Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients

TRUMATCHTM Graft Cage-Long Bone as a solution for tibial bone defect in traumatic aseptic non-union: a case report

BACKGROUND

Tibial fractures, with an annual incidence of 51.7 per 100.000 adults, often result in complications like non-union and infection, particularly in open fractures. Non-union rates after intramedullary nailing are 9.7%. Hypertrophic non-union stems from unstable fracture sites, while atrophic non-union arises from inadequate biological environments. Treatment involves rigid bone fixation for hypertrophic non-union and combining biological tissue supply with mechanical stability for atrophic non-unions. This case report outlines a complex tibial non-union post-high-impact injury, detailing the surgical technique and TRUMATCHTM Graft Cage-Long Bone usage. In addition, we outlined the current literature on this topic.

CASE REPORT

A male patient suffered a traumatic Gustilo II comminuted tibia and fibula fracture, Lisfranc injury and a Schatzker I tibial plateau fracture of the right leg. During follow-up the patient developed an aseptic non-union with eight-centimeter anterolateral bone defect after primary surgery. Surgical intervention was performed using the three-dimensional printed TRUMATCHTM Graft Cage-Long Bone. At one year follow-up, clinical and radiological consolidation of the right tibia was seen.

CONCLUSION

This case report describes a challenging case of aseptic traumatic non-union of the tibia with a critical-sized defect treated with a novel patient-specific implant in a one-stage procedure. The application of the TRUMATCHTM Graft Cage-Long Bone is promising and warrants further investigation in larger, more controlled studies to substantiate our findings.

Does internal fixation of shaft fracture show specificities in over-80 year-olds?

Osteoporotic fractures in the elderly are increasingly numerous, but diaphyseal locations on native bone are quite rare. Pathological and periprosthetic fractures are not included in this review, as they are specific in terms of context and treatment. Cortical thinning and widening of the medullary canal alter local mechanical properties, necessitating adaptation of internal fixation. Thus, for nailing, the diameter of the implant has to be greater, and fixed-angle or multidirectional locking screws are used; for plate fixation, locking screws are required. To avoid secondary periprosthetic fracture, fixation must protect the entire bone segment. Long plates should be used, with several divergent epiphyseal end-screws; in the femur, cervicocephalic proximal fixation is recommended. In practice, nailing is mostly used in femoral and tibial isthmic locations. In case of metaphyseal extension, nail and locking plate fixation, ideally percutaneous, show comparable results in terms of function, consolidation and complications. In the tibia, it is mandatory to be soft-tissue friendly given the fragility of pretibial skin in the elderly. In the humerus, the choice is wider. For nailing, passage through the rotator cuff seems acceptable in elderly patients. LEVEL OF EVIDENCE: V; expert opinion.

Cortical Venting: A Simple Surgical Adjunct for the Treatment of Long Bone Nonunion

Nonunions are a vexing problem for the orthopedic surgeon. Herein, we describe an adjunct to the standard exchange nailing procedure adapted from an established limb lengthening technique in which cortical vents are drilled adjacent to the nonunion site. These transcortical drill tunnels facilitate local dispersion of the osteogenic intramedullary reamings around the nonunion site during the exchange nailing, whereby the extruded reamings serve as autograft for the nonunion. This simple adjunctive technique can increase the likelihood of achieving union when performed with an exchange nailing procedure as demonstrated by our case series of recalcitrant tibia and femoral nonunions successfully treated when this surgical adjunct was implemented.

Treatment preferences and current practices regarding open tibial shaft fractures

Purpose

The purpose of this study was to reveal the treatment preferences and current practices regarding open tibial shaft fracture (OTSF).

Patients and methods

Online surveys of treatment preferences and current practice of OTSF were conducted by orthopedic trauma doctors from various medical institutions in Zhejiang Province. The survey contains three modules. The first module is the basic information of the participants, the second module is the treatment patterns for Gustilo-Anderson type I-II (GA I/II), and the third module is the treatment patterns for Gustilo-Anderson type IIIA (GA IIIA). Furthermore, each treatment pattern was divided into four aspects, including antibiotic prophylaxis, irrigation and debridement, fracture stabilization, and wound management.

