The management of segmental tibial shaft fractures: A systematic review

IntroductionSegmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures.MethodA PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data.ResultsThirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from ‘excellent’ to ‘fair’.DiscussionThe available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available.ConclusionIMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem.     

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.     

High incidence of screw penetration in the proximal and distal tibiofibular joints after intramedullary nailing of tibial fractures—A prospective cohort and mapping study

BackgroundIntramedullary-nails (IMN) are the treatment of choice for most tibial shaft fractures due to their minimally-invasive nature and non-demanding surgical technique. However, a potential iatrogenic pitfall is intra-articular interlocking screw positioning within the proximal (PTFJ) and distal (DTFJ) tibiofibular joints that may go unrecognized.ObjectiveTo evaluate the incidence of intra-articular screw penetration of the PTFJ and DTFJs after interlocking of IMN for tibial fractures.InterventionReamed IMN using modern techniques, including proximal interlocking via standard aiming jig and distal interlocking either freehand or using SureShot^®.MethodsProspective series of 165 consecutive patients with a tibial shaft fracture managed with an IMN. Diagnosis and incidence of penetration of the PTFJ and DTFJ was assessed on protocolled low-dose postoperative CT-scans (standardized clinical practice for assessing rotational alignment). The degree of penetration of the TFJ’s was graded as: Grade 1–slight breach of the tibial cortex; Grade 2–clear penetration of the tibial cortex with intra-articular screw tip; and Grade 3–penetration of both tibial- and fibular cortices with screw tip in fibula.ResultsOf the 165 tibial shaft fractures, using the AO/OTA classification, 69% were simple, 16% wedge and 15% complex fractures. Following IMN 42% of patients had intra-articular screw penetration of their PTFJ whilst 39% had penetration of their DTFJ. 66% of patients had penetration of either one- or both of their TFJs. The grading of PTFJ violation was distributed as follows: Grade 1 in 24 patients; Grade 2 in 26 patients and Grade 3 in 19 patients. DTFJ violation was graded as: Grade 1 in 21 patients; 40 patients had Grade 2 violation; and four patients had a Grade 3 penetration.ConclusionsThis diagnostic imaging study reports a high rate of intra-articular screw penetration of the PTFJ and DTFJ after interlocking of IMN for tibia shaft fractures. A prospective cohort study is underway to evaluate its clinical significance.Changes to enable alteration in forced angle of interlocking screw trajectory and avoidance of the anteromedial to posterolateral locking screw may reduce the incidence of TJF violation.Level of evidenceLevel II – Diagnostic Imaging Study     

Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures

Background:

We evaluated a series of diaphyseal fractures of the tibia using low-cost, Indian-made modified Kuntscher nail (Daga nail) with the provision of distal locking screw for the management of the tibial diaphyseal fractures.

Materials and Methods:

One hundred and fifty one consecutive patients with diaphyseal fractures of tibia with 151 fractures who were treated by Daga nail were enrolled. One of the patients who had died because of cancer, and the two patients who were lost to follow-up at 3 months were excluded from the study.Therefore data of 148 patients with one hundred and fortyeight fractures is described. One hundred twenty closed fractures, 20 open Grade I fractures, and eight open Grade II fractures as per Gustilo and Anderson classification were included in this study. One hundred fourteen men and 34 women, with a mean age of 38.4 years, were studied. The result were analysed for Surgical time, duration of hospitalisation, union time, union rate, complication rate, functional recovery and crutch walking time. The fractures were followed at least until the time of solid union.

Results:

The follow-up period averaged 15 months (range, 6–26 months). Union occurred in 140 cases (94.6%). The mean time to union was 13 weeks for closed fractures,17.8 weeks for Grade I open fractures, and 21.6 weeks for Grade II open fractures. Compartment syndrome occurred in two patients. Superficial infection occurred in five cases of Grade I and II compound fractures. Three closed fractures and one case of Grade I compound fracture required bone grafting for delayed union. Two cases of Grade II compound fracture with nonunion required revision surgery and bone grafting. Twelve cases resulted in acceptable malalignment due to operative technical error. In four cases, the distal screw breakage was seen, but none of these complications interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury.

