External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol

Between 1983 and 1989, forty-one open fractures of the tibial shaft were treated with débridement and provisional external fixation, followed by delayed soft-tissue closure and subsequent intramedullary nailing with reaming. The average duration of external fixation was seventeen days (range, six to fifty-two days). The average time between removal of the fixator and intramedullary nailing was nine days (range, zero to twenty-four days). Of thirty-nine patients who had adequate follow-up, two (5 per cent) subsequently had a deep infection. Both infections healed, with retention of the nail and without chronic osteomyelitis. There were two nonunions and one delayed union. Satisfactory alignment was achieved in thirty-seven patients (95 per cent). This sequential protocol for treatment, which involved a short period of external fixation and thus minimized colonization of the pin tracks, yielded excellent results and a low rate of infection.     

Sequential intramedullary nailing of open tibial shaft fractures after external fixation

We reviewed 32 tibial shaft fractures in 31 patients treated with sequential intramedullary nailing after primary external fixation. There were 30 open fractures and 2 closed injuries with severe blunt trauma requiring fasciotomy. Fifty per cent of the fractures were classified as Gustilo type III A and B injuries [13]. The mean external fixation treatment averaged 6.6 weeks, and secondary intramedullary nailing was done on average 7.4 weeks after injury. In 50% of the fractures, secondary nailing was done at the same procedure as removal of the external fixation. Overall, the incidence of osteomyelitis and nonunion was 3.1% each and of malunion 19%. The time to full weight-bearing averaged 31.2 weeks. The results were separately analyzed according to Gustilo types and subtypes. In the Gustilo type III B injuries, the incidence of osteomyelitis and non-union was 11 %, while malunion occurred in 33%. The time to full weight-bearing averaged 53 weeks. These results support the conclusion that this treatment modality is a valid alternative to other treatment options. However, previous pintract infections should be regarded as a contraindication for secondary nailing.Beispiel: Presented at the 15th Annual Meeting on Mycorrhizae, Chicago, 1992     

Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures

BACKGROUND: Risk factors for deep infection in secondary intramedullary nailing (IMN) after external fixation (EF) for open tibial fractures were investigated by multivariate analysis following univariate analyses. METHODS: Forty-two open tibial fractures were treated with secondary IMN after EF. The open tibial fractures were classified according to the criteria proposed by Gustilo et al.: type II, 11; type IIIA, 8; type IIIB, 22 and type IIIC, 1. Locked IMNs with limited reaming were performed in 27 patients, and locked IMNs without reaming in 15 patients. The following factors contributing to deep infection were selected for analysis: age, gender, Gustilo type (II or III), fracture grade by AO type (A or B+C), fracture site, existence of multiple trauma (Injury Severity Score, ISS<18 or ISS> or = 18), existence of floating knee injury, debridement time (< or = 6 h or > 6 h), reamed (R) versus unreamed (UR) nailing, duration of external fixation (< or = 3 weeks or >3 weeks), interval between removal of EF and IMN (< or = 2 weeks or >2 weeks), skin closure time (< or = 1 week or >1 week), existence of superficial infection (+ or -) and existence of pin tract infection (+ or -). The relationship between deep infection and the above factors was evaluated by univariate analyses. RESULTS: Seven (16.7%) of the 42 open tibia fractures developed deep infections. All deep infections occurred in Gustilo type III (22.6%, 7/31). Only the skin closure time was a significant factor affecting the occurrence of deep infection on the present analysis (p = 0.006). CONCLUSION: The present evaluation showed that early skin closure within 1 week is the most important factor in preventing deep infections when treating open tibial fractures with secondary IMN after EF.     

Primary external fixation and secondary intramedullary nailing in the treatment of tibial fractures.

The results of primary external fixation and secondary intramedullary nailing of 21 tibial fractures are presented. It is shown that if secondary nailing is delayed until after granulation of the pin sites the technique is associated with a low infection rate. The union time for tibial fractures compares well with that of external fixation, although in closed and Gustilo type I open fractures primary intramedullary nailing gives superior results.     

