Contemporary management of aseptic diaphyseal tibia non-unions - A systematic review

Centromedullary nailing during the second stage of induced membrane (Masquelet) for tibia septic nonunion enables bone union to be achieved without increasing the risk of recurrence of infection, with an earlier return to weight-bearing

INTRODUCTION

Septic nonunion is one of the most feared complications in traumatology. Two-stage management using the induced membrane technique is a validated treatment option, but to date there is no consensus on the ideal type of osteosynthesis for the second stage of surgery. The aim of this study was to compare the results of two-stage treatment of tibial septic nonunion, depending on the type of osteosynthesis used.

HYPOTHESIS

Our hypothesis was that internal centromedullary nailing osteosynthesis during the second stage of management of septic tibia nonunion would achieve bone union and healing of the infection, while allowing faster resumption of weight-bearing without increasing the complication rate.

MATERIAL & METHODS

This was a retrospective monocentric continuous comparative study including all 2-stage tibial septic nonunions treated from January 2008 to July 2018, with a minimum follow-up of 18 months. Healing and septic reactivation rates, as well as time to union and weight-bearing on the limb, were compared according to the type of osteosynthesis used. Primary success was defined as recovery from septic nonunion, and secondary success as recovery after at least one additional surgical procedure.

RESULTS

Forty-nine patients were included, aged 39.5 +/- 14.8 years. Primary and secondary success rates were 77.6% (38/49) and 87.8% (43/49), with a mean follow-up of 29.4 +/- 11.3 months. Internal osteosynthesis did not lead to more septic reactivation than external stabilization (p = 0.49), while allowing union within the same deadlines. Osteosynthesis with a centromedullary nail allowed earlier weight-bearing (1.5 +/- 0.9 months) vs. plate (4.8 +/- 1.5) or vs. external fixator (5.3 +/- 1.8) (p < 0.001).

CONCLUSION

Secondary conversion to internal osteosynthesis during the second stage of nonunion cure allows consolidation in same delays, without increasing the risk of infectious recurrence. It also enables faster weight-bearing on the operated limb, particularly in the case of centromedullary nailing.

LEVEL OF EVIDENCE

III; comparative study.

Circular external fixation for revision of failed tibia internal fixation

BACKGROUND

The management of failed tibial fracture fixation remains a challenge for orthopaedic surgeons. This study investigate the utility and outcomes of circular external fixation in the management of failed internal fixation of tibial fractures.

METHODS

Retrospective review of a prospectively collected database of a complex limb reconstruction unit at a major trauma centre was done during December 2022. Patients with failed internal fixation of tibial fracture who underwent revision surgery with circular external fixation frame were included.

RESULTS

20 patients with a mean age of 47.8 ± 16.5 years (range: 15-69) were included. Fourteen (70.0%) patients had failed plate and screws fixations, and the remaining six (30.0%) failed intramedullary nail fixation. The most common indication for revision surgery was development of early postoperative surgical site infection (5 patients; 25.0%). The mean duration of frame treatment was 199.5 ± 80.1 days (range = 49-364), while the mean follow-up duration following frame removal was 3.2 ± 1.8 years (range = 2-8). The overall union rate in this series was 100%; and all infected cases had complete resolution from infection. The total number of complications was 11, however, only two complications required surgical intervention. The most common complications reported were pin site infection (6; 30.0%) and limb length discrepancy of 2 cm (2; 10.0%).

CONCLUSIONS

Circular external fixation is a reliable surgical option in the treatment of failed internal fixation of tibia fractures. This technique can provide limb salvage in complex infected and noninfected cases with a high union rate and minimal major complications.

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.