Intramedullary nailing of distal metaphyseal tibial fractures

BACKGROUND: The treatment of distal metaphyseal tibial fractures remains controversial. This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint. METHODS: Over a sixteen-month period at two institutions, thirty-six tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Ten fractures with articular extension were treated with supplementary screw fixation prior to the intramedullary nailing. Radiographs were reviewed to determine the immediate and final alignments and fracture-healing. The Short Form-36 (SF-36) and Musculoskeletal Function Assessment (MFA) questionnaires were used to evaluate functional outcome. RESULTS: Acceptable radiographic alignment, defined as <5 degrees of angulation in any plane, was obtained in thirty-three patients (92%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. Complications included one deep infection and one iatrogenic fracture at the time of the intramedullary nailing. Six patients could not be followed. The remaining thirty fractures united at an average of 23.5 weeks. Three patients with associated traumatic bone loss underwent a staged autograft procedure, and they had fracture-healing at an average of 44.3 weeks. The functional outcome was determined at a minimum of one year for nineteen patients and at a minimum of two years (average, 4.5 years) for fifteen patients. At one year, there were significant limitations in several domains despite fracture union and maintenance of alignment, but there was improvement in the MFA scores with time. CONCLUSIONS: Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time.     

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

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

Reamed nailing of Gustilo grade-IIIB tibial fractures

Reamed intramedullary nailing was carried out on R57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis. Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures.     

Intramedullary nailing of proximal quarter tibial fractures

OBJECTIVE: To report the results of intramedullary nailing of proximal quarter tibial fractures with special emphasis on techniques of reduction. DESIGN: Retrospective clinical study. SETTING: Level 1 trauma center. PATIENTS: During a 36-month period, 456 patients with fractures of the tibial shaft (OTA type 42) or proximal tibial metaphysis (OTA type 41A2, 41A3, and 41C2) were treated operatively at a level 1 trauma center. Thirty-five patients with 37 fractures were treated primarily with intramedullary nailing of their proximal quarter tibial fractures and formed the study group. Thirteen fractures (35.1%) were open and 22 fractures (59.5%) had segmental comminution. Three fractures had proximal intraarticular extensions. MAIN OUTCOME MEASUREMENTS: Alignment and reduction postoperatively and at healing. An angular malreduction was defined as greater than 5 degrees in any plane. RESULTS: Fractures extended proximally to an average of 17% of the tibial length (range, 4% to 25%). The average distance from the proximal articular surface to the fracture was 67.8 mm (range, 17 mm to 102 mm, not corrected for distance magnification, included for preoperative planning purposes only). Postoperative angulation was satisfactory (average coronal and sagittal plane deformity of less than 1 degree) as was the final angulation. Acceptable alignment was obtained in 34 of 37 fractures (91.9%). Two patients had 5-degree coronal plane deformities (one varus and one valgus), and 1 patient had a 7-degree varus deformity.Two patients with open fractures with associated bone loss underwent a planned, staged iliac crest autograft procedure postoperatively. Four patients were lost to follow-up. In the remaining 31 patients with 33 fractures, the proximal tibial fractures united without additional procedures. No patient had any change in alignment at final radiographic evaluation. Secondary procedures to obtain union at the distal fracture in segmental injuries included dynamizations (n = 3) and exchange nailing (n = 1). Complications included deep infections in 2 patients that were successfully treated. CONCLUSIONS: Multiple techniques were required to obtain and maintain reduction prior to nailing and included attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia. Simple articular fractures and extensions were not a contraindication to intramedullary fixation. The proximal tibial fracture healed despite open manipulations. Short plate fixations to maintain this difficult reduction, either temporary or permanent, were effective.     

