Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia

Osseous Union after Mandible Reconstruction with Fibula Free Flap Using Manually Bent Plates vs. Patient-Specific Implants: A Retrospective Analysis of 89 Patients

The aim of this monocentric, retrospective clinical study was to evaluate the status of osseous union in uni- and poly-segmental mandible reconstructions regarding conventional angle-stable manually bent osteosynthesis plates (Unilock 2.0 mm) versus titan laser-melted PSI patient-specific implant’s (PSI). The clinical impact of PSI’s high stiffness fixation methods on bone healing and regeneration is still not well addressed. The special interest was in evaluating the ossification of junctions between mandible and fibula and between osteotomized fibula free flap (FFF) segments. Panoramic radiograph (OPT), computed tomography (CT) scans, or cone-beam CTs (CBCT) of patients who underwent successful FFF for mandible reconstruction from January 2005 to December 2020 were analyzed. A total number of 89 cases (28 females (31.5%), 61 males (68.5%), mean age 58.2 ± 11.3 years, range: 22.8–82.7 years) fulfilled the chosen inclusion criteria for analysis (conventional: n = 44 vs. PSI: n = 45). The present study found an overall incomplete ossification (IOU) rate of 24.7% (conventional: 13.6% vs. PSI: 35.6%; p = 0.017) for mandible to fibula and intersegmental junctions. Between osteotomized FFF segments, an IOU rate of 16% was found in the PSI-group, while no IOU was recorded in the conventional group (p = 0.015). Significant differences were registered for IOU rates in poly-segmental (p = 0.041), and lateral (p = 0.016) mandibular reconstructions when PSI was used. Multivariate logistic regression analysis identified plate exposure and type of plate used as independent risk factors for IOU. Previous or adjuvant radiotherapy did not impact incomplete osseous union in the evaluated study sample. PSI is more rigid than bent mini-plates and shields functional mechanical stimuli, and is the main reason for increasing the rate of incomplete ossification. To enhance the functional stimulus for ossification it has to be discussed if patient-specific implants can be designed to be thinner, and should be divided into segmental plates. This directs chewing forces through the bone and improves physiological bone remodeling.

Effect of Intramedullary Nailing Patterns on Interfragmentary Strain in a Mouse Femur Fracture: A Parametric Finite Element Analysis

Delayed long bone fracture healing and nonunion continue to be a significant socioeconomic burden. While mechanical stimulation is known to be an important determinant of the bone repair process, understanding how the magnitude, mode, and commencement of interfragmentary strain (IFS) affect fracture healing can guide new therapeutic strategies to prevent delayed healing or nonunion. Mouse models provide a means to investigate the molecular and cellular aspects of fracture repair, yet there is only one commercially available, clinically-relevant, locking intramedullary nail (IMN) currently available for studying long bone fractures in rodents. Having access to alternative IMNs would allow a variety of mechanical environments at the fracture site to be evaluated, and the purpose of this proof-of-concept finite element analysis study is to identify which IMN design parameters have the largest impact on IFS in a murine transverse femoral osteotomy model. Using the dimensions of the clinically relevant IMN as a guide, the nail material, distance between interlocking screws, and clearance between the nail and endosteal surface were varied between simulations. Of these parameters, changing the nail material from stainless steel (SS) to polyetheretherketone (PEEK) had the largest impact on IFS. Reducing the distance between the proximal and distal interlocking screws substantially affected IFS only when nail modulus was low. Therefore, IMNs with low modulus (e.g., PEEK) can be used alongside commercially available SS nails to investigate the effect of initial IFS or stability on fracture healing with respect to different biological conditions of repair in rodents.

Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail

Introduction

High-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures.

Materials and methods

Single-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation.

Results

A total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3–13) compared to IMF at 1 day (IQR 0–3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation.

Conclusion

Our study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation.

How to cite this article

Natalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161–167.

Impact on periosteal vasculature after dual plating of the distal femur: a cadaveric study

Although dual plating of distal femur fractures has been described for injuries at risk of varus displacement, the vascular insult to the medial distal femur utilizing this technique is unknown. The aim of this study was to evaluate the perfusion of the medial distal femoral periosteal arteries after supplemental medial plating of the distal femur.

Methods

Fifteen human fresh-frozen cadaveric femora were thawed and randomized to lateral locked plating alone or with supplemental medial plate fixation. Conventional submuscular medial plating was performed using a 12-hole small fragment plate and multiple cortical screws. The superficial femoral artery was injected with latex dye. Specimens were dissected. The patency of the medial distal femoral periosteal vessels was evaluated.

Results

Four vessels were consistently observed traversing the distal medial femur: the transverse and descending (d-MMPA) branches of the medial metaphyseal periosteal artery, and the transverse and longitudinal branches of the descending geniculate artery. The anterior longitudinal arch (ALA) was present in 13 of 15 specimens and was fed by the d-MMPA. The median number of periosteal arteries occluded by the medial plate was 2 (6 out of 8 specimens). The d-MMPA was occluded in 6 of 8 medially plated femurs, resulting in a complete lack of perfusion of the ALA.

Conclusions

Submuscular medial plating of the distal femur compressed the d-MMPA in the majority of specimens. This vessel gives rise to the ALA, which lacked perfusion in these specimens. This vascular insult could affect the healing of metaphyseal distal femur fractures treated with dual plating.