Conclusion:

Unreamed distally locked dynamic tibial nailing (modified Kuntscher nail/Daga nail) can produce excellent clinical results for diaphyseal tibial fractures. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.     

Comparison between intramedullary nailing and minimally invasive plate osteosynthesis for tibial shaft fractures

IntroductionIntramedullary nailing (IMN) is currently considered the gold standard in the surgical treatment of tibial shaft fractures in adult patients. In this case-control comparative study, we aimed to compare the efficacy of minimally invasive plate osteosynthesis (MIPO) and IMN in treating tibial shaft fractures.Materials and methodsThe clinical and radiological outcomes, such as a modified trauma scale, operation time, fracture healing, rate of re-operation, and complications such as malunion, nonunion, shortening, and infection were assessed between IMN and MIPO for the treatment of tibial shaft fractures.ResultsSeventy-three skeletally mature patients who underwent IMN (group I) or MIPO (group M) for a closed extra-articular tibial shaft fracture (AO/OTA type 42) from June 2010 to May 2016 were retrospectively reviewed. The mean age was 51.16 (18~79) years, and the mean follow-up period was 22 (12~50) months. Bony union was achieved in all cases but one for each group - group I (35 cases) and group M (36 cases) (p > 0.05). Mean callus formation was observed in 12 (8 – 16) weeks in both groups (p > 0.05). There was no significant difference in operative time, hospital stay, bone healing, and the rate of complications among the two groups (p > 0.05). There was also no postoperative difference in functional evaluation between the two methods (p > 0.05).ConclusionsNo discrepancy was found in radiological and clinical outcomes between IMN and MIPO for tibial shaft fractures. It can be concluded that both IMN and MIPO are equally effective treatment modalities for tibial shaft fractures.     

Ankle arthrodesis using the Taylor Spatial Frame for the treatment of infection,extruded talus and complex pilon fractures

IntroductionThe treatment of complex pilon fractures and talus fracture-dislocations present several challenges, like avoiding infection, achieving union, management of bone loss and function preservation.MethodsRetrospective cohort review of fourteen patients who underwent ankle arthrodesis (AA) using the Taylor Spatial Frame (TSF) after pilon and talus fracture-dislocations. Ten tibiocalcaneal (TC) and four tibiotalar (TT) fusions were performed. Eleven of these cases were Gustilo III open fractures. Seven cases involved an open extruded talus. Four cases had established infections. There was a mean of 2.7 (range 0 – 8) operations prior to AA using TSF. The primary objective was to determine infection and union rates. Patient-reported outcomes (Short Form 36, SF-36) and functional outcomes (Ankle Osteoarthritis Score, AOS) were the secondary measures.ResultsEradication and prevention of deep infection was achieved in all cases. Radiological union was achieved at a mean of 9 months (range 5 – 17). Solid AA was achieved in 12 of 14 cases using the TSF. Two TC fusions required a hindfoot fusion nail to achieve union. Eleven cases had concurrent bone transport, mean of 63 mm (range 33 - 180). Mean time of TSF treatment was 11.1 months (range 6 - 16). One case required delayed amputation. Eight patients were able to fully weight bear unaided after the treatment. Mean SF-36 was 65 (range 35 -100). Mean AOS was 36.5 (range 6.6 – 77.5) with 69.3% of scores graded good to excellent. Mean total number of operations was 5.9 (range 2 – 10). Minimum follow up time was 12 months (range 12 - 56).ConclusionAA using TSF can be considered for complex pilon fractures and extruded talus. It has shown to be effective in achieving a solid fusion and infection eradication. While using the TSF in isolation, non-union must be suspected in TC fusions, absence of radiological signs of healing, massive bone loss, and possibly not using bone graft. Patients must be aware that while treatment of these injuries will be prolonged and carries the risk of many potential complications, it provides a good alternative to amputation.     