External fixation compared to intramedullary nailing of tibial fractures in the rat

Background and purpose It is not known whether there is a difference in bone healing after external fixation and after intramedullary nailing. We therefore compared fracture healing in rats after these two procedures.Methods 40 male rats were subjected to a standardized tibial shaft osteotomy and were randomly assigned to 2 treatment groups: external fixation or intramedullary nailing. Evaluation of half of each treatment group at 30 days and the remaining half at 60 days included radiography, dual energy radiographic absorbtiometry, and mechanical testing.Results Radiographically, both treatment groups showed sign of fracture healing with gradual bridging of the fracture line, while with intramedullary nailing the visible collar of callus was increased peripherally, indicative of periosteal healing. At 30 days, densitometric and mechanical properties were similar in the 2 groups. At 60 days, however, the intramedullary nailed bones had more strength, greater callus area, and higher bone mineral content in the callus segment compared to externally fixated fractures.Interpretation Tibial shaft fractures in the rat treated with external fixation and intramedullary nailing show a similar healing pattern in the early phase of fracture healing, while at the time of healing intramedullary nailing provides improved densitometric properties and superior mechanical properties compared to external fixation. Clinical findings indicate that intramedullary nailing in human tibial fractures may be more advantageous for bone healing than external fixation, in a similar way.     

Treatment of open tibial shaft fractures by delayed closed intramedullary nailing.

Forty-seven open tibial fractures in 43 patients were internally fixed by delayed closed nailing after reaming the medullary canal. The procedure was usually undertaken after complete healing of the wound. Early mobilization was encouraged in all cases. In 37 patients (86%) the fractures were caused by road traffic accidents; 21 patients (49%) had other skeletal and soft tissue injuries. All fractures united with a mean of 19 weeks, but five had delayed union. Most patients had a full range of knee and ankle movements. No infection was encountered in the series.     

Locked intramedullary nailing of open tibial fractures

We report the use of Grosse-Kempf reamed intramedullary nailing in the treatment of 41 Gustilo type II and III open tibial fractures. The union times and infection rates were similar to those previously reported for similar fractures treated by external skeletal fixation, but the incidence of malunion was less and fewer required bone grafting. The role of exchange nailing is discussed and a treatment protocol is presented for the management of delayed union and nonunion.     

Hip fractures following intramedullary nailing fixation for femoral fractures

IntroductionProximal peri-implant femoral fractures occur following intramedullary nailing (IMN) fixation for trochanteric, femoral shaft, and distal femoral fractures. However, analyses of secondary hip fractures (SHFs) using large clinical samples are lacking. Therefore, we aimed to report the incidence and clinical outcomes of SHF after nailing fixation (IMN or cephalomedullary nailing [CMN]) for overall femoral fractures. In addition, we focused on IMN for femoral shaft fractures and investigated the risk factors for SHF.MethodsThis multicenter, retrospective, cohort study included 2,293 patients aged > 60 years who underwent nailing fixation for femoral fractures. The primary outcome was the incidence of SHF. In the assessment of clinical outcomes, we evaluated reoperation and the regaining of walking ability following SHF management. In addition, we conducted multivariable logistic regression analyses to examine the association between risk factors and SHF.ResultsSeventeen (0.7%) patients had SHFs, including 12 femoral neck fractures and 5 trochanteric fractures. Antegrade IMN was the most common type of nailing fixation. Multivariable analysis demonstrated that the absence of femoral head fixation was significantly associated with the incidence of SHF following IMN for femoral shaft fractures (odds ratio, 17.0; 95% confidence interval, 1.9–2265.7; p=0.006). In the assessment of clinical outcomes, there were two reoperations (16.7%) in the secondary femoral neck fracture group. Patients with secondary trochanteric fractures tended to have a lower probability of regaining walking ability than those with secondary femoral neck fractures (20% vs. 50%).ConclusionsIn this multicenter study, the incidence of SHF after nail fixation for femoral fractures was 0.7%. The absence of femoral head fixation was significantly associated with SHF, and the clinical outcomes were poor. Therefore, femoral head fixation at the initial IMN fixation for femoral fractures may be a fixation option for surgeons to consider as an SHF prevention measure.     

Primary intramedullary nailing of open femoral shaft fractures

The cases of 60 patients with 63 open femoral fractures treated by primary reamed intramedullary nailing were retrospectively reviewed. Twenty-two were classified as Type I open fractures, 26 as Type II and 15 as Type III open fractures by Gustilo's classification. All fractures were treated by wound debridement followed by immediate reamed intramedullary nailing. There were five early soft-tissue infections and three late deep infections. Of the late infections, only one was osteomyelitis (1.6%). There were three nonunions and seven malunions. All of the complications were dealt with effectively by standard methods. We concluded that primary reamed intramedullary nailing is an effective alternative for the treatment of Type I and II open femur fractures and for Type III open femur fractures associated with multiple trauma.     

Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation

Twenty-four patients had a severe open fracture of the tibia that was initially treated by external fixation and subsequently by reamed intramedullary nailing. The external fixation had been maintained for an average of fifty-two days (range, seven to 230 days). The mean interval between removal of the external fixator and intramedullary nailing was sixty-five days (range, three to 360 days). In five of the seven patients who had had an infection at one or more of the pin sites, an infection later developed around the intramedullary nail. In comparison, only one of the seventeen patients who had not had a pin-site infection had an infection later around the nail (p = 0.003). An analysis of other variables, including the duration of external fixation, wound coverage, other injuries, and the type of fracture, showed that none was a predictor of infection either at the pin sites or around the intramedullary nail. We concluded that a pin-site infection that develops during external fixation is a contraindication to the subsequent use of reamed intramedullary nailing in patients who have a fracture of the tibia.     

Unreamed intramedullary locking nailing for open tibial fractures

Summary. We reviewed the results of the treatment of 24 cases of open tibial fractures using unreamed intramedullary locking nailing. The fractures were classified, following the Gustilo system as grade I-7, grade II-7 and grade III-10. The average time to achieve bony union was 22 weeks with a 26% incidence of pseudoarthrosis. There were no cases of deep infection. Five cases healed with shortening of over 1 cm, but we did not observe angular deformity in any of the patients. In 2 fractures with associated articular lesions, joint motion was limited at final follow up. The nail broke in 2 cases and the screws in 5. The surgical procedure is well tolerated by patients, allows good management of soft tissue lesions and rehabilitation with low rate of infection and malunion. The main disadvantages have been the relative high incidence of nonunion and breakage of metal.

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Résumé. Les auteurs rapportent les résultats du traitement de vingt-quatre fractures ouvertes de la jambe stabilisées avec un enclouage verrouillé sans alésage. On a classifié les fractures en suivant le systeme de Gustilo: 7 grade I, 7 grade II et 10 grade III. La moyenne de consolidation fut de 22 semaines avec un pourcentage de pseudarthroses de 26%. Il n’y a pas eu d’infection profonde. Cinq cas ont consolidé avec un raccourcissement de plus d’un cm mais on n’a pas observé d’angulation. On a noté une limitation de la mobilité articulaire chez deux patients qui avaient des lésions articulaires. On a eu deux ruptures du clou et cinq de vis. Nous concluons que cette technique chirurgicale est bien tolerée par la patient, elle permet un bon maniement des tissus nous, une réhabilitation précoce et elle a un pourcentage bas d’infection ou mauvaise consolidation. Le principal désavantage a été la relative incidence de pseudarthroses et de ruptures du matériel par stabilité insuffisante.

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Accepted: 10 October 1997     

The effect of traction on compartment pressures during intramedullary nailing of tibial-shaft fractures. A prospective randomised trial

Our aim was to study the effect of traction on the compartment pressures during intramedullary nailing of closed tibial-shaft fractures. Thirty consecutive patients with Tscherne C1 fractures were randomised into two groups. Sixteen patients underwent intramedullary nailing of the tibia with traction and 14 patients without traction. Compartment pressures were measured before the application of traction or commencement of the procedure and at the end of the procedure. The data collected was analysed using Students t test. There was no statistically significant difference (p>0.05) in the pre-operative mean compartment pressures for both groups. The mean post-operative measurements were higher in all four compartments in the traction group (p<0.05). None of the pressures reached the critical level. These results show that traction as an aid unnecessarily increases compartment pressures.

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Résumé Notre but était détudier leffet de la traction sur la tension compartimentale pendant lenclouage centromédullaire des fractures tibiales fermées. Trente malades consécutifs avec des fractures Tscherne C1 ont été randomisés dans deux groupes. Seize malades ont subi un enclouage centromédullaire tibial avec traction et quatorze malades sans traction. Les pressions compartimentales ont été mesurées avant la mise en traction ou au commencement de lopération et à la fin de lopération. Les données ont été analysées avec le Student t-test. Il ny avait aucune différence statistiquement significative (p>0.05) dans les pressions moyennes préopératoires des compartiments pour les deux groupes. Les mesures postopératoires moyennes étaient plus élevées dans les quatre compartiments dans le groupe avec traction (p<0.05). Aucune des pressions nest arrivée au niveau critique. Ces résultats montrent que la traction augmente les pressions des compartiments.