超远端胫骨髓内钉治疗胫骨远端干骺端骨折的疗效分析

目的 评价超远端胫骨髓内钉治疗开放性或潜在开放性(Tscherne分型为2度、3度)的胫骨远端干骺端骨折的安全性与有效性.方法 2007年3月至2008年4月共收治15例胫骨远端骨折患者,男9例,女6例;年龄21～53岁,平均34.3岁.对于Gustilo Ⅰ型、Ⅱ型开放性骨折患者,于伤后6～48 h采用超远端胫骨髓内钉治疗;对于Gustilo Ⅲ型开放性骨折患者,将该髓内钉作为分期治疗策略中的最终治疗.对于闭合性骨折患者,先予消肿抗炎等对症处理,待肢体皮肤褶皱出现、局部软组织无红肿渗液时手术.通过随访患者影像学资料及术后1年Johner-Wruhs评分标准评估其临床疗效.结果 15例患者术后获12～18个月(平均14个月)随访;骨折愈合时间为18～25周(平均21.1周),所有患者均获解剖或功能复位.术后1年根据Johner-Wruhs评分标准评价疗效:优11例,良3例,可1例,优良率为93.3%.并发症:伤口浅层感染3例,皮肤局部坏死2例,经清创换药后愈合.未发生深部及髓内感染,无畸形愈合或不愈合发生.结论 对于开放性及潜在开放性胫骨远端干骺端骨折,超远端胫骨髓内钉是一种安全、有效的选择.

Abstract：

Objective To evaluate the safety and efficacy of extra-distal tibial intramedullary nailing for open and potentially open fractures of distal metaphyseal tibia.Methods Between March 2007 and April 2008, 15 patients (9 men and 6 women), with a mean age of 34.3 (from 21 to 53) years, were admitted to this study.For Gustilo Ⅰ and Ⅱ fractures, extra-distal tibial intramedullary nailing was performed 6 to 48 hours after injury; for Gustilo Ⅲ fractures, the intramedullary nailing was conducted as the definitive procedure of a staged strategy; for closed fractures, the operation was not performed until swelling subsided and exudation stopped following symptomatic treatments.All the patients were followed up by periodic X-ray examination.Functional outcomes were evaluated according to Johner-Wruhs criteria one year after surgery.Results The patients obtained a mean follow-up of 14 months (range, 12 to 18) after surgery.Anatomic or functional reduction was achieved and maintained in all the cases.The fractures healed 21.1 weeks (range,18 to 25) after surgery.By Johner-Wruhs criteria, the final outcomes were excellent in 11 cases (73.3%),good in 3 (20%), and fair in one(6.7% ).Complications included 3 cases of superficial infection and 2 cases of local skin necrosis, all responding to debridement and dressing.No deep infection, malunion or nonunion occurred.Conclusion Extra-distal tibial nail is a safe and effective alterative solution for open and potentially open fractures of distal metaphyseal tibia.     

LCP钢板和带锁髓内钉治疗新鲜胫骨干骨折的对比研究

目的回顾性分析LCP钢板和带锁髓内钉两种方法治疗新鲜胫骨干骨折的效果。方法2003年10月～2006年4月,收治55例胫骨干新鲜骨折患者。其中男39例,女16例;年龄14～62岁,平均39岁。左侧27例,右侧31例,其中3例为双侧。34处骨折采用带锁髓内钉固定治疗(髓内钉组),24处骨折给予LCP钢板内固定治疗(LCP组)。髓内钉组和LCP组伤后至手术时间分别平均为3d和3.1d。评估两组患者手术时间、膝、踝关节活动度、骨折愈合时间以及术后并发症。结果术后获随访8～26个月,平均13个月。手术时间髓内钉组为84.0±9.2min,LCP组为69.0±8.4min;平均住院费髓内钉组为19297.78元,LCP组为14116.55元,差异均有统计学意义(P<0.05)。髓内钉组膝关节屈曲为139.0±3.7°,LCP组为149.0±4.2°,伸直分别为4.0±0.7°和0±0.4°,差异均无统计学意义(P>0.05)。髓内钉组、LCP组踝关节背屈分别为13.0±1.7°、10.0±1.4°,跖屈分别为41.0±2.6°、44.0±2.3°,差异均无统计学意义(P>0.05)。骨折愈合时间LCP组略早,平均为3.1个月;髓内钉组平均为3.3个月。髓内钉组术后X线片示1例下肢短缩2.5cm,1例骨折延迟愈合,3例钉尾问题,1例旋转畸形(20°),6例膝前疼痛;LCP组1例开放骨折(AO分型为42B型)的患者术后1周发生感染,1例胫骨远端1/3骨折出现成角畸形。结论带锁髓内钉和LCP钢板内固定治疗胫骨骨折均可取得理想效果。两种方法在膝关节和踝关节背屈度及跖屈度方面影响很小,都可保证骨折愈合。LCP钢板内固定并发症较少,且在手术时间和住院费用上更加有优势。     

Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures.

