end  410  may include a drive socket  411  to receive and engage a driver of an implement useful to insert surgical nail  400  into a medullary canal. For example, drive socket  411  of intramedullary nail  400  may include a Hexalobe opening therein that can be rotated by a driver inserted therein to cause intramedullary nail  400  to be inserted as a unitary element into a medullary canal of a bone. 
     As in the embodiment of  FIG.  3   , a ratio of length l c  of cylindrical body portion  314  to length l i  of flexible intermediate portion  316  may be adapted to achieve an intended degree of flexibility and/or anchor support area. In this embodiment, the ratio is small relative to a corresponding ratio in the embodiment of  FIG.  3   , which may permit greater rigidity in specific bone healing processes utilizing surgical nail  400 . 
     As above, the intermediate flexible portion  416  is flexible and may be configured to bend. According to some embodiments, intermediate flexible portion  416  is configured to resist compression. In this regard, these embodiments differ substantially from concepts related to interfragmentary screws that may be configured to achieve compression. For example, intermediate flexible portion  416  is configured by two or more bonded cables  416   a  and  416   b  to resist compression, which is distinct and different from Muckter&#39;s interfragmentary screw that is configured to achieve bone compression. 
     In some embodiments, intermediate flexible portion  416  may comprise two or more cables  416   a  and  416   b  bonded together. For example, cables  416   a  and  416   b  may be twisted and bonded together in a helical arrangement. In other embodiments, cables  416   a  and  416   b  may be bonded together in a braided arrangement. 
     According to additional embodiments, surgical nail  400  may include a cylindrical body portion  414  and at least one through hole  413  for receiving a fixation element configured to anchor the surgical nail into a bone fragment (not shown). In some non-limiting examples, cable  416  may be a single or multi-layered HHS tube, or a simple stranded cable arranged in various n×m cable classifications, as described above. In some examples, cable  416  may be a multi-layered multi-directional cable. Additionally, cable  416  may be solid or cannulated. 
       FIG.  5 A  illustrates an exemplary driving device  500  for use in inserting a surgical nail, according to some embodiments. Driving device  500  can include a tang  510  and a driver  515  configured to engage the drive socket at the proximal end of the surgical nail. Driving device  500  is illustrated as one example of a device to engage a surgical nail, such as an intramedullary nail according to embodiments of any of  FIGS.  1  to  4  and  8   . However, any suitable device may be utilized to implant a surgical nail. As shown, exemplary driving device  500  can include driver  515 , which may include a solid or cannulated Hexalobe driver, in one example. 
       FIG.  5 B  illustrates an embodiment of an intramedullary nail system that can include driving device  500  that can be utilized to insert a surgical nail, such as intramedullary nail  400 . As shown, driver  515  can be a Hexalobe driver configured to engage a Hexalobe drive socket  411  of intramedullary nail  400 . The driving device can be rotated to insert intramedullary nail  400  as a unitary element into a medullary canal of a bone. 
     In one non-limiting example, as shown in  FIG.  6   , intramedullary nail  400  can be inserted in a clavicle  610  (e.g., a first bone fragment  610   a ) of a patient, when clavicle  610  has suffered a fracture  612 . Driving device  500  can be configured to drive the unitary intramedullary nail  400  such that a threaded end portion  418  is fixed into a second bone fragment  610   b  and a proximal portion  410  having at least one through hole  413  can be fixed by at least one anchoring element (not shown) into the bone fragment  610   a.  The above embodiment is illustrated as one non-limiting example of system that includes a surgical nail, such as an intramedullary nail according to embodiments of any of  FIGS.  1  to  4  and  8    having a flexible intermediate portion, and a device to engage the surgical nail. 
     Surgical Nail with Flexible Portion and Head 
       FIG.  8    illustrates a surgical nail  800 , which may be an embodiment of an intramedullary nail  100 ,  200 ,  300 ,  400 , etc. As above, surgical nail  800  is configured to be flexible and support bone fragments during a bone healing process. Surgical nail  800  includes a nail body that can be elongate along a central axis  802 . The nail body can comprise a proximal end  808 , an elongate intermediate portion comprising an intermediate flexible portion  816 , wherein the intermediate flexible portion comprises two or more cables that are bonded together (e.g., by welding, adhesive bonding, fusing, or the like) to maintain a fixed length, and a distal end  820 . As shown, proximal end  808  and distal end  820  are coupled and offset from one another by the elongate intermediate portion  816 . 
     According to some embodiments, proximal end  808  may include a proximal head portion  810 . Proximal end portion  808  may additionally include a proximal head portion  810 , which may include drive socket  811  to receive and engage a driver of an implement useful to insert surgical nail  800  into a medullary canal. 
     For example, drive socket  811  of intramedullary nail  800  may include a Hexalobe opening therein that can be rotated by a driver inserted therein to cause intramedullary nail  800 , including at least one washer  812 , to be inserted as a unitary element into a medullary canal of a bone. According to additional embodiments, proximal end portion  808  can be configured to include the at least one washer  812  to provide and/or expand an area of compression of surgical nail  800  applied to a bone fragment (not shown). 