Periosteal and endosteal microcirculatory injury following excessive osteosynthesis

INTRODUCTION

We examined the endosteal and periosteal circulations in a patient with fracture non-union who had undergone excessive osteosynthesis applications (two long plates had been placed medially and laterally on the left tibia extending from the proximal 2/7 to the distal 6/7 parts of the bone, while a tibial component of a total knee prosthesis with a long stem had been inserted at the same time).

METHODS

Concomitant perfusion changes were determined in the anterolateral and anteromedial periosteal sheath of the non-united bone ends and intramedullary nearest the osteosynthesis materials during their surgical removal on re-operation. The blood flow in the periosteum and endosteum was recorded by a laser-Doppler flowmetric device using a novel approach. Control measurements were made at identical points of the right tibia.

RESULTS

Considerably lower blood flow values were measured along the tibial periosteal region of the re-operated limb than on the contralateral side (the average perfusion unit (PU) was 76 vs. 106 PU, respectively). Perfusion values were markedly lower in the endosteal region (average values of approx. 30 PU) in the control tibia and were even more diminished in the re-operated tibial endosteum (average 9 PU).

CONCLUSIONS

Our study was conducted to characterize the microcirculatory changes of a long bone in response to intramedullary implantation and to provide quantitative data on the insufficiency of local perfusion in a patient with fracture non-union. Our results highlight the association between local perfusion failure and the unfavorable outcome (i.e. fracture non-union), confirming that the vital aspects of the microcirculation should not be disregarded when aiming for mechanical stability. Microcirculatory measurements constitute a new area of improvement in planning the adequate treatment for fracture non-unions with an unclear aetiology. Further refinement of the laser-Doppler technique could have potential benefits for bone surgery and postoperative trauma care in the future.

Comparison of intramedullary nailing and plate fixation in distal tibial fractures with metaphyseal damage: a meta-analysis of randomized controlled trials

Background

Distal metadiaphyseal tibial fractures are commonly seen lower limb fractures. Intramedullary nail fixation (IMN) and plate internal fixation (PL) are the two mainstay treatments for tibial fractures, but agreement on the best internal fixation for distal tibial fractures is still controversial. This meta-analysis was designed to compare the success of IMN and PL fixations in the treatment of distal metadiaphyseal tibial fractures, in terms of complications and functional recovery.

Methods

A systematic research of the literature was conducted to identify relevant articles that were published in PubMed, MEDLINE, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov, and OVID from the database inception to August 2018. All studies comparing the complication rate and functional improvement of I2MN and PL were included. Data on the 12 main outcomes were collected and analyzed using the Review Manager 5.3.

Results

Eleven studies were included in the current meta-analysis. A significant difference in malunion (RR = 1.76, 95%CI 1.21–2.57, P = 0.003), superficial infection (RR = 0.29, 95%CI 0.13–0.63, P = 0.002), FFI (MD = 0.09, 95%CI 0.01–0.17, P = 0.02), and knee pain (RR = 3.85, 95%CI 2.07–7.16, P < 0.0001) was noted between the IMN group and PL group. No significant difference was seen in the operation time (MD = − 10.46, 95%CI − 21.69–0.77, P = 0.07), radiation time (MD = 7.95, 95%CI − 6.65–22.55, P = 0.29), union time (MD = − 0.21, 95%Cl − 0.82–0.40, P = 0.49.), nonunion (RR = 2.17,95%CI 0.79–5.99, P = 0.15), deep infection (RR = 0.85, 95%CI 0.35–2.06, P = 0.72), delay union (RR = 0.92, 95%CI 0.45–1.87, P = 0.82), AOFAS (MD 1.26, 95%Cl − 1.19–3.70, P = 0.31), and Disability Rating Index in 6 or 12 months (MD = − 3.75, 95%CI − 9.32–1.81, P = 0.19, MD = − 17.11, 95%CI − 59.37–25.16, P = 0.43, respectively).

Conclusions

Although no significant difference was seen between IMN and PL fixation with regards to the operation time, radiation time, nonunion, deep infection delay union, union time, AOFAS, and Disability Rating Index, significant differences were seen in occurrence of malunion, superficial infection, FFI, and knee pain. Based on this evidence, IMN appears to be a superior choice for functional improvement of the ankle and reduction of postoperative wound superficial infection. PL internal fixation seems to be more advantageous in achieving anatomical reduction and decreasing knee pain.

Nonunion fracture healing: Evaluation of effectiveness of demineralized bone matrix and mesenchymal stem cells in a novel sheep bone nonunion model

Nonunion treatment has a high rate of success, although recalcitrant nonunion may determine the need for amputation. Therefore, new treatment options are continuously investigated in order to further reduce the risk of nonunion recurrence. This study aimed to (a) develop a new large animal model for bone atrophic nonunion and (b) compare the efficacy of demineralized bone matrix (DBM) and DBM in combination with mesenchymal stem cells (MSC) in the new nonunion model. The new model consists of a noncritical, full-thickness segmental defect created in the sheep tibia, stabilized by an intramedullary nail, and involves the creation of a locally impaired blood supply achieved through periosteum excision and electrocauterization of the stump ends. Six weeks after defect creation, lack of hard tissue callus and established nonunion was observed in all operated tibiae both by radiographic and clinical evaluation. Nonunion was treated with allogeneic DBM or autologous MSC cultivated on DBM particles (DBM + MSC) for 1 day before implantation. Twelve weeks after treatment, radiographic, microtomographic, histologic, and histomorphometric analysis showed the formation of bone callus in DBM group, whereas the fracture healing appeared at an early stage in DBM + MSC group. Torsional strength and stiffness of the DBM group appeared higher than those of DBM + MSC group, although the differences were not statistically significant. In conclusion, a new sheep bone nonunion model resembling the complexity of the clinical condition was developed. DBM is an effective option for nonunion treatment, whereas MSC do not improve the healing process when cultivated on DBM particles before implantation.