Fracture healing following high energy tibial trauma: Ilizarov versus Taylor Spatial Frame

Introduction

The optimal treatment of high energy tibial fractures remains controversial and a challenging orthopaedic problem. The role of external fixators for all these tibial fractures has been shown to be crucial.

Methods

A five-year consecutive series was reviewed retrospectively, identifying two treatment groups: Ilizarov and Taylor Spatial Frame (TSF; Smith & Nephew, Memphis, TN, US). Fracture healing time was the primary outcome measure.

Results

A total of 112 patients (85 Ilizarov, 37 TSF) were identified for the review with a mean age of 45 years. This was higher in women (57 years) than in men (41 years). There was no significant difference between frame types (p=0.83). The median healing time was 163 days in both groups. There was no significant difference in healing time between smokers and non-smokers (180 vs 165 days respectively, p=0.07), open or closed fractures (p=0.13) or age and healing time (Spearman''s r=0.12, p=0.18). There was no incidence of non-union or re-fracture following frame removal in either group.

Conclusions

Despite the assumption of the rigid construct of the TSF, the median time to union was similar to that of the Ilizarov frame and the TSF therefore can play a significant role in complex tibial fractures.     

Do Poller screws effect union in tibial shaft fractures treated with intramedullary nailing?

IntroductionTibial shaft fractures are a commonly encountered challenge presented to orthopaedic trauma surgeons. Intramedullary nailing (IMN) is often the treatment of choice and whilst effective, complications of delayed and/or non-union can cause significant morbidity and necessitate additional operative procedures. The use of Poller screws during IMN are a recognised way of aiding fracture reduction, however the clinical benefits of this are debated. This study evaluated the outcome of tibial shaft fractures treated with IMN with or without the addition of Poller screws.MethodsRetrospective cohort study of all patients undergoing IMN following tibial shaft fractures over a 5-year period. 154 operated tibial shaft fractures were identified, with patients divided into 3 groups - Group 1: IM nailing alone, Group 2: IMN + 1 conventional Poller screw, or Group 3: IMN + 2 Poller screws placed Epicentrically across the fracture site. Data collected included demographics, length of stay, fracture type, position and AO classification grade, operative time, and operating surgeons' grade. Primary outcome measure was the incidence of delayed and/or non-union. Secondary outcomes were differences in rates of infection and additional orthopaedic procedures between the 3 groups.ResultsOverall 139/154 fractures (90.3%) achieved a timely union. There was a statistically significant difference (p = 0.05) in fracture union between the 3 groups, with 75/88 fractures healing in group 1 (IMN alone) compared to 44/46 in Group 2 (IMN + 1 Poller screw) and 20/20 in group 3 (IMN + 2 Poller screws). There was no statistical difference in the incidence of superficial infection, (p = 0.95) additional procedures (p = 0.23) or deep infection (p = 0.65) between the 3 groups.ConclusionThe addition of Poller screws appear to be a safe and effective adjunct in the treatment of tibial shaft fractures via IMN. Further prospective randomised trials are needed to fully elucidate both the role and potential benefits of Poller screw augmentation in acute lower limb fracture management.     

Minimally invasive plate osteosynthesis using posterolateral approach for distal tibial and tibial shaft fractures

ObjectiveThe objective of the study was to evaluate the effectiveness of the posterolateral minimally invasive plate osteosynthesis (MIPO) method for managing distal tibial or tibial shaft fractures with severe anterior and medial soft tissue injuries.Materials and methodsFive consecutive patients with three distal tibial and two tibial shaft fractures (three open fractures) at a level-1 trauma and tertiary referral center were retrospectively reviewed. All patients were definitively treated and followed to bone union. Main outcome was measured by American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score, complications, and bone union on radiographs.ResultsThe average follow-up period was 15.8 months (range, 12–24 months). The average AOFAS score was 88.2 (range, 81–90). There were no complications, such as incision breakdown, deep infection, or impingement of the flexor hallucis longus tendon. Bone union was achieved in all cases.ConclusionsPosterolateral MIPO is a feasible option when treating these fractures, especially in cases with severe anterior and medial soft tissue injuries.     

