Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: a report of four successful cases

The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23-64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9-21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures.     

Intramedullary nailing in femoral shaft fractures. Evaluation of a group of 101 cases

The Authors analyse the results of intramedullary nailing in a group of 101 femoral shaft fractures. Used nails: Universal Synthes (62 cases), Russel-Taylor (14), Gamma long (10), uncannulated femoral nail (9), cannulated femoral nail (4) and proximal femoral nail (2). Stabilisation of the femoral shaft fracture was possible using a reamed technique in 91 cases, unreamed in 10. All nails were locked. Dynamisation was performed in 35 cases and was not in 66. The fracture heal was faster with the reaming and dynamisation technique. Ten fractures were open (5 Gustilo I, 5 Gustilo II) and stabilisation with Universal Synthes nail (8 cases), Russel-Taylor nail (1) and Gamma long nail (1) was performed. No infection was detected. Lung embolism (6) and deep vein thrombosis (3) occurred only in the case of reamed nails. All results confirm the locking nail system as the best treatment in the shaft fractures, especially with new-generation nails.     

Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up

OBJECTIVE: To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures. DESIGN: Prospective, randomized. SETTING: Level 1 trauma center. PATIENTS: Forty-five patients with displaced closed and open Gustilo type I-IIIA fractures of the central two thirds of the tibia. INTERVENTION: Stabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail. MAIN OUTCOME MEASUREMENTS: Nonunions, time to fracture healing, and rate of malunions. RESULTS: The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements. CONCLUSION: Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails.     

Unreamed interlocking nailing in open fractures of tibia

PURPOSE: To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the unreamed intramedullary nailing. METHODS: Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at Safdarjung Hospital, New Delhi, India. Records of 56 patients (4 women and 52 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures in all patients. All fractures were classified according to Gustilo and Anderson system for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted with assistance by an image intensifier. All nails were statically locked with one screw each proximally and distally. RESULTS: The patients were followed up for a mean period of 20 months (range, 18-24 months) and were evaluated according to the modified Ketenjian's criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Two of 4 type-IIIA and all 4 type-IIIB fractures had chronic osteomyelitis. Of 56 patients, 6 had early infection, 6 had delayed union, 6 had infected non-union, 2 had nail breakage, 8 had screw breakage, and 10 had anterior knee pain. CONCLUSION: Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in those type-III fractures with delayed presentation was not recommended, because of high incidence of complications.     

Gustilo grade IIIB tibial fractures requiring microvascular free flaps: external fixation versus intramedullary rod fixation

BACKGROUND: Gustilo IIIB fractures involve high-energy tibial fractures for which there is inadequate soft tissue coverage. In addition to orthopedic fixation, these injuries require soft tissue reconstruction, often in the form of a microvascular free flap. Although the majority of orthopedic literature favorably compares intramedullary rod fixation to external fixation in open tibial fractures, these studies have not focused on the role of either method of fixation in relation to the soft tissue reconstruction. METHODS: Because we had noted numerous complications after providing free-flap coverage over intramedullary rodded fractures, we sought to investigate whether there were differences in outcomes between free flap-covered lower-extremity fractures which were fixated by external fixation versus intramedullary rods. A retrospective chart review was performed on all patients in our institution who had lower-extremity free flaps for coverage of Gustilo IIIB fractures from 1995-2005 in relation to the type of bony fixation. RESULTS: Of the 38 patients studied, 18 underwent external fixation of the tibial fracture, and 20 had intramedullary rodding. Overall flap survival was 95%, with 1 failure in each group. However, the intramedullary rod group had higher incidences of wound infection, osteomyelitis, and bony nonunion (25%, 25%, and 40%, respectively) than the external fixation group (6%, 11%, 17%, respectively). CONCLUSIONS: For Gustilo IIIB fractures that require free-flap coverage, the added bony and soft tissue manipulation required for intramedullary rodding may disrupt the surrounding blood supply and lead to higher rates of complications that threaten the overall success of the reconstruction. Plastic and orthopedic surgeons should discuss the optimal method of bony fixation for complex tibial fractures when a free flap will likely be needed for soft tissue coverage. This integrated team approach may help minimize complications.     

The ortho-plastic management of Gustilo grade IIIB fractures of the tibia in children: A systematic review of the literature

Background

The challenges of managing Gustilo IIIB tibial fractures in children are unique. A multi-disciplinary, evidence based approach is needed. We aimed to evaluate the evidence for the ortho-plastic management of Gustilo grade IIIB open tibial shaft fractures in children based on a review of all published data in order to rationalise the orthopaedic and plastic surgical approach to these complex injuries.