Intramedullary Nailing of Tibial Shaft Fractures: Size Matters

OBJECTIVES

To determine optimal ratio of intramedullary nail diameter to tibial canal diameter that leads to reliable and timely healing in tibial shaft fractures.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS

One hundred thirty-three fractures in 132 patients with tibial shaft fractures that underwent intramedullary nailing as definitive fixation were identified between June 2004 and July 2012 at our level I trauma center. Of these, 78 had serial radiographs out to 12 months that could be analyzed for radiographic healing with an average age of 37 years old (range 16-86 years). There were 52 males and 26 females.

INTERVENTION

All patients underwent intramedullary nailing of the tibia with documentation of both the diameter of the nail and radiographic canal width at the isthmus to determine the nail to canal ratio.

MAIN OUTCOME MEASURES

Patients were followed with serial radiographs for at least 12 months to determine time to healing as a function of nail to canal ratio. The senior author assessed healing at 3, 6, 9, and 12 months using RUST criteria.

RESULTS

Patients with an intramedullary nail to canal diameter ratio of less than 0.8 or greater than 0.99 were 4.4 times more likely not to heal than patients with a ratio of between 0.8 and 0.99.

CONCLUSION

The ideal intramedullary nail to tibial canal diameter ratio to optimize tibial shaft fracture healing is between 0.8 and 0.99.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

BACKGROUND

Open tibial shaft fractures are one of the most devastating orthopaedic injuries. Surgical treatment options include reamed or unreamed nailing, plating, Ender nails, Ilizarov fixation, and external fixation. Using a network meta-analysis allows comparison and facilitates pooling of a diverse population of randomized trials across these approaches in ways that a traditional meta-analysis does not.

QUESTIONS/PURPOSES

Our aim was to perform a network meta-analysis using evidence from randomized trials on the relative effect of alternative approaches on the risk of unplanned reoperation after open fractures of the tibial diaphysis. Our secondary study endpoints included malunion, deep infection, and superficial infection.

METHODS

A network meta-analysis allows for simultaneous consideration of the relative effectiveness of multiple treatment alternatives. To do this on the subject of surgical treatments for open tibial fractures, we began with systematic searches of databases (including EMBASE and MEDLINE) and performed hand searches of orthopaedic journals, bibliographies, abstracts from orthopaedic conferences, and orthopaedic textbooks, for all relevant material published between 1980 and 2013. Two authors independently screened abstracts and manuscripts and extracted the data, three evaluated the risk of bias in individual studies, and two applied Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria to bodies of evidence. We included all randomized and quasirandomized trials comparing two (or more) surgical treatment options for open tibial shaft fractures in predominantly (ie, > 80%) adult patients. We calculated pooled estimates for all direct comparisons and conducted a network meta-analysis combining direct and indirect evidence for all 15 comparisons between six stabilization strategies. Fourteen trials published between 1989 and November 2011 met our inclusion criteria; the trials comprised a total of 1279 patients surgically treated for open tibial shaft fractures.

RESULTS

Moderate confidence evidence showed that unreamed nailing may reduce the likelihood of reoperation compared with external fixation (network odds ratio [OR], 0.38; 95% CI, 0.23-0.62; p < 0.05), although not necessarily compared with reamed nailing (direct OR, 0.74; 95% CI, 0.45-1.24; p = 0.25). Only low- or very low-quality evidence informed the primary outcome for other treatment comparisons, such as those involving internal plate fixation, Ilizarov external fixation, and Ender nailing. Method ranking based on reoperation data showed that unreamed nailing had the highest probability of being the best treatment, followed by reamed nailing, external fixation, and plate fixation. CIs around pooled estimates of malunion and infection risk were very wide, and therefore no conclusive results could be made based on these data.

CONCLUSION

Current evidence suggests that intramedullary nailing may be superior to other fixation strategies for open tibial shaft fractures. Use of unreamed nails over reamed nails also may be advantageous in the setting of open fractures, but this remains to be confirmed. Unfortunately, these conclusions are based on trials that have had high risk of bias and poor precision. Larger and higher-quality head-to-head randomized controlled trials are required to confirm these conclusions and better inform clinical decision-making.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Non-osteotomy and osteotomy large animal fracture models in orthopedic trauma research

Large animal fracture models are important in the field of orthopedic trauma research. New implants are tested in animals before being implanted into humans. Large animals like sheep or swine often are more properly to simulate conditions in humans, e.g. biomechanical demands, compared to rodents. Cited articles mainly analyze shock or fracture healing. Both osteotomy and non-osteotomy fracture models have been used in the past. However, comparative studies are rare and clear recommendation when to use which model are missing. This review will summarize large animal fracture models putting special emphasis on non-osteotomy fracture models.

