An economic analysis of management strategies for closed and open grade I tibial shaft fractures

Background Closed and open grade I (low-energy) tibial shaft fractures are a common and costly event, and the optimal management for such injuries remains uncertain.

Methods We explored costs associated with treatment of low-energy tibial fractures with either casting, casting with therapeutic ultrasound, or intramedullary nailing (with and without reaming) by use of a decision tree.

Results From a governmental perspective, the mean associated costs were USD 3,400 for operative management by reamed intramedullary nailing, USD 5,000 for operative management by non-reamed intramedullary nailing, USD 5,000 for casting, and USD 5,300 for casting with therapeutic ultrasound. With respect to the financial burden to society, the mean associated costs were USD 12,500 for reamed intramedullary nailing, USD 13,300 for casting with therapeutic ultrasound, USD 15,600 for operative management by non-reamed intramedullary nailing, and USD 17,300 for casting alone.

Interpretation Our analysis suggests that, from an economic standpoint, reamed intramedullary nailing is the treatment of choice for closed and open grade I tibial shaft fractures. Considering financial burden to society, there is preliminary evidence that treatment of low-energy tibial fractures with therapeutic ultrasound and casting may also be an economically sound intervention.     

Current management of tibial shaft fractures: A survey of 450 Canadian orthopedic trauma surgeons

Background and purpose?Strategies to manage tibial fractures include nonoperative and operative approaches. Strategies to enhance healing include a variety of bone stimulators. It is not known what forms of management for tibial fractures predominate among Canadian orthopedic surgeons. We therefore asked a representative sample of orthopedic trauma surgeons about their management of tibial fracture patients.

Methods?This was a cross-sectional survey of 450 Canadian orthopedic trauma surgeons. We inquired about demographic variables and current tibial shaft fracture management strategies.

Results?268 surgeons completed the survey, a response rate of 60%. Most respondents (80%) managed closed tibial shaft fracture operatively; 47% preferred reamed intramedullary nailing and 40% preferred unreamed. For open tibial shaft fractures, 59% of surgeons preferred reamed intramedullary nailing. Some surgeons (16%) reported use of bone stimulators for management of uncomplicated open and closed tibial shaft fractures, and almost half (45%) made use of this adjunctive modality for complicated tibial shaft fractures. Low-intensity pulsed ultrasound and electrical stimulation proved equally popular (21% each) and 80% of respondents felt that a reduction in healing time of 6 weeks or more, attributed to a bone stimulator, would be clinically important.

Interpretation?Current practice regarding orthopedic management of tibial shaft fractures in Canada strongly favors operative treatment with intramedullary nailing, although respondents were divided in their preference for reamed and unreamed nailing. Use of bone stimulators is common as an adjunctive modality in this injury population. Large randomized trials are needed to provide better evidence to guide clinical decision making regarding the choice of reamed or unreamed nailing for tibial shaft fractures, and to inform surgeons about the actual effect of bone stimulators.     

扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的疗效比较

目的　比较扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的临床疗效。方法　对 6 4例共 6 7侧开放性胫骨骨折采用带锁髓内钉治疗 ,其中非扩髓组 36侧 ,扩髓组 31侧。伤口愈合拆线后扶拐下地活动 ,术后定期随访 6个月～ 1年。结果　非扩髓组与扩髓组局部感染率分别是 13 9%和 12 9% (P >0 0 5 ) ,无全身感染 ;非扩髓组 5例锁钉断裂 ,扩髓组无断钉 ;非扩髓组与扩髓组平均骨折愈合时间分别为 2 2 5周和 17 2周 (P <0 0 5 )。延迟愈合分别为 5例、 3例 ,非扩髓组有 1例骨折不愈合。结论　与非扩髓组比较 ,扩髓带锁髓内钉具有骨折固定强度大、骨折愈合快、延迟愈合或不愈合少 ,感染率没有明显升高     

扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折

目的比较扩髓与非扩髓型带锁髓内钉治疗开放性胫骨骨折的临床疗效。方法对86例共92侧开放性胫骨骨折采用带锁髓内钉治疗,其中扩髓组54侧,非扩髓组38侧。伤口拆线后扶拐下地活动,术后定期随访6个月～2年。结果扩髓组与非扩髓组局部感染率分别是20．3％和5．3％（P〈0．05）;扩髓组与非扩髓组平均骨折愈合时间分别为22．5周和19周（P〉0．05）;延迟愈合分别为8例,3例。结论与扩髓组比较,非扩髓带锁髓内钉延迟愈合或不愈合少,感染率低,两组平均骨折愈合时间无明显差异。     

Marknagelung geschlossener Unterschenkelschaftbrüche

Intramedullary nailing is the operative method of first choice for closed fractures of the tibial shaft. In general, the method is well taught and has proven its worth in many clinics. If attention is paid to the technical recommendations very good results can be obtained with both the reamed and the unreamed technique. In German-speaking areas unreamed locked nailing with solid nails is preferred; in the Anglo-American world the reamed technique is more widely accepted. After-treatment aims at achieving early functional recovery. The favorable biomechanical conditions for load transfer associated with osteosynthesis mean that weight-bearing is possible early, even while the soft tissue situation is still settling down and the fracture healing. Provided there are no complications or malalignments, closed intramedullary nailing of closed tibial shaft fractures is one of the most gratifying operative procedures permitting early functional rehabilitation.     

Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature.

OBJECTIVE: To compare the results and complications of the various modalities for treating closed fractures of the tibial shaft described in the prospective literature. DATA SOURCES: A MEDLINE search of the English language literature from 1966 to 1999 was conducted using the MeSH heading "tibial fractures." Studies pertaining to the management of closed tibial shaft fractures were reviewed, and their reference lists were searched for additional articles. STUDY SELECTION: An analysis of the relevant prospective, randomized controlled trials was performed. Studies including confounding data on open fractures or fractures in children were excluded. The 13 remaining studies were reviewed. DATA EXTRACTION: Raw data were extracted and pooled for each method of treatment. DATA SYNTHESIS: The 13 studies described 895 tibial shaft fractures treated by application of a plaster cast, fixation with plate and screws, and reamed or unreamed intramedullary nailing. Although definitions varied, the combined incidence of delayed and nonunion was lower with operative treatment (2.6% with plate fixation, 8.0% with reamed nailing and 16.7% with unreamed nailing) than with closed treatment (17.2%). The incidence of malunion was similarly lower with operative treatment (0% with plate fixation, 3.2% with reamed nailing and 11.8% with unreamed nailing) than with closed treatment (31.7%). Superficial infection was most common with plate fixation (9.0%) compared with 2.9% for reamed nailing, 0.5% for unreamed nailing and 0% for closed treatment. The incidence of osteomyelitis was similar for all groups. Rates of reoperation ranged from 4.7% to 23.1%. CONCLUSIONS: All forms of treatment for tibial shaft fractures are associated with complications. A knowledge of the incidence of each complication facilitates the consent process. To fully resolve the controversy as to the best method of treatment, a large, randomized, controlled trial is required. This review more precisely predicts the expected incidence of complications, allowing the numbers of required patients to be more accurately determined for future randomized controlled studies.     

Current Concepts: Aseptic Nonunion of Femoral Shaft Diaphysis

Abstract  In spite of increased understanding of biomechanics and improvements of implant design, nonunion of femoral shaft fractures continues to hinder the treatment of these injuries. Femoral nonunion presents a difficult treatment challenge for the surgeon and a formidable personal and economic hardship for the patient. In most series of femoral fractures treated with intramedullary nailing techniques, the incidence of this complication is estimated to be 1%. A higher frequency has recently been reported due to advances in trauma care leading to increased survivorship among severely injured patients and expanded indications of intramedullary nailing. Whereas the treatment of femoral shaft fractures has been extensively described in the orthopedic literature, the data regarding treatment of femoral shaft nonunions are sparse and conflicting, as most of the reported series consisted of a small number of cases. However, careful review of the existing literature does provide some answers regarding either conservative or operative management. The gold standard for femoral shaft nonunions invariably includes surgical intervention in the form of closed reamed intramedullary nailing or exchange nailing, but several alternative methods have been reported including electromagnetic fields, low-intensity ultrasound, extracorporeal shock wave therapy, external fixators and exchange or indirect plate osteosynthesis. In this paper, a comprehensive review of the current treatment modalities for aseptic midshaft femoral nonunion is presented, after a concise overview of the incidence, definition, classification and risk factors of this complication.     