Management of paediatric tibial fractures using two types of circular external fixator: Taylor spatial frame and Ilizarov circular fixator

Background

The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management.

Method

A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months.

Results

Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group.

Conclusion

In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter.

Level of evidence

Level II—comparative study.     

Combination of radiographic apparent bone gap and nonunion risk determination score improves accuracy of prediction of tibial shaft delayed union

BackgroundThere is a need for a novel therapeutic strategy for an earlier prediction of long bone union failure as compared to previous methodologies. This study aimed to determine whether a combination of two diagnostic tools would result in a more accurate diagnosis of delayed union.MethodsThe inclusion criteria were as follows: patients with tibial shaft fracture who underwent treatment with intramedullary nailing (IMN) as definitive internal fixation (IF). The study included a total of 114 patients with 116 tibial shaft fractures treated with IMN as definitive IF. Radiographic apparent bone gap (RABG) and nonunion risk determination score (NURDS) can be used to predict nonunion. However, this study aimed to determine whether combination of RABG and NURDS could help deduce a more accurate prediction of delayed union.ResultsThe union rate was found to be 85% (99 fractures), the delayed union rate was found to be 15% (17 fractures), and the rate of nonunion requiring additional surgical intervention was estimated to be 4% (5 out of the 17 delayed union cases). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RABG were found to be 82.3%, 76.0%, 36.8%, and 96.2%, respectively, when an RABG cutoff value of 5.0 mm was applied to our patient cohort. The sensitivity, specificity, PPV, and NPV of NURDS were found to be 47.1%, 82.0%, 30.8%, and 90.1%, respectively, when a NURDS cutoff value of 8.0% was applied to our patient cohort. When RABG and NURDS were above their respective cutoff values, the sensitivity and PPV were estimated to be 90.0% and 56.3%, respectively. When RABG and NURDS were below their respective cutoff values, the specificity and NPV were estimated to be 90.1% and 98.5%, respectively.ConclusionsThe combination of RABG and NURDS evaluation immediately after surgery helps surgeons identify patients who are at a high risk of delayed union, facilitating careful monitoring of these patients and consideration of additional treatments.     

Early versus delayed weight bearing after intramedullary nailing for tibial shaft fracture: A multicenter,propensity score-matched study,the TRON study

ObjectivesThe purpose of this multicenter study was to assess the differences in the rates of implant failure and bone union by X-ray examination, and walking ability between an early weight-bearing group (EWB) and a non-weight-bearing group (NWB) following treatment with intramedullary nailing (IMN) for tibial shaft fractures with a propensity score-matching method.Material and MethodsWe collected data from 336 patients with tibia fractures that were treated surgically. We excluded patients lost to follow-up and polytrauma patients. Finally, 263 patients were included who were divided into two groups, the early weight-bearing (EWB) group, in which partial weight-bearing walking within four weeks was encouraged, and a non-weight-bearing (NWB) group, in which no weight bearing was allowed for more than four weeks. To adjust for baseline differences between groups, a propensity score algorithm was used to match the EWB group with the NWB group in a 1:1 ratio of 75 cases each. After matching, we compared the rate of implant failure, the rate of bone union at six months and one year after surgery, and walking ability at the last follow-up between the two groups.ResultImplant failure occurred in 0 of 75 patients in the EWB group vs. 1 of 75 in the NWB group (P = 1.0). Delayed bone union at six months occurred in 20 of 75 (26%) vs. 13 of 75 (17%) patients, and that at one year occurred in 5 of 75 (6.7%) vs. 3 of 75 (4%) patients. The median New Mobility Score was 9 (4–9) vs. 9 (0–9) points.ConclusionsThere were no statistically significant differences in the rate of implant failure, the rates of the bone union at six months and one year after surgery, and walking ability between the EWB group and NWB group. We suggest that instruction in early weight-bearing after IMN nailing for tibial shaft fracture may not be harmful.     