The effect of patient position during trauma surgery on fat embolism syndrome: An experimental study

BACKGROUND

The aim of this study was to compare the effect of supine versus lateral position on clinical signs of fat embolism during orthopedic trauma surgery. Dogs served as the current study model, which could be extended and/or serve as a basis for future in vivo studies on humans. It was hypothesized that there would be an effect of position on clinical signs of fat embolism syndrome in a dog model.

MATERIALS AND METHODS

12 dogs were assigned to supine (n = 6) and lateral (n = 6) position groups. Airway pressures, heart rate, blood pressure, cardiac output, pulmonary artery pressure, pulmonary artery wedge pressure, right atrial pressure, arterial and venous blood gases, white blood count, platelet count and neutrophil count were obtained. Dogs were then subjected to pulmonary contusion in three areas of one lung. Fat embolism was generated by reaming one femur and tibia, followed by pressurization of the canal.

RESULTS

No difference was found in any parameters measured between supine and lateral positions at any time (0.126 < P < 0.856).

CONCLUSIONS

The position of trauma patients undergoing reamed intramedullary nailing did not alter the presentation of the features of the lung secondary to fat embolism.

In vivo models of bone repair

This review is aimed at clinicians appraising preclinical trauma studies and researchers investigating compromised bone healing or novel treatments for fractures. It categorises the clinical scenarios of poor healing of fractures and attempts to match them with the appropriate animal models in the literature.

We performed an extensive literature search of animal models of long bone fracture repair/nonunion and grouped the resulting studies according to the clinical scenario they were attempting to reflect; we then scrutinised them for their reliability and accuracy in reproducing that clinical scenario.

Models for normal fracture repair (primary and secondary), delayed union, nonunion (atrophic and hypertrophic), segmental defects and fractures at risk of impaired healing were identified. Their accuracy in reflecting the clinical scenario ranged greatly and the reliability of reproducing the scenario ranged from 100% to 40%.

It is vital to know the limitations and success of each model when considering its application.

Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review

INTRODUCTION

Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults.

METHODS

Cochrane Central Register of Controlled Trials (October 2010), PubMed (October 2010) and EMBASE (October 2010) were searched. Randomized and quasi-randomized controlled clinical trials were included. After independent study selection by two authors, data were collected and extracted independently. The methodological quality of the studies was assessed. Pooling of data was undertaken where appropriate.

RESULTS

Seven trials with 952 patients (965 fractures) were included. Compared with unreamed nailing, reamed nailing was significantly lower reoperation rate (RR 0.25, 95% CI 0.11-0.59, P = 0.002), lower non-union rate (RR 0.20, 95% CI 0.05-0.77, P = 0.02) and lower delay union rate(RR 0.30, 95% CI 0.14-0.64, P = 0.002). There was no significant difference when comparing reamed nailing with unreamed nailing for implant failure (RR 0.51, 95% CI 0.16-1.61, P = 0.25), mortality(RR 0.94, 95% CI 0.19-4.58, P = 0.94) and acute respiratory distress syndrome(RR 1.53, 95% CI 0.37-6.29, P = 0.55). Unreamed nailing was significantly less blood loss (SMD 119.23, 95% CI 59.04-180.43, P = 0.0001).

CONCLUSION

Reamed intramedullary nailing has better treatment effects than unreamed intramedullary nailing for shaft fracture of femur in adults.

The effect of intramedullary reaming on a diaphyseal bone defect of the tibia

BACKGROUND

The effect of intramedullary reaming on diaphyseal tibial defects has not been examined in the literature. The present aim was to relate the extent of reaming to angiogenesis and bone formation occurring around a critical-sized defect in the tibia for two scenarios, namely, when the bone defect is left empty and when the bone defect is treated with autograft.

METHODS

Eleven canines were allocated into two groups, namely, empty (n=5) or iliac crest autograft (n=6). All tibiae were reamed to 7.0 mm and fixed with a 6.5-mm statically locked intramedullary nail after creation of an 8.0-mm diaphyseal defect. The extent of reaming of the canal was dependent on the cross-sectional area of the tibia, because all tibiae were reamed to 7.0 mm. Fluorescent markers were administered at different times: calcein green (6 weeks), xylenol orange (9 weeks), and tetracycline (11 weeks and 14 weeks). Animals were sacrificed at 15 weeks and perfused with a barium compound. Analysis consisted of radiography, micro-computed tomography scan, and histology.

RESULTS

Linear regression analysis of percent bone volume and canal area provided a Pearson correlation coefficient of r=0.925 (p=0.025) for empty samples and r=0.244 (p=0.641) for autograft samples. Linear regression analysis of percent vasculature volume and canal area provided a Pearson correlation coefficient of r=0.784 (p=0.117) for empty samples and r=-0.146 (p=0.783) for autograft samples. Bone formation rates were reported as the distance between the fluorescent labels and were less within the endosteum, cortex, and periosteum, with extensive reaming in empty samples.

CONCLUSIONS

The results suggest that limited reaming may be beneficial to the acute management of tibial shaft fractures with a bone defect.

The effect of muscle contusion on cortical bone and muscle perfusion following reamed, intramedullary nailing: a novel canine tibia fracture model

Background

Management of tibial fractures associated with soft tissue injury remains controversial. Previous studies have assessed perfusion of the fractured tibia and surrounding soft tissues in the setting of a normal soft tissue envelope. The purpose of this study was to determine the effects of muscle contusion on blood flow to the tibial cortex and muscle during reamed, intramedullary nailing of a tibial fracture.

Methods

Eleven adult canines were distributed into two groups, Contusion or No-Contusion. The left tibia of each canine underwent segmental osteotomy followed by limited reaming and locked intramedullary nailing. Six of the 11 canines had the anterior muscle compartment contused in a standardized fashion. Laser doppler flowmetry was used to measure cortical bone and muscle perfusion during the index procedure and at 11 weeks post-operatively.

Results

Following a standardized contusion, muscle perfusion in the Contusion group was higher compared to the No-Contusion group at post-osteotomy and post-reaming (p < 0.05). Bone perfusion decreased to a larger extent in the Contusion group compared to the No-Contusion group following osteotomy (p < 0.05), and the difference in bone perfusion between the two groups remained significant throughout the entire procedure (p < 0.05). At 11 weeks, muscle perfusion was similar in both groups (p > 0.05). There was a sustained decrease in overall bone perfusion in the Contusion group at 11 weeks, compared to the No-Contusion group (p < 0.05).

Conclusions

Injury to the soft tissue envelope may have some deleterious effects on intraosseous circulation. This could have some influence on the fixation method for tibia fractures linked with significant soft tissue injury.

Open tibial shaft fractures: II. Definitive management and limb salvage

Definitive treatment of open fractures of the tibial diaphysis is challenging. The high-energy nature of these fractures, as well as the contamination of the fracture site and devitalization of the soft-tissue envelope, greatly increases the risk of infection, nonunion, and wound complications. The goals of definitive treatment include wound coverage or closure; prevention of infection; restoration of length, alignment, rotation, and stability; fracture healing; and return of function. Advances in orthobiologics, modern plastic surgical techniques, and fracture stabilization methods, most notably locked intramedullary nailing, have led to improved prognosis for functional recovery and limb salvage. Despite improved union and limb salvage rates, the prognosis for severe type III open fracture of the tibial shaft remains guarded, and outcomes are often determined by patient psychosocial variables.

Fat marrow embolism during intramedullary bone endoscopy: an experimental study in sheep

We present a study designed to investigate whether the intramedullary bone endoscopy (IBE) procedure within the cavity of an intact long bone will create embolic loads on the lungs similar to that of other orthopedic procedures (e.g., stem implantation in total hip arthroplasty [THA]). In a sheep model, 10 animals underwent the IBE procedure with complete perioperative anesthesiology monitoring. The lungs were harvested postoperatively and examined for fat embolisms. One animal showed evidence of intraoperative fat embolism with temporary increases in mean pulmonary arterial pressure (MPAD) and the mean CO(2)-gradient. The histological examination in this animal revealed fat embolism with a 2% surface area of the investigated fields covered with fat vacuoles. All peri- and postoperative data on the other nine animals were normal. Our findings indicate that, as with other intramedullary manipulation in intact long bones, there is a potential risk for systemic fat excavation during IBE. However, the embolic load is much lower than the rates reported for other orthopedic interventions.

Intramedullary nailing of the femur: current concepts concerning reaming

Intramedullary fixation has advanced to the standard of care for fractures of the femoral shaft. Current controversies center on whether to prepare the intramedullary canal by reaming, particularly in certain subsets of patients. As understanding of the local and systemic effects of reaming deepens, there is a role for maximizing the benefits of intramedullary preparation before nail fixation, while attempting to minimize the major disadvantages of this technique. Several treatment strategies have emerged to address the downsides of intramedullary reaming. The purpose of this review is to discuss the history and current knowledge of intramedullary reaming with respect to problems associated with its use and the evolution of treatment modalities and their clinical applicability for orthopaedic trauma care.

Unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third tibial fractures

PURPOSE

To assess the outcome of unreamed intramedullary nailing through the lateralised entry point using oblique proximal and biplanar distal interlocking screws.

METHODS

15 men and 3 women aged 25 to 58 (mean, 37) years underwent unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third metaphyseal tibial fractures. The entry point was kept proximal to the tibial tuberosity and slightly lateral to midline. Proximal locking was at 45 degrees to the coronal and sagittal planes. Biplanar distal locking was in the coronal and sagittal planes.

RESULTS

16 patients had bone union within 20 (mean, 17; range, 14-27) weeks; 2 underwent dynamisation for delayed union. Three patients had valgus angulation of less than 5 degrees; 2 had a loss of terminal knee flexion; 3 had a loss of ankle dorsiflexion; and 3 had shortening of more than 0.5 cm. Functional outcomes were excellent in 13, good in 4, and fair in one patient. No patient endured neurovascular injury, compartment syndrome or implant failure.

CONCLUSION

Unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third tibial fractures was effective in preventing malalignment.

The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures

INTRODUCTION

Stabilisation of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults. To ream or not to ream is still debated. The primary objective of this study was to determine the incidence of non-union following unreamed intramedullary stabilisation of femoral fractures. Secondary objectives were intra- and postoperative complications and implant failure.

METHODS

Between March 1995 and June 2005, 125 patients with 129 traumatic femoral shaft fractures were treated with as unreamed femoral nail. From this retrospective single centre study, 18 patients were excluded due to insufficient follow up data, including 1 patient who died within 2 days after severe head injury. Sixty-six patients had suffered multiple injuries. 21 fractures were open. According to the AO classification, there were 54 type A, 42 type B, and 14 type C fractures. Dynamic proximal locking was performed in 44 cases (36 type A and 8 type B fractures).

RESULTS

Non-union occurred in two patients (1.9%; one type B and one type C fractures). Intra-operative complications were seen in three patients (2.8%). Postoperative in-hospital complications occurred in 29 patients (27%). Local superficial infection occurred in two patients (1.9%), there were no cases of deep infection. Implant failure occurred in three patients (2.8%): nail breakage was seen in two patients.

CONCLUSION

In this study, the incidence of non-union following unreamed intramedullary nailing is low (1.9%) and comparable with the best results of reamed nailing in the literature.

The effect of high and low pressure pulsatile lavage on soft tissue and cortical blood flow: a canine segmental humerus fracture model

OBJECTIVE

To determine the effect of high pressure pulsatile lavage (HPPL) and low pressure pulsatile lavage (LPPL) on cortical and soft tissue blood flow in a canine humerus segmental fracture model.

DESIGN

Midshaft humeral osteotomies to create a 2-cm segment of diaphyseal bone were performed on bilateral canine humeri. Each osteotomy site was irrigated using either high pressure (n = 6) or low pressure (n = 5) pulsatile lavage prior to stabilization with a 5-mm steinman pin. Perfusion of cortical bone, periosteum, and biceps muscle was measured using Laser Doppler Flowmetry during four intraoperative intervals: pre-osteotomy, post-osteotomy, post-lavage, and post-nailing.

RESULTS

Following osteotomy, a significant drop occurred in cortical perfusion (HPPL P = 0.049, LPPL P = 0.021) and in periosteal flow (HPPL P = 0.019, LPPL P = 0.012). Following irrigation there was no significant decrease in blood flow in either group for muscle (HPPL P = 0.249, LPPL P = 0.41), periosteum (HPPL P = 0.381, LPPL P = 0.402), or cortex (HPPL P = 0.398, LPPL P = 0.352) measurements. There was no significant difference between irrigation groups in post-lavage perfusion values for muscle (P = 0.326), periosteum (P = 0.452), and cortex (P = 0.464). Cortical perfusion decreased significantly post-nailing (HPPL P = 0.027, LPPL P = 0.047). Measurements did not differ significantly between groups at any other time interval.

CONCLUSION

Although previous work has demonstrated an association between HPPL and detrimental structural changes in bone, this study demonstrates that HPPL does not adversely affect cortical or soft tissue blood flow acutely. Further, LPPL offers no acute benefit to cortical or soft tissue perfusion.

Cortical heat generation using an irrigating/aspirating single-pass reaming vs conventional stepwise reaming

OBJECTIVE

To compare the heat generation and pressure generation of a prototype irrigating aspirating intramedullary reaming system to traditional stepwise reaming.

DESIGN

This in vitro study used 8 pairs of fresh-frozen human cadaver tibias. Thermocouples were mounted in the mid-diaphysis and distal diaphysis. A pressure transducer was placed distally to assess intramedullary pressure, a load cell measured axial load was applied by the surgeon, and the entire construct was placed in a 37 degrees C saline bath. One specimen from each pair underwent single-pass reaming with the prototype reamer irrigator aspirator (RIA), and the contralateral limb underwent standard stepwise reaming. All variables were recorded.

RESULTS

There were no significant differences in pressure applied to the load cells during reaming. The maximum temperatures reached in the distal diaphysis in the RIA group (42.0 +/- 9.1 degrees C) were significantly lower (P = 0.025) than in the standard reaming group (58.7 +/- 15.9 degrees C). The maximum pressure generated in the distal tibia in the RIA group (32.7 +/- 39.4 kPa) was significantly higher (P = 0.019) than in the standard reaming group (17.0 +/- 32.6 kPa).

CONCLUSIONS

This study demonstrated substantially decreased temperatures with the RIA prototype when compared with standard stepwise reaming. It appears that the continuous flow of room temperature saline irrigant into the system manages to cool the cortical bone, despite the aggressive nature of a single-pass reaming method. However, in this model, contrary to the findings of other studies, the RIA system did generate higher pressures in the distal tibial metaphysis, perhaps as a result of congestion within the outflow of the RIA system. The results of this study confirm that cortical heat generation is not a problem but definitely indicate further development of this prototype aspirator function is warranted, followed by careful in vivo evaluation.

Open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: a prospective study

OBJECTIVE

Does immediate tibial nail insertion without reaming as part of protocol-driven management provide a safe and effective treatment for open tibia fractures?

STUDY DESIGN

Prospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

A consecutive series of 161 patients with Gustilo grade I-IIIb open tibia fractures.

INTERVENTION

Emergent incision and debridement of the wound with immediate tibial nail insertion without reaming, repeat incision and debridement, and soft-tissue coverage within 14 days.

MAIN OUTCOME MEASUREMENTS

Time to union, number of secondary procedures performed to obtain union, implant failures, and the type and incidence of complications.

RESULTS

One hundred and forty-three fractures were followed to union. Follow up averaged 2.2 years (0.6-5.5 years). Seventy-six fractures united in less than 6 months, 35 took between 6 and 9 months, and 32 took longer than 9 months. Twenty-five additional procedures were needed to obtain union in 16 of the delayed unions (12 nail exchanges, 4 bone grafts, 9 dynamizations). Complications included 3 patients with cellulitis, 1 superficial infection, 4 deep infections (1 grade I, 2 grade II, 1 grade IIIb), 3 loose screws, 2 broken screws, 5 malunions greater than 5 degrees, and 30 patients with decreased ankle motion when compared with the uninjured side. Not counting the ankle loss of motion, 18 complications occurred in 143 fractures (13%). Twenty-nine patients (20%) had complaints of minor knee pain and 30 (21%) had occasional fracture site pain after activity despite clinical and radiographic evidence of union. Eleven patients (8%) considered themselves completely disabled. Five patients were not treated by the standard protocol and are not included in the previously listed statistics; 3 were grade IIIB that did not have adequate coverage by 14 days, and 2 were grade II injuries that did not have a second debridement. Four of these 5 patients developed a complication.

CONCLUSIONS

Protocol-driven management emphasizing meticulous soft-tissue management and the use of immediate tibial nailing without reaming appears to be safe and effective in the treatment of open tibia fractures. The deep infection rate for the patients who were treated by protocol was 3% and the implant failure rate was lower than has been previously reported, most likely attributable to attempts to obtain cortical contact and avoid fracture gaps. Overall satisfaction was good, but approximately 41% of the patients had complaints of knee or fracture site pain or both well after union.

Intramedullary nailing of the lower extremity: biomechanics and biology

The intramedullary nail or rod is commonly used for long-bone fracture fixation and has become the standard treatment of most long-bone diaphyseal and selected metaphyseal fractures. To best understand use of the intramedullary nail, a general knowledge of nail biomechanics and biology is helpful. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints that allow for secondary fracture healing. Like other metallic fracture fixation implants, a nail is subject to fatigue and can eventually break if bone healing does not occur. Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter. Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics. Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing.

The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature

The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6 degrees . The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6 degrees . The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union.

Human reaming debris: a source of multipotent stem cells

The biological characteristics of human reaming debris (HRD) generated in the course of surgical treatment of long bone diaphyseal fractures and nonunions are still a matter of dispute. Therefore, the objective of the present investigation has been to characterize the intrinsic properties of human reaming debris in vitro. Samples of reaming debris harvested from 12 patients with closed diaphyseal fractures were examined ultrastucturally and were cultured under standard conditions. After a lag phase of 4-7 days, cells started to grow out from small bone fragments and established a confluent monolayer within 20-22 days. The cells were characterized according to morphology, proliferation capacity, cell surface antigen profile, and differentiation repertoire. The results reveal that human reaming debris is a source of multipotent stem cells which are able to grow and proliferate in vitro. The cells differentiate along the osteogenic pathway after induction and can be directed toward a neuronal phenotype, as has been shown morphologically and by the expression of neuronal markers after DMSO induction. These findings have prompted interest in the use of reaming debris-derived stem cells in cell and bone replacement therapies.

Intramedullary nailing in open tibia fractures: a comparison of two techniques

We analyzed 51 patients with open tibial fractures treated with intramedullary nailing. In 29 patients the nailing was performed without reaming and in 22 after the "reamed-to-fit" technique. There was no statistically significant difference in the rate of union. The nonreamed group required a greater number of secondary procedures to achieve union and had a higher but not statistically significant incidence of infection. Analysis of the operative and anesthesia cost associated with the additional procedures revealed that on average, patients receiving nonreamed nailing incurred a cost of $4,900 more per fracture than patients of the reamed-to-fit technique. The healing rates of open tibia fractures using either minimally reamed or nonreamed techniques of intramedullary nailing are comparable. No increase in the rate of infection with the reamed-to-fit technique was found. A significant increase in the number of secondary procedures required to achieve union was found with the nonreamed nailing technique.

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

OBJECTIVE

To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures.

DESIGN

Prospective, randomized.

SETTING

Level 1 trauma center.

PATIENTS

Forty-five patients with displaced closed and open Gustilo type I-IIIA fractures of the central two thirds of the tibia.

INTERVENTION

Stabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail.

MAIN OUTCOME MEASUREMENTS

Nonunions, time to fracture healing, and rate of malunions.

RESULTS

The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements.

CONCLUSION

Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails.

Use of a plate-rod construct and principles of biological osteosynthesis for repair of diaphyseal fractures in dogs and cats: 47 cases (1994-2001)

OBJECTIVE

To determine outcome for dogs and cats with diaphyseal fractures in which a plate-rod construct was used for fracture repair.

DESIGN

Retrospective study.

ANIMALS

35 dogs and 12 cats.

PROCEDURES

Medical records and radiographs were reviewed to obtain information concerning signalment, fracture severity, construct design, time to radiographic union, complications, and outcome. Clients were contacted by telephone to obtain information on complications, limb usage, and overall satisfaction with the procedure.

RESULTS

31 femoral, 9 humeral, and 7 tibial fractures were assessed. Thirteen fractures consisted of 2 fragments, 22 consisted of 3 to 5 fragments, and 12 consisted of > 5 fragments. Forty-six of 47 (98%) fractures reached union. Mean +/- SD times to radiographic union were 7.5 +/- 2.7 weeks for the dogs and 4.8 +/- 1.3 weeks for the cats. There were 4 short-term, minor complications and 15 long-term complications (2 major and 13 minor). Owners of 21 of 30 dogs (70%) and 9 of 12 cats reported that their animals had normal limb function. Twenty-six of 28 dog owners (93%) and 12 of 12 cat owners indicated that they were satisfied with results of the procedure. As surgery time increased, time to union also increased. Time to union for fractures with > 5 fragments was significantly shorter than time to union for fractures with < or = 5 fragments.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that plate-rod constructs can successfully be used for repair of diaphyseal fractures of a wide range of severity in dogs and cats.

Open fractures: evaluation and management

Open fractures are complex injuries that involve both the bone and surrounding soft tissues. Management goals are prevention of infection, union of the fracture, and restoration of function. Achievement of these goals requires a careful approach based on detailed assessment of the patient and injury. The classification of open fractures is based on type of fracture, associated soft-tissue injury, and bacterial contamination present. Tetanus prophylaxis and intravenous antibiotics should be administered immediately. Local antibiotic administration is a useful adjunct. The open fracture wound should be thoroughly irrigated and debrided, although the optimal method of irrigation remains uncertain. Controversy also exists regarding the optimal timing and technique of wound closure. Extensive soft-tissue damage may necessitate the use of local or free muscle flaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and characteristics of the injury.

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 mm(2) and 699.4 mm(2), 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.

Unreamed locked tight-fitting nailing for acute tibial fractures

OBJECTIVES

Treatment of tibial fractures by unreamed locked nailing with loose-fitting nails has previously been shown to be associated with a low union rate and high implant failure rate. This report describes the authors' experience in using tight-fitting nails that were relatively larger than loose-fitting nails.

DESIGN

Prospective cohort study.

SETTING

University medical center.

PATIENTS

Forty-eight consecutive patients with fifty-two tibial fractures (excluding open IIIC fractures and those with bone loss) were studied: thirty-four men and fourteen women, with a mean age of 38 years. There were twenty-five closed fractures, nine Type I, eight Type II, four Type IIIA, and six Type IIIB open fractures.

INTERVENTION

Unreamed nailing with tight-fitting nails using the Russell-Taylor system.

OUTCOME MEASURES

Union rate, time to union, complication rate, and functional recovery, as well as nailing time, hospital time, and crutch-walking time were recorded.

RESULTS

Union occurred in forty-eight of fifty-two fractures (92%) with a mean time to union of 18.2 weeks. Compartment syndrome occurred in three patients. Deep infection occurred in one Type II and one Type IIIB open fracture. Four fractures required additional exchange nailing or bone grafting to achieve union: one Type II, one Type IIIA, and two Type IIIB open fractures. Three malalignments resulted from operative technical error. The rate of both intraoperative bony split and screw breakage was 3.8% (2 of 52), but neither complication interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury.

CONCLUSIONS

Unreamed locked nailing with tight-fitting nails can produce satisfactory clinical results for acute tibial fractures. It has the advantages of technical simplicity and an acceptable risk of implant failure.

The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device

We present the clinical and radiographic results of a prospective study with the Orthofix tibial nailing system. The ease and safety of distal locking with the use of an improved targeting system was also evaluated. Sixty fresh tibial fractures in 60 patients with a mean age of 37.3 years (range 17-73 years) were treated. Eighteen of the fractures were grade I open fractures. All operations were performed in a conventional operating theatre on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site. Hand reaming was then performed to ensure, where possible, the insertion of a nail of at least 9 mm in diameter. Fracture healing was observed at a mean of 17 weeks (12-28 weeks). No tibial non-unions occurred in our series, and only three fractures, two segmental and one severely comminuted, showed delayed union. No infection, either superficial or deep, was found and no cardio-pulmonary complications were recorded. Following surgery, all patients gained a full range of pain-free movement of the ankle and knee joints and only six patients (10%) complained of mild anterior knee pain. All patients returned to their previous jobs one month after fracture healing had been confirmed clinically and radiographically. Following nailing, no deviation from normal tibial alignment was detected. No mechanical failure of either the nails or the locking screws was recorded. The mean duration of operation (skin to skin) was 30 min (range 20-45 min) and the mean total theatre time was 55 min (range 40-75 min). The mean total intensification time was 5 s. In total, 120 distal locking screws were inserted using the external targeting device. All attempts at distal locking except five (4.2%) were successful with two failures in the same patient being a result of inappropriate use of the system. We conclude that this nailing system is clinically effective and that distal locking can be performed easily, without exposure to radiation.

A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft

OBJECTIVES

To determine if there are differences in healing, complications, or number of procedures required to obtain union among open and closed tibia fractures treated with intramedullary (IM) nails inserted with and without reaming.

DESIGN

Prospective, surgeon-randomized comparative study.

SETTING

Level One trauma center.

PATIENTS

Ninety-four consecutive patients with unstable closed and open (excluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997.

INTERVENTION

Interlocked IM nail insertion with and without medullary canal reaming.

MAIN OUTCOME MEASURES

Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union.

RESULTS

For open fractures, there were no significant differences in the time to union or number of additional procedures performed to obtain union in patients with reamed nail insertion compared with those without reamed insertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary procedures were needed to obtain union after unreamed nail insertion for the treatment of closed tibia fractures, but the difference was not statistically significant given the limited power of our study (p = 0.155). Broken screws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncompliant with weight-bearing restrictions. There were no differences in rates of infection or compartment syndrome.

CONCLUSION

Our findings support the use of reamed insertion of IM nails for the treatment of closed tibia fractures, which led to earlier time to union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.