Thirty-five displaced tibial shaft fractures, treated with functional bracing were compared with 43 similar fractures, treated with locked intramedullary nailing. There were 22 excellent/good results in the brace group and 38 in the nail group. There was one infection in the brace group and three in the nailed group. There were five delayed unions and two nonunions in the brace group and one delayed union in the nail group. The functional results in the nailed group were better than the braced group but locked intramedullary nailing of tibial shaft fractures require special resources and training. Locked intramedullary nailing fullfils all the functional criteria for acceptable fracture care.     

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.     

Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union

Distal third tibial fractures are prone to non-union following tibial nail insertion. The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws. Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed. Our results showed that 80% of non-unions in distal third fractures had only one distal locking screw compared to 20% who had two distal locking screws. This is statistically significant (p<0.01). We therefore conclude that two distal locking screws are essential for distal third fractures.     

Treatment for distal tibial fractures with intramedullary nails and blocking screws

Introduction

This retrospective study was designed to define the technical details for the treatment for distal tibial fractures with intramedullary nails and blocking screws, and to assess the effectiveness of the method based on our clinical practice.

Materials and methods

Twenty-one patients in whom adequate reduction could not be achieved with distal tibial intramedullary nailing, blocking screws were inserted under fluoroscopy. Blocking screws were inserted from the medial side in eighteen patients, in the medial and anterior side in one patient, and in the posterior side in two patients. Patients were followed up clinically and radiologically. Fracture alignment and union were monitored by X-ray, and complications were noted.

Results

Neutral alignment with union in both coronal and sagittal plane was achieved in all patients. None of the patients experienced infection. The only complication of the blocking screws was fissure in one patient in the location of the screw during surgery. In another patient, nonunion was developed with 8° flexion angle. Union was achieved in this patient at 9?months with auto grafting.

Conclusion

Blocking screws helped to achieve better reduction and alignment with intramedullary nailing of distal tibial fractures by decreasing the effective diameter of the medullary canal. The use of blocking screws enabled to use the intramedullary nailing as an alternative while treating distal tibial fractures.     

交锁髓内钉与加压钢板固定治疗胫骨骨折的疗效对比分析

目的评价交锁髓内钉与加压钢板固定两种疗法治疗胫骨骨折的疗效。方法将108例胫骨骨折患者随机采用交锁髓内钉或加压钢板固定治疗;观察两种方法的疗效、并发症。结果临床疗效:交锁髓内钉组优48例,加压钢板组优39例,x2=4.79,P<0.05;并发症:交锁髓内钉组7例,加压钢板组18例,x2=6.30,P<0.05。结论与加压钢板内固定治疗胫骨骨折相比,交锁髓内钉固定治疗胫骨骨折具有创伤小,功能恢复快,固定稳定性好,愈合率高、感染率低等优点,疗效满意,可以作为临床上优选方案之一。     

Insertion of intramedullary nails from the suprapatellar pouch for proximal tibial shaft fractures. A technical note

Intramedullary nailing of proximal tibial fractures can be difficult when using the standard entry portal. We evaluated the suprapatellar portal, using a midline quadriceps tendon incision, to perform intramedullary nailing of the tibia. Seven patients were treated with this adaptation of the standard intramedullary nailing procedure. An arthroscopy was done before and after the nailing procedure. No special equipment was used to perform the intramedullary nailing. We evaluated the handling and necessary modifications of the standard intramedullary technique to introduce the locked tibial nail through the suprapatellar approach. We found this technique not necessarily more difficult than the standard intramedullary nailing of the tibia through the infrapatellar entry portal. Although the patients did not complain of patellofemoral discomfort after the suprapatellar nailing, definitive scuffing of the cartilage in the lower part of the femoral trochlea was visible. Introduction of a locked tibial nail via the suprapatellar approach was found to be possible and even advantageous for some complex upper tibial shaft fractures in compromised limbs. Some possible downsides of this approach need to be taken into account but, in some cases, they can be outweighed by the benefits.     

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.     