闭合复位LISS钢板治疗胫骨近端多段骨折的临床疗效

目的：通过应用闭合复位AO微创内固定系统（LISS）治疗胫骨近端多段骨折,探讨闭合复位LISS固定对该类骨折复位及愈合的影响。方法：2003年7月至2007年12月,采用闭合复位LISS钢板治疗胫骨近端多段骨折19例,男14例,女5例;年龄21—49岁,平均39．2岁;直接暴力致伤15例,间接暴力致伤4例。致伤原因：交通伤14例,高处坠落伤3例,摔伤2例。于术后随访观察患肢功能恢复情况,及摄X线片显示骨痂生成和骨折愈合情况。结果：患者均获随访,时间8-21个月,平均12．2个月。无固定丢失和骨折不愈合,无钢板和螺钉变形,无软组织感染。膝关节功能按Merchan等评分标准评定,优14例,良3例,可2例。结论：采用闭合复位LISS钢板治疗胫骨近端多段骨折,是一种有效的内固定方法,具有稳定固定、愈合率高、创伤低等优点。     

Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?

IntroductionDistal femur fractures make up < 1% of all fractures and 3–6% of all femur fractures. In the literature, both intramedullary nailing (IMN) and locked plating (LP) have shown favorable results, but there is no consensus on a gold standard. The purpose of this systematic review is to compare outcomes of native distal femur fractures treated via IMN versus LP in an effort to determine if one is superior to the other.MethodsSystematic review of MEDLINE, EMBASE, and Cochrane Library databases was conducted according to PRISMA guidelines. Only articles published within the last ten years were included. Evidence and study quality were evaluated with the MQOE and Oxford Criteria.ResultsForty-six articles were included in the review. Fractures treated with IMN were found to have a 93.9% union rate, an average time to union of 19.2 weeks, an average arc of motion of 105.1 degrees, with an average of 14.4 degrees of malalignment. Fractures treated with LP were found to have a 90.2% union rate, an average time to union of 20.5 weeks, an average arc of motion of 104 degrees, with an average of 12.6 degrees of malalignment.ConclusionCompiled data comparisons revealed no differences in union rate, malalignment, time to union, average arc of motion, or complication rates requiring a return to the operating room. Until higher level randomized data is available, either IMN or LP are acceptable methods of treatment for native distal femur fractures.     

Elastic nailing of tibia shaft fractures in young children up to 10 years of age

IntroductionAlthough tibia shaft fractures in children usually have satisfactory results after closed reduction and casting, there are several surgical indications, including associated fractures and soft tissue injuries such as open fractures. Titanium elastic nails (TENs) are often used for pediatric tibia fractures, and have the advantage of preserving the open physis. However, complications such as delayed union or nonunion are not uncommon in older children or open fractures. In the present study, we evaluated children up to 10 years of age with closed or open tibial shaft fractures treated with elastic nailing technique.MethodsA total of 16 tibia shaft fractures treated by elastic nailing from 2001 to 2013 were reviewed. The mean patient age at operation was 7 years (range: 5–10 years). Thirteen of 16 cases were open fractures (grade I: 4, grade II: 6, grade IIIA: 3 cases); the other cases had associated fractures that necessitated operative treatments. Closed, antegrade intramedullary nailing was used to insert two nails through the proximal tibial metaphysis. All patients were followed up for at least one year after the injury. Outcomes were evaluated using modified Flynn's criteria, including union, alignment, leg length discrepancies, and complications.ResultsAll fractures achieved union a mean of 16.1 weeks after surgery (range: 11–26 weeks). No patient reported knee pain or experienced any loss of knee or ankle motion. There was a case of superficial infection in a patient with grade III open fracture. Three patients reported soft tissue discomfort due to prominent TEN tips at the proximal insertion site, which required cutting the tip before union or removing the nail after union. At the last follow-up, there were no angular or rotational deformities over 10° in either the sagittal or coronal planes. With the exception of one case with an overgrowth of 15 mm, no patient showed shortening or overgrowth exceeding 10 mm. Among final outcomes, 15 were excellent and 1 was satisfactory.SummaryEven with open fractures or soft tissue injuries, elastic nailing can achieve satisfactory results in young children, with minimal complications of delayed bone healing, or infection.     