Results

A total of 132 orthopedic trauma doctors from 41 hospitals in Zhejiang province, participated the online surveys. In GA I-IIIA OTSF, more than three-quarters of participants considered <3 h as the appropriate timing of antibiotic administration after trauma. In fact, only 41.67% of participants administered antibiotics within 3 h after trauma. 90.91 and 86.36% of participants thought debridement within 6 h was reasonable for GA I/II and GA IIIA OTSF, respectively. However, in reality only about half of patients received debridement within 6 h on average. The most common reason for delayed debridement was patients' transport delay. 87.88 and 97.3% of participants preferred secondary internal fixation following external fixation for GA I/II and GA IIIA OTSF, respectively. Additionally, over half of participants preferred use of locking plate for treating GA I-IIIA OTSF. The most common reasons for choosing delayed internal fixation for GA I-IIIA OTSF were infection risk and damage control. 78.79 and 65.91% supported immediate internal fixation after removing the external fixation for GA I-IIIA OTSF, respectively. Regarding wound closure, 86.36 and 63.64% of participants reported primary closure for GA I/II and GA IIIA OTSF, respectively. Over three fourths of participants agreed that preoperative and postoperative multiple wound cultures should be performed to predict infection for GA I-IIIA OTSF.

Conclusion

The study first presents the current preference and practice regarding management of GA I-IIIA OTSF in Zhejiang. Majority of surgeons in our study preferred secondary internal fixation following external fixation for GA I-IIIA OTSF and over half of surgeons preferred use of locking plate for treating GA I-IIIA OTSF. This study may provide a reference for trauma orthopedic surgeons in the treatment of GA I-IIIA OTSF.

RISK FACTORS AT NON-UNION OF TIBIAL FRACTURE TREATED WITH INTRAMEDULLARY NAIL

Objective

Identify the predictors associated with delayed union at 6 months and non-union at 12 months in tibial shaft fractures treated with intramedullary nailing (IMN).

Methods

This retrospective longitudinal study included a cohort of 218 patients who sustained tibial shaft fractures and received IMN between January 2015 and March 2022. We gathered data on a range of risk factors, including patient demographics, trauma intensity, associated injuries, fracture characteristics, soft tissue injuries, comorbidities, addictions, and treatment-specific factors. We employed logistic bivariate regression analysis to explore the factors predictive of delayed union and non-union.

Results

At the 6-month follow-up, the incidence of delayed union was 28.9%. Predictors for delayed union included flap coverage, high-energy trauma, open fractures, the use of external fixation as a staged treatment, the percentage of cortical contact in simple type fractures, RUST score, and postoperative infection. After 12 months, the non-union rate was 15.6%.

Conclusion

the main predictors for non-union after IMN of tibial shaft fractures are related to the trauma energy. Furthermore, the initial treatment involving external fixation and postoperative infection also correlated with non-union. Level of Evidence III; Retrospective Longitudinal Study.

Open fractures of the limbs in children and adolescents

Open fracture is rare in children, raising dual issues of sepsis and mechanics. Here, we address certain practical questions regarding childhood open fracture. Should the recognized adult classifications be used in children? Two classifications exist for adults, without pediatric specificities; of these, we recommend Gustilo's, as being more precise in its description of severe grades. Is there any consensus on emergency prophylactic antibiotic therapy in children? The risks seem to be the same, and 24hours' prophylactic antibiotic therapy should be initiated as soon as possible, as in adults. What are the most recent guidelines on time to treatment, type of internal fixation and possible associated procedures in tibial fracture in children? Wound cleansing is indispensable. Treatment under anesthesia can be delayed up to 24hours in the absence of neurovascular complications on condition that antibiotic therapy is implemented immediately. In Gustilo grade I and II, or IIIA, external fixation is not systematic and non-operative treatment or intramedullary nailing is possible. In grades IIIB and IIIC, external fixation is the rule, although conversion is possible if indicated early enough. Do the particular cases of nail bed injury or lawn mower foot injury in children require specific management? Nail bed injury is not to be minimized and should be treated strictly. In case of serious accidents with garden equipment, initial wound care in surgery should be economic, but experienced practitioners should weigh the risk/benefit ratio between conservation and early amputation. LEVEL OF EVIDENCE: IV.

Kneeling tolerance following intramedullary nailing or plate fixation of uncomplicated distal tibia fractures

INTRODUCTION

Distal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee function in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following distal tibia fracture to assist in the preoperative consent process.

HYPOTHESIS

There is no difference in kneeling tolerance following either tibial nailing or plate fixation of distal tibia fractures.

MATERIAL AND METHODS

Retrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome measure was the Kneeling Test (KT). Secondary outcome measures were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. There were 28 patients recruited (18 IMN and 10 ORIF) with a mean age of 44years. Mean overall follow-up was 13.3months (range 8-25, SD 3.6). All fractures had completely healed without postoperative complication.

RESULTS

The IMN affected limb had a significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs. 94.9 respectively, p<0.005) Additionally, the IMN group performed significantly worse when compared to the ORIF group (mean KT 70.4 vs. 92.5 respectively, p<0.005). No significant differences (p>0.05) in kneeling function existed for the ORIF group when comparing affected to non-affected limbs. Secondary outcome analysis showed significantly worse overall WOMAC and FJS in the IMN group compared to the ORIF group (mean WOMAC 19.3 vs. 6.9 respectively, p=0.040; mean FJS 38.3 vs. 75.9 respectively, p=0.005).