Cast treatment and intramedullary locking nailing for simple and spiral wedge tibial shaft fractures--a cost benefit analysis

BACKGROUND AND AIMS: The aim of this retrospective study was to compare the relative costs of treating simple and spiral wedge (requiring closed reduction under anaesthesia) tibial shaft fractures in a plaster cast or with intramedullary locking nail. MATERIAL AND METHODS: The material consisted of 26 fractures treated in a plaster cast and 51 fractures treated with an intramedullary locking nail. The costs caused by the direct costs (treatment, hospitalisation, and outpatient appointments) as well as indirect costs (lost productivity) were taken into account. Costs caused by complications were also included in the analysis. RESULTS: Mean direct costs per patient were FIM 22920 and FIM 26952 and mean overall costs per patient were FIM 120486 and FIM 82224 in plaster cast and intramedullary locking nailing groups, respectively (FIM 1 = USD 0.19). The higher mean overall costs of the plaster cast group were attributable to the longer sick leave periods in this group (218 days in plaster cast group and 124 in intramedullary nailing group). CONCLUSION: Plaster cast treatment of simple and spiral wedge tibial shaft fractures requiring closed reduction under anaesthesia is more expensive to society than operative treatment with intramedullary locking nail.     

The diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail

BackgroundThe nonunion of open and closed tibial shaft fractures continues to be a common complication of fractures. Tibial nonunions constitute the majority of long bone nonunions seen by orthopaedic surgeons. In this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions.MethodsBetween 2008 and 2014, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. The initial fracture management consisted of external fixation (27 patients), plate fixation (2 patients) and cast treatment (4 patients). All patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. There were 13 hypertrophic, 16 oligotrophic (atrophic) and 4 defect nonunions registered in our material. The primary goal was to perform a closed intramedullary nailing on antegrade manner. An open procedure was only unavoidable when implants had to be removed or an osteotomy had to be performed to improve the alignment. Functional rehabilitation was encouraged with the assistance of a physiotherapist early postoperative. Patients were examined regularly during followed-up for a minimum of 12 months period for clinical and radiological signs of union, infection, malunion, malalignment, limb shortening, and implant failure.ResultsThe time that elapsed from injury to intramedullary nailing ranged from 9 months to 48 months (mean 17 months).Open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). Osteotomy or resection of the fibula was performed in 78,8% of the cases. All patients were followed up in average period of 2 years postoperative (range 1–4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. Mean union time was 5±0.8 months. Complications included 2 (6,06%) patients, one with deep infection and another case with absence of bone healing. Anatomical alignment has been achieved in the majority of patients, 28 patients (84,8%). The additionally autogenous bone chips were added in 4 patients (12,1%) where cortical defect was greater than 50% of the bone circumference.ConclusionIn conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. Reaming of the medullary canal with preservation of periosteal sleeve create the "breeding ground" for sound healing of tibial shaft nonunions. Additionally cancellous bone grafting is recommended only in the case of defect nonunion.     

Infection after reamed intramedullary nailing of the tibia: a case series review

OBJECTIVE: We reviewed those patients who developed a postoperative infection after reamed intramedullary nailing of tibial shaft fractures to investigate the possible causes of infection, its effect on union time, and the requirement for reconstructive surgery. DESIGN: Retrospective review of patients who developed deep infection after reamed tibial nailing during a 15-year period. SETTING: University Level II Trauma Center. PATIENTS: Thirty-five with tibial diaphyseal fractures. INTERVENTION: All patients were treated with reamed intramedullary nailing. OUTCOME MEASURES: Union, union time, compartment syndrome, requirement for reconstructive procedures, and development of deep infection. RESULTS: In the closed-fracture group, 43.8% of patients were considered to have developed infection because of inappropriate fasciotomy closure, exchange nailing, and thermal necrosis. In the open-fracture group, 62.5% were considered to have developed infection attributable to late complications of plastic surgery. The most significant problem was marginal necrosis after flap cover. CONCLUSIONS: A number of deep infections after reamed intramedullary tibial nailing are avoidable. Particular attention must be paid to correct reaming, exchange nailing, and fasciotomy closure in closed fractures. In open fractures, marginal flap necrosis should be actively treated and not left to granulate.     