     Proximal end portion  808  can additionally include a cylindrical body portion  814  that defines an outer perimeter of surgical nail  800 . According to some embodiments, cylindrical body  814  may have an outer surface defining a first perimeter of the surgical nail  800  and the proximal head portion  810  may have an outer surface defining a second perimeter of the surgical nail  800 . In some embodiments, the second perimeter can have a diameter greater than the first perimeter. According to some embodiments, an outer perimeter of washer  812  may have a greater diameter than the second perimeter. For example, a first perimeter corresponding to cylindrical body  814  may have a diameter of 3 mm-5.5 mm, a second perimeter corresponding to proximal head portion  810  may have a diameter of 5.5 mm-8 mm, and an outer perimeter of washer  812  may have a diameter of 8 mm-12 mm Cylindrical body  814  may be an embodiment of cylindrical body  214 . For example, cylindrical body  814  may include at least one through hole (not shown) for receiving a fixation element configured to anchor the surgical nail into a bone fragment. 
     As above, the intermediate flexible portion  816  is flexible and may be configured to bend. According to some embodiments, intermediate flexible portion  816  is configured to resist compression. In this regard, these embodiments differ substantially from concepts related to interfragmentary screws that may be configured to achieve compression. 
     Performing Intramedullary (IM) Fixation Using Intramedullary Nail Having Bonded Cables 
       FIG.  7    depicts a flow diagram of a method for performing a surgical procedure  700  to drive an intramedullary nail having bonded cables (e.g., for repair of clavicle, rib, etc.) that impart flexibility to an implant and therefore the healing bone, according to some embodiments. 
     Referring to  FIG.  7   , surgical procedure  700  includes an operation  705  of identifying a starting point on an end, such as a distal end, of a bone and creating an opening in a lumen of a medullary canal of the bone. For example, the starting point can be confirmed by a user of surgical nail  400  (e.g., a health care practitioner, or the like). The starting point may be on a distal tip of the bone in some embodiments. In other embodiments, the starting point may be on a proximal end. In some embodiments, operation  705  can include insertion of a guide wire from the tip into the intramedullary canal. 
     A surgical nail  400  is discussed for illustration, although any method  700  can be implemented using any embodiment of a surgical nail (e.g.,  100 ,  200 ,  300 ,  400 ,  800 ). According to some embodiments, a reamer or other suitable device may be used to access a lumen of the bone. For example, a patient may be prepared for surgery, including placing the patient under general anesthesia or sedation, administering antibiotics, and placing the patient on an operating room table. A radiographic/fluoroscopic imaging device can be directed toward the site of the procedure. According to some embodiments, reaming can be performed. 
     Procedure  700  continues with operation  710 , in which the health practitioner may insert the surgical nail (e.g.,  100 ,  200 ,  300 ,  400 ,  800 ) into the medullary canal of a first bone fragment, where the surgical nail is inserted as a unitary element. In other words, the surgical nail is disposed such that the proximal end (e.g.,  110 ,  210 ,  310 ,  410 ,  810 ) and distal end (e.g.,  120 ,  220 ,  320 ,  420 ,  820 ) are integrated together by the intermediate flexible portion (e.g.,  116 ,  216 ,  316 ,  416 ,  816 ) prior to use/insertion into the medullary canal. According to some embodiments, the intermediate flexible portion is configured to permit the proximal end to bend at an angle relative to the distal end such that the health practitioner is enabled to implant the surgical nail in a medullary canal as a unitary, integrated element. 
     Procedure  700  continues with operation  715 , in which the health practitioner can driver the intramedullary nail through a bone fracture via a portion of the medullary canal. According to some embodiments, the unitary surgical nail (e.g.,  100 ,  200 ,  300 ,  400 ,  800 ) is inserted utilizing a driving device, such as driving device  500 . 
     Procedure  700  continues with operation  720 , where the health practitioner fixes the surgical nail to a second bone fragment. In some examples, a threaded end portion (e.g.,  118 ,  218 ,  318 ,  418 ,  818 ) is driven utilizing driving device  500  into the second bone fragment. In an embodiment, syndesmotic fixation members can be placed, for example, in through holes  413  to enable the bone fragments to join efficiently having some degree of flexibility while minimizing compression of the bone. 
     The present invention has been described above with the aid of functional building blocks illustrating the implementation of specified functions and relationships thereof. The boundaries of these functional building blocks have been arbitrarily defined herein for the convenience of the description. Alternate boundaries can be defined so long as the specified functions and relationships thereof are appropriately performed. 
     The foregoing description of the specific embodiments will so fully reveal the general nature of the invention that others can, by applying knowledge within the skill of the art, readily modify and/or adapt for various applications such specific embodiments, without undue experimentation, without departing from the general concept of the present invention. Therefore, such adaptations and modifications are intended to be within the meaning and range of equivalents of the disclosed embodiments, based on the teaching and guidance presented herein. It is to be understood that the phraseology or terminology herein is for the purpose of description and not of limitation, such that the terminology or phraseology of the present specification is to be interpreted by the skilled artisan in light of the teachings and guidance. 
     The breadth and scope of the present invention should not be limited by any of the above-described exemplary embodiments but should be defined only in accordance with the following claims and their equivalents.