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.     

Surgical outcomes after treatment of fractures in femur and tibia in pycnodysostosis

Pycnodysostosis is a rare hereditary disease, characterized by systemic bone sclerosis. The most important orthopedic problem in this condition is the recurrent pathological fracture of long bones. In this paper, the surgical results for fractures of six limbs (three femurs and three tibias) in five cases of pycnodysostosis are reported. Five limbs achieved fracture union and union is developing in one tibia after intramedullary nail (IM) nailing or Ilizarov external fixation (IEF), although fracture line tends to persist for longer periods of time. One femoral fracture was treated by IM nailing, and one femoral and one tibial fracture were treated by IEF leading to final bone union. One femoral and one tibial fracture were initially treated by IEF, and were treated by IM nailing after re-fracture. One tibial fracture was initially treated by IEF leading to a failure of union, and was converted to IM nailing. All cases are able to walk; one case requires a single crutch. Infection was noted in two limbs after IM nailing following IEF. Fixation with IM nail was effective in preventing re-fracture as well as in alignment correction. Although the surgical technique is more difficult, IM nailing in the initial surgery may be a better choice for achieving successful union while reducing the risk of re-fracture or infection.     

Treatment of tibial nonunion with posterolateral bone grafting

ObjectivesPosterolateral bone grafting to treat nonunions of the distal two-thirds of the tibia avoids the often traumatized and more tenuous anterior soft-tissue envelope. Few modern reports of its effectiveness are available. We assessed whether posterolateral bone grafting leads to high union and low complication rates.MethodsWe conducted a retrospective review at a Level I trauma center. Our study group was 59 patients with distal two-thirds tibial fractures treated with posterolateral bone grafting. Patients included those with history of deep surgical site infection (SSI) before bone grafting (n = 17), established nonunions (n = 42), and impending nonunions associated with open fractures and bone gaps (n = 17). All patients were followed for a minimum of 12 months unless they achieved union before that time point. Our primary outcome measurement was fracture union. Secondary outcome measurements were any complication associated with the approach and infection requiring return to the operating room.ResultsFracture union was achieved in 44 (75%) of 59 patients without further intervention. The mean interval to union was 9.9 months (range, 3–22). Of 11 infected nonunions treated, nine progressed to union. Seventeen of 23 patients with defects >2 cm, including defects up to 5.4 cm without infection, were successfully treated. Two patients who underwent grafting at least 10 years after initial injury achieved union. No complications were associated with the approach (specifically, no wound breakdown, vascular injury, or tendon injury). Fourteen percent of patients experienced SSI after bone grafting. Seven of eight deep SSI occurred in patients with previous infection or positive intraoperative cultures. Only one (3%) of 36 patients without infection pre- or intraoperatively experienced SSI.ConclusionsEven in this relatively difficult patient cohort that included large bone gaps and history of infection, union was achieved at a relatively high rate with posterolateral bone graft. The approach seems to be safe, considering no known complications specifically associated with the approach occurred, and seems to reduce the risk of SSI in the absence of previous infection.     

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.     

Outcome of limb reconstruction system in open tibial diaphyseal fractures

Background:Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously.Results:Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal.Conclusion:Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.