The incidence of compartment syndrome after flexible nailing of pediatric tibial shaft fractures

Purpose  

Pediatric tibial shaft fractures are common injuries encountered by the orthopaedic surgeon. Flexible intramedullary nailing has become popular for pediatric patients with tibial shaft fractures that require operative fixation. The purpose of our study was to evaluate the incidence of, and the risk factors for, compartment syndrome (CS) after flexible intramedullary nailing of these injuries.     

Obesity is associated with increased postoperative complications after operative management of tibial shaft fractures

ObjectivesTo assess the association of obesity and postoperative complications after operative management of tibial shaft fractures.MethodsPatients who underwent operative management of a tibial shaft fracture were identified in a national database by Current Procedural Terminology (CPT) codes for: (1) open reduction and internal fixation (ORIF) and (2) intramedullary nailing (IMN) procedures in the setting of International Classification of Diseases, Ninth Revision (ICD-9) codes for tibial shaft fracture. These groups were then divided into non-obese, obese, and morbidly obese cohorts using ICD-9 codes. Each cohort was then assessed for grouped complications within 90 days, removal of implants within 6 months, and nonunion within 9 months postoperatively. Odds ratios and 95% confidence intervals were calculated.ResultsFrom 2005 to 2012, 14,638 patients who underwent operative management of tibial shaft fractures were identified, including 4425 (30.2%) ORIF and 10,213 (69.8%) IMN. Overall, 1091 patients (7.4%) were coded as obese and 820 (5.6%) morbidly obese. In each operative group, obesity and morbid obesity was associated with a substantial increase in the rate of major and minor medical complications, venous thromboembolism, infection, procedures for implant removal, and nonunion.ConclusionsIn patients who undergo either ORIF or IMN for tibial shaft fractures, obesity and its related medical comorbidities are associated with significantly increased rates of postoperative medical complications, infection, nonunion, and implant removal compared to non-obese patients.     

Systematic review shows lowered risk of nonunion after reamed nailing in patients with closed tibial shaft fractures

Nonunion after intramedullary nailing (IMN) in patients with tibial shaft fractures occurs up to 16%. There is no agreement whether reaming prior to IMN insertion would reduce the nonunion rate. We aimed to compare the nonunion rate between reamed and unreamed IMN in patients with tibial shaft fractures.A systematic search was conducted in Pubmed, Embase, and the Cochrane Library. The selected publications were: (1) randomised controlled trials; (2) comparing the nonunion rate; (3) in patients with tibial shaft fractures; (4) treated with either reamed or unreamed IMN.Seven studies that satisfied the criteria were identified. They showed that reamed IMN led to reduction of nonunion rate compared to unreamed IMN in closed tibial shaft fractures (risk difference ranging 7.0-20%, number needed to treat ranging 5-14), while the difference between compared treatments for open tibial shaft fractures was not clinically relevant.The evidence showed a consistent trend of reduced nonunion rate in closed tibial shaft fracture treated with reamed compared to unreamed IMN.     

Safe surgical technique: intramedullary nail fixation of tibial shaft fractures

Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.     

Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study

OBJECTIVE: To compare anterior and deep posterior compartment pressures during reamed and unreamed intramedullary nailing of displaced, closed tibial shaft fractures. DESIGN: Randomized prospective study. SETTING: University Hospital/Level I trauma center. PATIENTS: Forty-eight adults with forty-nine fractures treated with intramedullary nailing within three days of injury. INTERVENTION: After intraoperative placement of compartment pressure monitors, the tibia fractures were treated by either unreamed intramedullary nailing or reamed intramedullary nailing. A fracture table and skeletal traction were not used in any of these procedures. MAIN OUTCOME MEASUREMENTS: Compartment pressures and deltaP ([diastolic blood pressure] - [compartment pressure]) were measured immediately preoperatively, intraoperatively, and for twenty-four hours postoperatively. RESULTS: Compartment syndrome did not occur in any patient. Peak average pressures were obtained during reaming in the reamed group (30.0 millimeters of mercury anterior compartment, 34.7 millimeters of mercury deep posterior compartment) and during nail insertion in the unreamed group (33.9 millimeters of mercury anterior compartment, 35.2 millimeters of mercury deep posterior compartment). The average pressures quickly returned to less than thirty millimeters of mercury and remained there for the duration of the study. The deep posterior compartment pressures were lower in the reamed group than in the unreamed group at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours postoperatively (p < 0.05 at each of these times. A statistically significant difference between anterior compartment pressures could not be shown with the numbers available. The deltaP values were greater than thirty millimeters of mercury at all times after nail insertion in both the reamed and unreamed groups. CONCLUSION: These data support acute (within three days of injury) reamed intramedullary nailing of closed, displaced tibial shaft fractures without the use of a fracture table.     

Mortality and morbidity following operative management of tibial shaft fractures in octogenarians

Purpose

As the geriatric population continues to grow, the incidence of tibial shaft fractures in octogenarians is projected to increase. There is significant variation in the functional and physiologic status within the geriatric population. The purpose of this study is to compare the complications following operative treatment of tibial shaft fractures for patients who are 65- to79-year-old compared to patients who are 80- to 89-year-old.

Methods

Data were collected through the National Surgical Quality Improvement Program database for the years 2007–2018. All isolated tibial shaft fractures that were treated with open reduction internal fixation (ORIF) or intramedullary nail (IMN) were identified. Patients were divided into a 65- to 79-year-old group and an 80-to 89-year-old group. Primary and secondary outcomes were studied and included 30-day mortality. Univariate and multivariate analyses were performed with a significance set at p  <  0.05.

Results

In total, 434 patients with tibial shaft fractures were included in the study. Of these, 333 were 65- to 79-year-old and 101 were 80- to 89-year-old (Table 1). On multivariate analysis, there was no significant difference in complication rates between the two cohorts.

Conclusion

After controlling for demographics and comorbidities, age was not independently associated with 30-day mortality or any other peri-operative complications between patients aged 80 to 89 and patients aged 65 to 79 following operative management of tibial shaft fractures. In appropriately selected octogenarian patients, operative management of tibial shaft fractures represents a relatively safe treatment modality that may promote early rehabilitation.

     

Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review

Introduction  

Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults.     

Smoking,Obesity, and Disability Benefits or Litigation Are Not Associated with Clinically Important Reductions in Physical Functioning After Intramedullary Nailing of Tibial Shaft Fractures: A Retrospective Cohort Study

BackgroundForty percent of long bone fractures involve the tibia. These fractures are associated with prolonged recovery and may adversely affect patients’ long-term physical functioning; however, there is limited evidence to inform what factors influence functional recovery in this patient population.Question/purposeIn a secondary analysis of a previous randomized trial, we asked: What fracture-related, demographic, social, or rehabilitative factors were associated with physical function 1 year after reamed intramedullary nailing of open or closed tibial shaft fractures?MethodsThis is a secondary (retrospective) analysis of a prior randomized trial (Trial to Re-evaluate Ultrasound in the Treatment of Tibial Fractures; TRUST trial). In the TRUST trial, 501 patients with unilateral open or closed tibial shaft fractures were randomized to self-administer daily low-intensity pulsed ultrasound or use a sham device, of which 15% (73 of 501) were not followed for 1 year due to early study termination as a result of futility (no difference between active and sham interventions). Of the remaining patients, 70% (299 of 428) provided full data. All fractures were fixed using reamed (298 of 299) or unreamed (1 of 299) intramedullary nailing. Thus, we excluded the sole fracture fixed using unreamed intramedullary nailing. The co-primary study outcomes of the TRUST trial were time to radiographic healing and SF-36 physical component summary (SF-36 PCS) scores at 1-year. SF-36 PCS scores range from 0 to 100, with higher scores being better, and the minimum clinically important difference (MCID) is 5 points. In this secondary analysis, based on clinical and biological rationale, we selected factors that may be associated with physical functioning as measured by SF-36 PCS scores. All selected factors were inserted simultaneously into a multivariate linear regression analysis.ResultsAfter adjusting for potentially confounding factors, such as age, gender, and injury severity, we found that no factor showed an association that exceeded the MCID for physical functioning 1 year after intramedullary nailing for tibial shaft fractures. The independent variables associated with lower physical functioning were current smoking status (mean difference -3.0 [95% confidence interval -5 to -0.5]; p = 0.02), BMI > 30 kg/m² (mean difference -3.0 [95% CI -5.0 to -0.3]; p = 0.03), and receipt of disability benefits or involvement in litigation, or plans to be (mean difference -3.0 [95% CI -5.0 to -1]; p = 0.007). Patients who were employed (mean difference 4.6 [95% CI 2.0 to 7]; p < 0.001) and those who were advised by their surgeon to partially or fully bear weight postoperatively (mean difference 2.0 [95% CI 0.1 to 4.0]; p = 0.04) were associated with higher physical functioning. Age, gender, fracture severity, and receipt of early physical therapy were not associated with physical functioning at 1-year following surgical fixation.ConclusionAmong patients with tibial fractures, none of the factors we analyzed, including smoking status, receipt of disability benefits or involvement in litigation, or BMI, showed an association with physical functioning that exceeded the MCID.Level of EvidenceLevel III, therapeutic study.     