Elastic stable intramedullary nailing of tibial shaft fractures in children

Most pediatric tibia shaft fractures are amenable to nonoperative treatment with satisfying results, yet surgical stabilization is necessary in certain cases. The purpose of our study was to determine the effectiveness and the complications associated with elastic stable intramedullary nailing in severe pediatric tibial fractures. We retrospectively reviewed 24 tibia shaft fractures in 24 patients that were treated operatively by elastic stable intramedullary nailing between 1997 and 2005 at our institution. Extensive review of all charts and radiographic data was completed at Cincinnati Children's Hospital Medical Center. There were 8 closed and 16 open fractures. The average union time for all tibia fractures was 20.4 weeks. The average union time for closed and open fractures was 21.5 and 20.2 weeks, respectively. Complications include 2 (8%) neurovascular, 2 (8%) infections, 2 (8%) malunions, and 1 (4%) leg-length discrepancy. Although complications do exist, elastic stable intramedullary nailing of pediatric tibia shaft fractures using Nancy nails is an effective treatment option.     

Flexible intramedullary nails for ipsilateral femoral and tibial fractures

Between June 1981 and August 1983, six patients were treated with flexible intramedullary nails for both femoral and tibial fractures in six floating knees. All six patients were males averaging 26 years of age and all six were involved in motor vehicle accidents. Concomitant associated injuries were common. Two femoral and five tibial fractures were open. All fractures were stabilized within 24 hours of injury by closed intramedullary nailing with Ender nails. At final followup, there was one femoral and one tibial nonunion in the same patient. For the remaining patients, femoral union averaged 10.3 weeks and tibial union averaged 18 weeks. Five patients regained full motion at the hip, and four regained full motion at the knee and ankle. Four patients returned to their preinjury level of function; two were less active, one ambulating without the use of external assistive devices, and one using a cane.     

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.     

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.     

Comparative study of the use of electromagnetic fields in patients with pseudoarthrosis of tibia treated by intramedullary nailing

We made a comparative cohort study in patients suffering from tibial pseudoarthrosis, all of whom were treated by intramedullary nailing. We divided patients into two groups: one treated by intramedullary nailing only (control group) and the other by intramedullary nailing combined with pulsed electromagnetic fields (PEMFs). The study included 57 cases of tibial pseudoarthrosis in 57 patients from February 1987 to February 2002. Pseudoarthrosis was treated surgically in all cases (Grosse-Kempf dynamic intramedullary nailing). This was combined with PEMFs in 22 cases. The average age was 38.3 years (range 14–89 years) and the average duration of follow-up was 27.2 months (range 12–48 months). Forty-nine fractures (86%) healed and eight (14%) did not. Of the group treated with PEMFs, 20 (91%) healed and two (9%) did not; from the group that did not receive PEMF (35), 29 (83%) healed compared to six (17%) that did not. The relationship between union and use of PEMFs, and between time to union and use of PEMFs was clinically relevant. PEMFs are useful when treating tibial pseudoarthrosis. Its noninvasive nature means that there are more complication-free unions.     

Eight years' clinical experience with the Orthofix tibial nailing system in the treatment of tibial shaft fractures

Intramedullary nailing has become a popular and effective procedure for the treatment of most tibial fractures. However, concerns regarding difficulties with reduction, the use and extent of intramedullary reaming, and hardware failure are probably the only constraints to its widespread use. In this prospective study, we present the clinical and radiographic results of the Orthofix tibial nailing system used in the treatment of tibial shaft fractures. One hundred and fifteen fresh tibial fractures in the same number of patients with a mean age of 37.5 years (17-85 years) were treated with operative stabilisation using the Orthofix tibial nailing system. All of the operations took place in a conventional operating theatre, on a simple tranlucent operating table and with manual reduction of the fracture. In the majority of the cases closed reduction and conventional reaming were performed and the mean duration of the operation was 38 min. Fracture healing occurred at 16 weeks (11-30 weeks) and was confirmed both clinically and radiographically. In six cases (two severely comminuted and four segmental fractures) delayed union occurred, however there were no tibial non-unions necessitating re-operation. There were no substantial differences in time to fracture union or in the rate of complications related to minimal open reduction. In addition, there seem to be more benefits than risks in the use of power intramedullary reaming during intramedullary fixation of tibial shaft fractures. In conclusion, most tibial shaft fractures can effectively and safely be treated using this type of locking intramedullary nailing device, with relatively few complications, and with satisfactory long-term clinical results.     

Conservative management or closed nailing for tibial shaft fractures. A randomised prospective trial

We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft.