Conversion of External Fixation to Definitive Intramedullary Nailing in Experimental Tibial Fractures

ABSTRACT

Background and Purpose: Initial treatment with external fixation of tibial fractures is indicated in severely injuried multitrauma patients. A conversion procedure to secondary nailing is often performed later to enhance fracture repair. The aim of the study was to compare definitive treatment of experimental tibial fractures with external fixation to an early conversion to secondary intramedullary nailing with large and small diameter nails. Methods: Thirty male rats were subject to a standardized tibial shaft osteotomy initially stabilized with external fixation. On day 7, they were assigned to either the control group (group A, N = 10) or conversion to secondary nailing with a small (group B, N = 10) or large diameter nails (group C, N = 10). Evaluation at 60 days included radiography, dual energy radiographic absorptiometry (DXA), and mechanical bending testing. Results: All fractures healed radiographically with bridging of the fracture line and more or less visible periosteal callus formation. Group B demonstrated significantly increased mineralization and callus formation measured as DXA parameters, bone mineral content (BMC), and callus area (CA) compared to both the other two groups. This group also tended to have mechanically stronger bones with higher fracture energy compared to both the other two groups, but no significant difference in mechanical prioperties between the groups was found in our study. Interpretation: In conclusion, we found that conversion from external fixation of leg fractures in rats to intramedullary nailing did not improve bone healing significantly supporting external fixation as definitive fracture management.     

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.     

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.     

Acute unreamed intramedullary nailing and soft tissue reconstruction with muscle flaps for the treatment of severe open tibial shaft fractures

BACKGROUND: The treatment of open tibial shaft fractures remains controversial. Important considerations in surgical management include surgical timing, fixation technique and soft tissue coverage. This study was performed to evaluate the results of acute surgical debridement, unreamed nailing and soft tissue reconstruction in the treatment of severe open tibial shaft fractures. PATIENTS AND METHODS: During a 10-year period between January 1993 and July 2002, 927 tibial shaft fractures were treated with interlocking intramedullary nails. Among them, there were 19 consecutive patients with Gustilo type IIIB to IIIC open tibial shaft fractures with extensive soft tissue injury needing a muscle flap coverage and being suitable for intramedullary nailing. All 19 patients were called for a late follow-up which was conducted with a physical examination and a radiographic and functional outcome assessment. The radiographs were reviewed to determine the fracture healing time and the final alignment. RESULTS: All 19 open fractures with severe soft tissue injury healed without any infection complications. The fractures united in a mean of 8 months. Nine patients had delayed fracture healing (union time over 24 weeks). One of these patients needed exchange nailing, one patient autogenous bone grafting and dynamisation on the nail and seven patients needed dynamisation of the nail before the final fracture healing. In all patients, the alignment was well maintained. However, seven patients had shortening of the tibia by 1-2 cm and two of them also external rotation of 10 degrees . The functional outcome was good in 18/19 patients. INTERPRETATION: Acute surgical debridement, unreamed interlocking intramedullary nailing and soft tissue reconstruction with a muscle flap appear to be a safe and effective method of treatment for Gustilo type IIIB open tibial shaft 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.     

Femoral shaft fracture callus formation after intramedullary nailing: a comparison of interlocking and Ender nailing

 Intramedullary nailing is widely used for the operative treatment of femoral fractures. Recently, the biologic healing of fractures has become better understood from fundamental investigations. However, there has been no clinical comparison between the fracture healing process with these two fixation methods. The purpose of this study was to use radiographs to compare callus formation with two types of intramedullary nailing for femoral shaft fractures: reamed interlocking (IL) nails and Ender nails. Femoral shaft type A fractures (AO classification) were studied. Twenty-seven fractures were treated with reamed IL nailing, and 81 fractures were treated with Ender nailing. The callus area was calculated from the maximum cross-sectional area on the anteroposterior and lateral radiographs. The callus appeared at a mean of 3.9 weeks after surgery in the IL group, and at a mean of 2.8 weeks in the Ender group (P < 0.05). In the IL and Ender groups, fracture healing was noted at a mean of 3.4 and 2.0 months, respectively. The mean area of callus formation in the IL and Ender nailing groups was 439.5 mm² and 699.4 mm², respectively (P < 0.02). Ender nailing results in abundant callus, which forms at an earlier stage after the procedure than in patients treated with IL nailing. Dynamization at the fracture site is reported to increase external callus formation. Our results indicate that the elasticity of the fixation obtained with Ender nailing promotes callus formation. Received: November 9, 2001 / Accepted: February 13, 2002     

The effects of reaming and intramedullary nailing on fracture healing

Most closed fractures of the shaft of the femur and tibia can be treated successfully with internal fixation with medullary or interlocking nails. Unlike plate fixation, intramedullary nailing does not provide absolutely rigid fixation, so that some motion at the fracture site exists. The process of reaming causes circulatory disturbances in the inner two-thirds of the diaphyseal cortex. However, this does not impede the formation of external callus. The parts of bone that have sustained vascular damage by trauma or surgery are revascularized. Delay in the healing process due to disruption of the blood supply to fracture fragments is not known. The majority of patients are able to weight-bear a few days after surgery.     

交锁髓内钉治疗股骨干骨折术后感染和骨吸收的处理

目的 探讨交锁髓内钉治疗股骨干骨折术后感染及骨吸收的治疗方法。方法股骨十骨折交锁髓内钉固定术后感染及骨吸收13例,术后感染平均14．5个月。第一期拔除髓内钉、彻底清创、外同定支架固定,第二期植骨、抗感染;术后膝关节功能锻炼。结果随访平均4．2年。1年后骨折和感染均治愈,随访期内均无复发。结论合理的二期手术,是治疗交锁髓内钉固定股骨干骨折术后感染及骨吸收的可行方法。     

The Effect of timing of conversion from external fixation to secondary intramedullary nailing in experimental tibial fractures

Diaphyseal tibial fractures with initial temporary external fixation (EF) are usually converted to intramedullary nailing (IMN) within 2 weeks, and no consensus on the optimal conversion time point exists. Current clinical practice is mainly based on estimation of the risk of postoperative infection. This is the first investigation of the effect of timing of such conversion on fracture healing. Forty male rats received a standardized tibial shaft osteotomy and EF. The animals were then randomly assigned to conversion to IMN at either 7 (group A, N = 10), 14 (group B, N = 10), or 30 (group C, N = 10) days after initial fixation. Group D (N = 10) served as a control group without conversion. Evaluation at 60 days included X‐ray, DXA, and mechanical testing. Group A had significantly increased bone mineral content and callus area compared to the control group. Groups B and C showed significantly inferior mechanical bending strength and rigidity compared to both group A and the control group (D). The timing of the conversion procedure has a significant effect on fracture healing. Early conversion procedure did not improve healing compared to control, but was advantageous compared to late conversion (at 2 or 4 weeks) with higher mineralization and superior biomechanical properties. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:126–130, 2011     

Management of infected tibial intramedullary nailing using an organized treatment protocol

Twenty cases of osteomyelitis following intramedullary nailing of the tibial shaft fracture were managed with a prospective treatment protocol comprising intramedullary reaming debridement, antibiotic-bead depot, external skeletal fixation, microvascular muscle flap and early cancellous bone grafting. The follow-up period ranged from 25 to 48 months (average, 34.3 months). Pseudomonas aeruginosa (37.5%) and staphylococcus aureus (20.8%) were the organisms most commonly involved. There were 8 united and 12 ununited fractures after reaming debridement surgery. Nineteen infections were initially arrested by one debridement. One infection was arrested by two sequential debridements. All 12 ununited fractures were stabilized by Hoffmann unilateral external fixation until the fracture healed. The time spent in external fixation ranged from 3 to 7 months (average, 5.2 months). Early cancellous bone grafting was successfully accomplished for 9 ununited fractures with major debridement bone loss. The average union time of the 9 fractures with bone grafting was 7.2 months (range, from 6 to 8 months). We believe that this treatment protocol gives a predictable and rapid recovery. The complications were infection recurrence in two cases at the old tibial shaft fracture sites, minor pin tract infection of Hoffmann external fixators in two cases, and stiffness in two ankles and one knee.     

Fatigue behavior of Ilizarov frame versus tibial interlocking nail in a comminuted tibial fracture model: a biomechanical study

Background  

Treatment options for comminuted tibial shaft fractures include plating, intramedullary nailing, and external fixation. No biomechanical comparison between an interlocking tibia nail with external fixation by an Ilizarov frame has been reported to date. In the present study, we compared the fatigue behaviour of Ilizarov frames to interlocking intramedullary nails in a comminuted tibial fracture model under a combined loading of axial compression, bending and torsion. Our goal was to determine the biomechanical characteristics, stability and durability for each device over a clinically relevant three month testing period. The study hypothesis was that differences in the mechanical properties may account for differing clinical results and provide information applicable to clinical decision making for comminuted tibia shaft fractures.     