DISCUSSION

The use of intramedullary nailing for the treatment of distal tibia fracture results in a mean reduction of 20% in kneeling tolerance in comparison to ORIF. The resulting kneeling tolerance is comparable to that of patients post-total knee arthroplasty. The present findings should assist in the consent process for patients with high kneeling demands in sportive, professional or cultural pastimes.

LEVEL OF EVIDENCE

IV; retrospective cohort study with quantitative outcome measurement.

Secondary intramedullary nailing for open tibial shaft fractures. Comparison of a one-stage versus two-stage surgical procedure

INTRODUCTION

The objective of this study was to compare the rates of radiological and clinical complications after sequential treatment of a tibial shaft fracture by external fixation followed by secondary nailing with an early-stage conversion (C1S) versus a two-stage late conversion (C2S). The hypothesis of this work was that treatment with C1S does not increase the risk of surgical site infections compared to C2S, and allows faster healing with a lower malunion rate.

MATERIAL AND METHODS

We carried out a retrospective and comparative study based on the files of the traumatology department of the Édouard Herriot University Hospital in Lyon. We reviewed the records of patients who presented with a Gustilo grade 1, 2 or 3a open tibial fracture treated with external fixation with conversion by intramedullary nailing within 6 months from January 2010 to December 2020. We assessed the occurrence of Surgical Site Infections (SSI), consolidation time, time until resumption of weight bearing and the malunion rate.

RESULTS

Of the 55 patients included, a C1S procedure was performed in 25 cases (45.5%) versus 30 cases (54.5%) for C2S. No significant difference was found concerning the occurrence of SSI after intramedullary nailing between the two groups (p=0.81). A significant difference was observed in terms of bone healing (p=0.036) and the malunion rate (0.0013) in favor of nailing in one stage.

DISCUSSION

The strategy of converting an open leg fracture early, in one stage (C1S), after initial external fixator placement allows for faster healing and weight bearing, while ensuring a lower malunion rate compared to that of a late two-stage conversion. In the absence of a scar at the time of intramedullary nailing, C1S does not increase the risk of surgical site infections. While the choice of a late and sequential two-stage operation is likely related to the surgeon's apprehension around conversion of an open leg fracture by intramedullary nailing, this study could promote the use of C1S in a greater number of situations.

LEVEL OF EVIDENCE

IV.

The relevance of the number of distal locking planes and nail to canal ratio in bone healing after intramedullary nailing in tibial shaft fractures

INTRODUCTION

The objective of this retrospective study was to assess the effect of the nail to canal ratio and the number and configuration of distal locking screws in bone healing in tibial shaft fractures.

METHODS

We analyzed 223 consecutive tibial shaft fractures treated with reamed intramedullary nailing between January 2014 and December 2020. We recorded and evaluated the nail to canal ratio (NCR) and the number and configuration of distal locking screws. Median NCR was 0.87 (IQR 0.82-0.94). Ten (4.48%) fractures were treated with one distal locking screw, 173 (77.57%) with two, and 40 (17.93%) with three. Uniplanar fixation was used in 63 (28.25%), biplanar in 150 (67.26%), and triplanar in 10 (4.48%) cases. Uni-, bi-, and multivariate analyses were performed to compare patients who achieved bone union with those who did not.

RESULTS

Bone union was achieved in 195 (87.44%) patients. Uni- and bivariate analyses showed that bone union increased significantly with larger NCR (p = 0.0001) and a greater number of locking planes (p = 0.001) and distal screws (p = 0.046). NCR > 0.78 (OR 48.77 CI 95% 15.39-154.56; p =  < 0.0001) and distal locking screw configuration (OR 2.91 CI 95% 1.12-9.91; p = 0.046) were identified as independent variables for union.

CONCLUSION

Our findings suggest that in tibial shaft fractures treated with intramedullary nailing, NCR should be equal to or greater than 0.79. Additionally, distal locking screws should be used with a biplanar or triplanar configuration.

Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings

INTRODUCTION

Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes.

METHODS

We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier.

RESULTS

There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6 h. Mean duration of antibiotics therapy was 4.3 days, and the mean duration of hospital stay was 4.1 days. All patients were followed up to union. Mean time to radiographic union was 6.1 months for the tibia and 5.7 months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection.

CONCLUSION

The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.

Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis

PURPOSE

Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing.

METHOD

This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis.

RESULTS

Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion.

CONCLUSION

The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.