Method

A systematic review of the literature was performed. Gustilo grade IIIB tibial shaft fractures in pre-adolescent and adolescent children were identified and evaluated with regard to both the skeletal and soft tissue management, and the outcome.

Results

Of 54 children with grade IIIB tibial fractures, a mean union time of 31 weeks included 33 weeks for 42 adolescents and 23 weeks for 12 pre-adolescents. Faster union time in pre-adolescents tended towards significance. Delayed union occurred in 22%, nonunion in 13%, mostly in adolescents. Two of 45 covered by vascularised flaps and 3 of 9 treated without flaps developed deep infection (p = 0.028). There was no correlation between method of skeletal fixation and union time.

Conclusion

Gustilo IIIB tibial shaft fractures in pre-adolescents tended towards faster healing with fewer complications, irrespective of the method of skeletal fixation. In adolescents, healing times were similar to adults. Soft tissue closure without flaps was associated with deep infection in one-third of patients, requiring debridement and flap cover. Adequate debridement and flap cover is suggested in all cases, irrespective of age.     

Unreamed tibial nail in tibial shaft fractures with severe soft tissue damage. Initial clinical experiences]

In a prospective study, since March 1989, 55 tibial shaft fractures have been treated with a new, unreamed solid tibial nail (UTN). This nail was initially designed as a temporary implant. The first 33 cases with second or third degree soft tissue damage were reviewed 6 months or more after the operation. Fractures were classified according to Müller: 6 type A (18.2%), 15 type B (45.5%), and 12 type C (36.7%). In 9 cases (27.3%), there was GII (n = 4) or GIII (n = 5) closed soft tissue damage according to Tscherne's classification. The 24 open fractures (72.7%) comprised 11 OII, 3 OIIIA and 10 OIIIB fractures (Gustilo classification). 24 patients (72.7%) were polytraumatized, the mean PTS (Hannover Polytrauma Score) was 18 points (range: 8-65 points). All fractures were stabilized without reaming. The implant diameter was 8mm (n = 14) or 9 mm (n = 19). Static locking was performed in 31 cases. Dermatofasciotomy was necessary because of compartment syndrome in 14 cases. In 1 grade IIIB open fracture soft tissue coverage was performed with a latissimus dorsi myocutaneous free flap 4 days after nailing. In 32 of the 33 cases the use of an additional cast or brace was not necessary during the follow-up treatment; 1 patient had a cast for 8 weeks for the treatment of accompanying injuries. Full weight-bearing was achieved in 5 cases within 3 weeks, in 16 cases within 12 weeks, and in 30 cases within 26 weeks. In 16 cases (48.5%) the interlocking screws were removed after 5-26 weeks (mean: 10 weeks).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of unreamed nailing and external fixation of tibial diastases--mechanical conditions during healing and biological outcome.

Locked intramedullary nailing and external fixation are alternatives for the stabilization of tibial shaft fractures. The goal of this study was to determine to what extent the mechanical conditions at the fracture site influence the healing process after unreamed tibial nailing compared to external fixation. A standardized tibial diastasis was stabilized with either a locked unreamed tibial nail or a monolateral fixator in a sheep model. Interfragmentary movements and ground reaction parameters were monitored in vivo throughout the healing period. After sacrifice, the tibiae were examined mechanically and histologically. Bending angles and axial torsion at the fracture site were larger in the nail group within the first five weeks post-operatively. Unlike the fixator group, the operated limb in the nail group did not return to full weight bearing during the treatment period. Mechanical and histomorphometrical observations showed significantly inferior bone healing in the nail group compared to the fixator group. In this study, unreamed nailing of a tibial diastasis did not provide rotational stability of the osteosynthesis and resulted in a significant delay in bone healing.     

闭合复位带锁髓内钉治疗股骨干骨折

目的：探讨闭合复位带锁髓内钉治疗股骨干骨折的临床疗效.方法：自2006年3月至2011年12月采用闭合复位带锁髓内钉治疗103例股骨干骨折患者,其中男76例,女27例;年龄19～55岁,平均36岁.按照AO分型：A型64例,B型27例,C型12例;开放性骨折13例（Gustilo Ⅰ型5例,Ⅱ型8例）.观察术后患者骨折愈合时间,并采用膝关节HSS评分标准对术后1年膝关节功能恢复情况进行评价.结果：术中发生股骨颈骨折1例,股骨近端骨折1例,均于术中更换重建钉固定,术后骨折愈合.术中发生腓总神经损伤1例,营养神经治疗4个月后恢复.103例患者全部获得随访,时间12～28个月,平均22个月.全部患者获得骨性愈合,愈合时间3～9个月,平均5个月.髋关节功能全部恢复正常,术后1年膝关节行HSS评分平均90.89±5.06.结论：注重手术操作,力求闭合复位,减少并发症,带锁髓内钉是治疗股骨干骨折的首选方法.     

Distal Tibial Fractures: Intramedullary Nailing

The tibia is an exposed bone with vulnerable soft tissue coverage and is therefore predisposed to local soft tissue problems and delayed bone healing. The objective in distal tibial fracture treatment is to achieve stable fixation patterns with a minimum of soft-tissue affection. Thus, the risk of soft tissue breakdown and bone healing complications is more likely related to open reduction and plating. Percutaneous, minimally invasive intramedullary nailing is a proven fixation mode for fracture stabilization in tibial shaft fractures. Anticipating the pitfalls, intramedullary nailing meets the requirements of the method of choice in distal tibial fracture fixation. In conclusion, intramedullary nailing of distal tibial fractures is a reliable method of fixation, possessing the advantages of closed reduction and symmetric fracture stabilization of an area with a delicate soft tissue situation, but prospective randomized trials are needed to compare modern intramedullary fracture fixation with modern plate fixation in distal tibial fractures.     

Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and “other complications” (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for “other complications” were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.     

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.     

Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: A multivariate analysis of factors affecting deep infection and fracture healing

Background:

The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis.

Materials and Methods:

We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (≤6 h or >6 h), method of soft-tissue management, skin closure time (≤1 week or >1 week), existence of polytrauma (ISS< 18 or ISS≥18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection.

Results:

Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r² = 0.263, P = 0.0001).

Conclusion:

Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.     

Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures

OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).     

Primary unreamed intramedullary nailing for open fractures of the tibia

Forty-six open tibial fractures (42 patients) were treated by primary unreamed intramedullary nailing, with debridement of open wounds and treatment of soft tissue. According to Gustilo-Anderson classification there were 18 grade I cases, 18 grade II cases and 10 grade III cases. The incidence of infection was low with two cases of superficial infection and one of deep infection. The mean time for union was 21.9 weeks and the rate of nonunion was 10.8%. There was no significant difference in the mean time to union, infection rate and rate of nonunion with different site and grade of fracture, but there was a longer union time and a higher rate of nonunion in complex and comminuted fractures. Unreamed intramedullary nailing, with appropriate soft tissue treatment, gives good results in the treatment of open tibial fractures including grade III.     

LISS钢板治疗胫骨干复杂开放性骨折

目的探讨LISS钢板治疗胫骨干复杂开放性骨折的疗效。方法对25例胫骨干复杂开放性骨折病例,GustiloⅢa型彻底清创后一期行LISS钢板联合封闭式负压引流,创面置管持续冲洗、创面用封闭式负压引流材料覆盖,接负压封闭式引流,GustiloⅢb型彻底清创后一期行外固定架固定,5—7d更换VSD材料,二期行LISS钢板固定骨折并植皮或行皮瓣转移术修复皮肤缺损。结果25例骨折24例骨性愈合,GustiloⅢa型19例行游离皮瓣及游离肌皮瓣,GustiloⅢb型4例行游离肌皮瓣转移术,2例行背阔肌皮瓣转移术。1例合并糖尿病发生软组织感染。结论在彻底清创的前提下VSD联合LISS钢板治疗GustiloⅢa、Ⅲb型胫骨干开放性复杂骨折是一种安全、有效的方法。     

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.     