Effect of intermittent administration of parathyroid hormone on fracture healing in ovariectomized rats

The effects of intermittent administration of parathyroid hormone on fracture healing in ovariectomized rats were examined to evaluate its potential use as a therapeutic agent for osteoporotic fractures. Three months postovariectomy, bilateral tibial shaft fractures were induced and stabilized by intramedullary nailing with Kirschner wires. Saline, 17beta-estradiol (Sigma Chemical Corp, St Louis, Mo), or recombinant human parathyroid hormone (1-84) (Korean Green-Cross Pharm Corp, Seoul, Korea) was given once a day for 30 consecutive days during fracture healing. Fracture healing was assessed by morphometric and mechanical analysis of fracture callus. Intermittent parathyroid hormone administration increased the morphometric and mechanical parameters in a dose-dependent manner. A bone-resorption inhibiting agent, 17beta-estradiol did not offer advantage in terms of fracture healing in ovariectomized rats. Findings suggest intermittent parathyroid hormone administration may benefit osteoporosis and fracture.     

胫骨干骨折带锁髓内钉固定和钢板螺钉固定的对比研究

目的：对照回顾性分析带锁髓内钉和钢板内固定两种方法治疗胫骨干骨折的效果。方法：髓内钉组32例（35处骨折）,根据AO分型,42A型11处,42B型18处,42C型6处;钢板组42例（45处骨折）,42A型10处,42B型22处,42C型13处。平均伤后手术时间在髓内钉和钢板组分别为3d和3.5d。随访评估患者手术时间,活动度,愈合时间,术后并发症之间的差别。结果：术后平均随访13个月（8～26个月）。髓内钉组平均手术时间为84min,钢板螺钉组平均为93min。髓内钉组踝关节平均背屈度为13°（0°～20°）,钢板组为11°（0°～20°）;跖屈分别为41°（30°～50°）,47°（30°～50°）。愈合时间髓内钉组平均为3.3个月,钢板螺钉平均为3.5个月。术后X线片显示髓内钉固定有1例出现旋转畸形,钢板组有3例出现成角畸形,均为胫骨远端1/3骨折。结论：在治疗胫骨骨折方面,带锁髓内钉和钢板内固定两种方法都可以取得理想的效果。     

Fractures of the femur and tibial shaft

Fractures of the femoral and tibial shaft are common injuries. They exhibit a bimodal age distribution and are frequently associated with other injuries. Their fracture patterns vary, and so are managed using a range of treatment options.The first priority is to check that there are no life-threatening injuries or acute complications associated with the injuries sustained. Once these are ruled out, the orthopaedic team can begin planning the treatment option best suited to the fracture and patient. For femoral fractures this usually involves intramedullary nailing, or plating, across the fracture site. Conservative and mono-lateral external fixation of the femur is now considered inadvisable because of the higher risk of complications and decreased rehabilitation potential. For tibial fractures the options are either conservative management, in a non-weight-bearing cast, or intramedullary nailing or plating. External fixation remains a useful modality in severe deformity or open fractures of the tibia. Complications commonly associated with both these fractures include venous thromboembolism, infection, compartment syndrome, fat embolism, vascular injury and mal- or non-union of bone.     

扩髓带锁髓内钉治疗股骨、胫骨干骨折不愈合、延迟愈合

目的　总结使用扩髓带锁髓内钉治疗股骨、胫骨干骨骨折不愈合、延迟愈合的临床经验。方法　回顾自 1999年 4月～2 0 0 1年 6月使用扩髓带锁髓内钉治疗股骨干、胫骨干骨折不愈合、延迟愈合病人 2 1例 ,其中股骨 8例 ,胫骨 13例 ,钢板固定术后 ,股骨 3例 ,胫骨 6例。普通髓内针股骨 5例。外固定架胫骨 2例。石膏固定胫骨 3例 ,骨牵引股骨 2例。均采用有限切口切开复位顺行扩髓 ,静力锁定加植骨术。结果　随访半年以上 18例 ,骨折均愈合 ,临近关节功能达正常。无感染、断钉等并发症。结论　采用有限切口切开复位、扩髓、静力锁定治疗股骨、胫骨干骨折不愈合、延迟愈合 ,具有骨折稳定性可靠、有利于骨折愈合和早期关节活动的优点 ,是治疗股骨、胫骨干骨折不愈合、延迟愈合的有效方法之一。     

可膨胀髓内钉和交锁髓内钉在胫骨干骨折治疗中的比较

目的 对可膨胀髓内钉和交锁髓内钉在胫骨骨折治疗中的相关因素进行比较分析。方法 2004年6月至2005年10月间，收治胫骨干骨折57例，42例行交锁髓内钉固定，15例行可膨胀髓内钉固定。对两组病例的手术时间、术中出血量、术中透视时间、术后并发症、骨折愈合时间进行比较。结果 两组在手术时间、术中出血量、术中透视时间、骨折愈合时间等方面差异有统计学意义（P〈0．05），在术后并发症上无显著性差异（P〉0．05）。因此可膨胀髓内钉组在多方面均优于交锁髓内钉组。结论 可膨胀髓内钉具有操作方便、创伤小、愈合快等优点，但费用昂贵，适应症较窄。     

扩髓灌洗联合抗生素骨水泥涂层髓内钉内固定治疗胫骨骨折髓内钉内固定术后感染

目的探讨扩髓灌洗并更换成含抗生素骨水泥涂层髓内钉内固定治疗胫骨骨折髓内钉内固定术后感染的临床疗效。方法回顾性分析自2012-06—2018-12诊治的10例胫骨骨折髓内钉内固定术后感染,术中扩大髓腔进行髓腔灌洗、彻底清创,然后更换成含抗生素骨水泥涂层髓内钉一期内固定胫骨骨折。3例经窦道清创切除感染骨后用抗生素骨水泥填充骨缺损,8周后取出骨水泥并行自体松质骨颗粒植骨。结果 10例术后均获得随访,随访时间平均28(12~48)个月。所有患者术后感染均未复发,未再次骨折。7例无骨缺损者胫骨骨折愈合时间平均5(4.0~5.5)个月。3例骨缺损取自体髂骨植骨者骨折愈合时间分别为4、5、6个月,平均5个月。3例术后1年内出现髌前疼痛,经康复治疗后痊愈。结论扩髓灌洗并更换成含抗生素骨水泥涂层髓内钉内固定是胫骨骨折髓内钉内固定术后感染的有效治疗方法,治疗周期短,感染治愈率高,同时还有利于骨折愈合。     

Simultaneous ipsilateral diaphyseal fractures of the femur and tibia: treatment and complications

We present our experience of intramedullary nailing (IM) and external fixation in the treatment of 54 patients with ipsilateral diaphyseal fractures of the femur and tibia. Eight femoral and 24 tibial fractures were open. They were classified into three groups: IM nailing of both fractures (group A, 19 patients); IM nailing of the femoral and external fixation of the tibial fracture (group B, eight patients); and external fixation of both fractures (group C, 27 patients). In group C (which included all but one grade III open fracture), two patients died and four underwent amputation. Femoral fractures treated with external fixation had significantly more complications and reoperations than those treated with IM nailing. In tibial fractures this difference was also present but not statistically significant. We believe that IM nailing is the method of choice for femoral fractures and is preferable for tibial fractures, with the exception probably of grade III B and C open injuries.     

Femoral and tibial fractures

Femoral shaft fractures have a bimodal distribution with high energy injuries in young patients and an increasing incidence of osteoporotic fractures in elderly patients. Adult diaphyseal fractures are invariably managed operatively and the procedure most commonly performed is stabilisation with antegrade reamed intramedullary nailing. Retrograde nailing is also used for specific indications. Plating is still used for more distal fractures. External fixation and non-operative treatment by traction are seldom used now due to high risk of complications. Tibial shaft fractures are the most common long bone fracture and the most common open long bone fracture (21%). Reamed intramedullary nailing is the most common treatment for unstable fractures. Low energy undisplaced fractures can be treated non-operatively in a cast or brace. Plating is not often used for diaphyseal injuries but is useful for metaphyseal fractures. External fixation is still commonly used for some severe open injuries or to correct deformity. Complications of femoral and tibial fractures include nonunion, malunion and infection in association with open fractures. Compartment syndrome complicates 2-10% of tibial fractures. For closed fractures the incidence of all of these complications should be less than 5%. Open fractures have a greater risk of complication which is generally proportional to the energy of the injury.