     

External fixation and sequential nailing in the treatment of open diaphyseal fractures of the tibia

Between September 1996 and April 1998 a total of 26 open fractures of the tibia (Gustilo Anderson grade I in 4 cases, grade II in 3, grade IIIA in 8, grade IIIB in 11) were treated by debridement and monoaxial external fixation followed by locked intramedullary nailing after healing of the soft tissues had been observed. Nailing by reamed Grosse Kempf nail was carried out in all of the cases. The mean duration of external fixation was 50 days (with a minimum of 18 days and a maximum of 6 months). Upon removal of the external fixator intramedullary osteosynthesis was performed during the same surgical session in 25 cases. Nailing was carried out 45 days after removal of the external fixator in 1 case. Healing was obtained in all of the patients an average of 6 months after trauma, and 3 and 1/2 months after the second operation. There were two cases of infection, one deep (3.8%) and the other superficial (3.8%). No cases of chronic osteomyelitis were ever observed. Poor consolidation with valgus equal to 10 degrees and 15 degrees was observed in 2 patients. This method of treatment, based on our experience, allows for healing in some open fractures of the tibia in a relatively short amount of time and with an acceptable risk of complications.     

External fixation for open proximal ulnar fractures.

We describe our experience with the use of a pyramidal configuration external fixator in the management of open fractures of the proximal ulna. A prospective study was conducted. 21 patients with open fractures of the proximal ulna (Gustilo-Anderson Grade II and III A) were treated by the application of a new fixator frame. The soft tissue injury was managed with the help of the plastic surgeons. All the patients were followed up clinically and radiologically for a total duration of 3 years after the injury. They were rated on a combined objective and subjective assessment scale by an independent observer. All the patients were rated as good to excellent at the end of a 3 year follow up. The main advantages were simplified wound care and ease of supplementary plastic procedures. No vascular or neurological complications were encountered. The average time taken for union with the fixator was 9 weeks. All the fractures united well. Mobility and function of the elbow were preserved in all cases.     

带锁髓内钉治疗胫骨骨折

1998年6月～2003年12月．我科应用带锁髓内钉治疗胫骨骨折40例,疗效满意。     

Flexible intramedullary nailing versus external fixation of paediatric femoral fractures

Treatment outcomes were compared in two groups of children with femoral diaphyseal fractures which were treated with external fixation (20 fractures) or flexible intramedullary nailing (20 fractures). These 40 children were between 5.4 to 14.1 years of age. The duration of the operation averaged 52 minutes for the external fixator compared with 70 minutes for the flexible nail group. The time taken to gain full weight bearing, full range of movements and return to school was shorter in the flexible intramedullary nail group. There was a higher complication rate in the external fixator group than in the flexible nail group. At final review, three patients in the external fixator group had pain, two had leg-length discrepancy of up to 1 cm, and four had malalignment of 5 degrees -10 degrees. In the nailing group, there were no leg-length discrepancies or malalignments. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft in children which require surgery, and reserve external fixation for open or severely comminuted fractures.     

可膨胀自锁髓内钉在下肢骨折中的应用

目的探讨Fixion~(TM)膨胀自锁髓内钉内固定治疗下肢骨折的初步临床疗效。方法2004年11月～2005年11月采用Fixion~(TM)系统的膨胀髓内钉内固定治疗下肢骨折21例,其中股骨转子间骨折5例,股骨干骨折9例,胫骨骨折7例。开放性骨折1例,骨不连1例；其中使用髓内钉系统12例,交锁髓内钉系统4例,股骨近端髓内钉系统5例。结果所有患者均获得随访,时间4．0～12．5个月,平均7．0个月。全部患者骨折均愈合,愈合时间3～7个月,平均4．5个月。无术后感染、肢体短缩、旋转移位、骨不连或脂肪栓塞等并发症发生。结论使用膨胀髓内钉治疗下肢骨折手术操作简便、创伤小,大多不需交锁螺钉且并发症少,作为一种新的微创手术方法,疗效满意。由于其抗折弯强度和扭转力不高,对于大范围粉碎性骨折患者不宜使用。