Treatment of distal metaphyseal tibia fractures with involvement of the ankle by combination of locked intramedullary nailing and covered screw osteosynthesis

Fractures of the distal metaphysis of the tibia often include an extension into the ankle. Intramedullary nailing combined with covered screw osteosynthesis should reduce the high incidence of soft tissue and ankle problems and should be an alternative to open plate fixation, with good ultimate functional outcome. Between January 1993 and December 1995, a prospective study on 49 patients with distal metaphyseal tibia fracture and involvement of the ankle was performed. All the fractures were treated with intramedullary nailing combined with covered screw osteosynthesis, and plate fixation in cases of fibula fractures. There were 27 men and 22 women with an average age of 46.4 +/- 12.7 years (range 21-90). In most studies of the use of intramedullary nailing in distal tibial fractures the classification has been inadequate. Therefore a new classification according to Robinson et al. (1995) was used: 10 fractures were type II B (20.4%), 13 were type II C (26.5%), and 26 patients suffered a combination of type II B and type II C (53.1%). This fracture type was defined as type II D for use in this study. The severity of soft tissue injury was recorded using the Gustilo system in case of open (n = 19) and the Tscheme system in case of closed fractures (n = 30). In 31 patients distal tibia fracture was accompanied by a fracture of the fibula, which was first stabilized using a plate. For reconstruction of the distal articular surface, covered screw osteosynthesis was done. At the next step intramedullary nails were inserted and were statically locked proximally and distally. From January 1993 to February 1994, the reamed AO standard nail was used. After introduction of the unreamed tibial nail (UTN) all fractures were treated by this implant. Full load on the operated leg was allowed after 8 weeks. Union of the fracture was assessed by standard radiological and clinical criteria. Misalignment was defined as more than 5 degrees of angular rotation. Further surgery due to a valgus deformity in the ankle joint had to be done in three cases. There were no deep infections. Three patients had a superficial infection in the ankle area, but surgical debridement was not necessary. A leg shortening was found in 4 cases, but it was less than 1 cm in every case. Therefore, surgical correction was not done. Patients were reviewed at intervals of 2, 6, and 12 weeks, and after 6, and at least 12 months. All 49 patients were finally reviewed after an average time of 15.7 months (range 12-38). Bone fusion was reached 12.8 weeks (range 9-21) after the operative treatment. A specific assessment of the ankle symptoms was made using the score of Olerud and Molander (1984). In 29 patients excellent results were recorded. A satisfactory result was attained with 17 patients and just 3 patients were found to be unsatisfactory. Although proximity of distal tibia fracture to the ankle makes the treatment more complicated than for fractures of the tibial diaphysis, closed intramedullary nailing combined with covered screw fixation is a good alternative to open reduction and plate fixation. The major advantages are closed procedure and simplified interlocking techniques. Therefore, closed intramedullary nailing combined with covered screw fixation is a safe and effective method of managing this type of fracture.     

Fresh femoral shaft fractures treated with un-reamed intramedullary nail: 203 cases

OBJECTIVE: To discuss the experience treating fresh femoral shaft fractures with un-reamed intramedullary nail. METHODS: 203 cases of fresh femoral shaft fractures who had been treated with un-reamed intramedullary nail from November. 1995 to January. 1999 were analyzed retrospectively. 18 cases were open, classified as Gustilo I, and. 185 cases were closed. Traction table and image intensifier were used during operation. Closed reduction, un-reamed and free hand distal locking technique were used. Active movements of nearby joints were encouraged and partial weight bearing of 10 - 15 kg were allowed right after operation. RESULTS: All 203 cases of fresh femoral shaft fractures got bone union within 4 - 6 months. No case of delayed union and infection happened. 1 distal locking screw was broken. All patients gained normal extremity functions. CONCLUSION: Un-reamed intramedullary nailing of fresh femoral shaft fracture has less damage to the local soft tissue and blood supply. It has a relative stable fracture fixation, and less interruption to the healing procedure. It is one of the best methods for treating femoral fracture.     

非扩髓交锁髓内钉治疗开放性胫骨干骨折

目的:评估非扩髓交锁髓内钉治疗开放性胫骨干骨折的疗效。方法:应用非扩髓交锁髓内钉治疗21例开放性胫骨干骨折。男18例,女3例,年龄23岁～59岁,平均36.3岁。AO/ASIF分类A型10例,B型9例,C型2例。Gustilo分类Ⅰ型9例,Ⅱ型11例,ⅢA型1例。结果:所有患者得到4～21个月随访(平均14.3个月)。所用髓内钉直径平均8.9mm。骨折平均愈合时间27周(13～34周)。采用Johner-Wruh评分,结果优14例,良6例,差1例,无感染,无断钉和骨不连。结论:非扩髓交锁髓内钉治疗开放性胫骨干骨折,只要严格掌握适应证和手术时机,彻底清创,熟练掌握操作技术,具有创伤小、能早期活动、骨折愈合率高和感染率低等优点。