Distal articular involvement in tibial shaft fractures: an evaluation of 125 consecutive cases

Purpose

To report the incidence and morphology of ipsilateral distal articular involvement (DAI) in a consecutive series of tibial shaft fractures.

Method

A retrospective review was performed on 115 patients who underwent intramedullary nailing for tibia shaft fractures. Ankle evaluations included preoperative radiographs and computed tomography (CT) scans in all patients.

Results

Thirty-two patients (27.8%) in our series presented with tibial shaft fractures associated with DAI. Tibial spiral fractures (42A1) were significantly related to DAI (RR: 1788). In 28 (87.5%; 28/32) articular fractures, posterior malleolus fractures (PMF) were present; 22 were isolated, and six (18.8%) occurred in combination with medial malleolus or anterolateral fractures. The remaining (12.5%; 4/32) were isolated medial malleolus fractures. Ten (31.2%; 10/32) articular fractures were occult on the radiographs and only detected on CT scan.

Conclusion

DAI is common in tibial shaft fractures. CT evaluation is mandatory due to the high number of occult fractures. Although isolated PMF is the most frequent pattern of DAI involvement, 31.3% of the cases exhibited different patterns.

     

Minimally invasive plate osteosynthesis has equal safety to reamed intramedullary nails in treating Gustilo-Anderson type I,II and III-A open tibial shaft fractures

ObjectivesThe best fixation method for open tibial fractures has long been a matter of debate, many studies have recommended the use of intramedullary nails over external fixation for treating such fractures, recent studies also showed favorable results for the use of plates in managing open tibial fractures. However, there are very few (if any) reports in the literature comparing the use of minimally invasive plate osteosynthesis to reamed intramedullary nails in the fixation of open tibial fractures.The aim of this study was to compare the safety & efficiency of minimally invasive plate osteosynthesis to reamed intramedullary nails in treating open tibial shaft fractures.DesignA single-center, parallel group, prospective, randomized study.SettingAcademic Level 1 Trauma Center, during the period from October 2014 to December 2016.PatientsA total of 60 patients with open tibial fractures were randomized to reamed intra-medullary nails (R-IMN) (group A) or minimally invasive plate osteosynthesis (MIPO) (group B).Outcome measurementPatients were assessed for union (clinical & radiographic) & complications (e.g.; non–union, infection).ResultsNo statistically significant differences were found between the 2 methods in term of the incidence of infection or non-union. Time to full union was shorter for the R-IMN group when compared to that of the MIPO group & that was found to be statistically significant.ConclusionMIPO technique has equal safety to R-IMN technique in treating Gustilo-Anderson type I, II and III-A open tibial shaft fractures, as both techniques have similar rate of infection & non-union. These findings suggest that the MIPO technique can be considered a valid treatment alternative for such fractures.Level of evidenceLevel II, Therapeutic study.