Reamed versus minimally reamed nailing: a prospectively randomised study of 100 patients with closed fractures of the tibia

Progression of Tibia Fracture Healing Using RUST: Are Early Radiographs Helpful?

OBJECTIVES

To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs.

DESIGN

Retrospective case series.

SETTING

Urban academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up.

INTERVENTION

Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure.

MAIN OUTCOME MEASUREMENTS

Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure.

RESULTS

The fifth percentile and median times, respectively, for reaching "any radiographic healing" (RUST = 5) was 4.0 weeks and 8.4 weeks, "radiographically healed" (RUST = 9) was 12.1 and 20.9 weeks, and "healed and remodeled" (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs.

CONCLUSIONS

The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Non-union bone fractures

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.

Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study

INTRODUCTION

Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful.

MATERIAL AND METHODS

This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation.

RESULTS

The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%.

CONCLUSIONS

The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.

Systematic Review and Analysis of the Quality of Randomized Controlled Trials Comparing Reamed and Unreamed Intramedullary Nailing of Tibial Fractures

OBJECTIVES

To evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems.

DATA SOURCE

PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail." Filters were applied for the years 1991-2019, full articles, human subjects, and English language.

STUDY SELECTION

Inclusion criteria were (1) prospective and randomized trials, (2) studies reported >80% follow-up, and (3) articles amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) skeletally immature patients or (2) incomplete data sets.

DATA EXTRACTION

Articles were assessed with the Coleman Methodology Score, the Consolidated Standards of Reporting Trials systems, and Cowan's Categorical Rating by 2 independent observers.

DATA SYNTHESIS

Scores for individual articles were averaged for the 2 observers. The total and subcategory scores for all included articles were also averaged with SD from both observers. Categories from the 2 grading systems with deficient reporting were measured as a percentage based on grading from both observers. Data were analyzed using kappa statistic and correlation coefficient to assess agreement and reliability.

CONCLUSIONS

All included articles supported the use of reamed tibial intramedullary nails, but the overall quality of the literature fell in the middle of both the modified Coleman Score and Consolidated Standards of Reporting Trials grading scheme ranges despite being Oxford Level 1.

LEVEL OF EVIDENCE

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

Multiple Comparisons of the Efficacy and Safety for Seven Treatments in Tibia Shaft Fracture Patients

Background: A tibia shaft fracture is one of the most common long bone fractures, with two general types, open fracture and close fracture. However, there is no universally accepted guideline suggesting which treatment to use under certain circumstances. Therefore, a comprehensive network meta-analysis (NMA) is needed to summarize existing studies and to provide more credible data-based medical guidelines.

Methods: Available literature was identified by searching medical databases with relevant key terms. Studies that met the inclusion and exclusion criteria, baseline, intervention, and the outcome of treatments, were extracted. A comparative connection of these studies was demonstrated through net plots. Continuous variables and binary variables were reported as mean difference (MD) and odds ratio (OR) with a 95% credible interval (CrI), respectively. The comparison of direct and indirect outcome and their P-value were listed in the node-splitting table. Treatments for each endpoint were ranked by their surface under the cumulative ranking curve (SUCRA) value. A heat plot was created to illustrate the contribution of raw data and the inconsistency between direct and indirect comparisons.

Results: According to the search strategy, 697 publications were identified, and 25 records were included, involving 3,032 patients with tibia shaft fractures. Seven common surgical or non-surgical treatments, including reamed intramedullary nailing (RIN), un-reamed intramedullary nailing (UIN), minimally reamed intramedullary nailing (MIN), ender nailing (EN), external fixation (EF), plate, and cast, were compared, in terms of time to union, reoperation, non-union, malunion, infection and implant failure. Plate performed relatively better for time to union, while cast might be the best choice in close cases to reduce the risks of reoperation, non-union, malunion, and infection. To prevent implant failure, EN seemed to be better.

Conclusion: Cast might have the highest probability of the most optimal choice for tibia shaft fracture in close cases, while reamed intramedullary nailing ranked second.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Genomewide Association Study of Fracture Nonunion Using Electronic Health Records

Nonunion is a clinically significant complication of fracture associated with worse outcomes, including increased pain, disability, and higher healthcare costs. The risk for nonunion is likely to be complex and multifactorial, and as such, the biology underlying such risk remains poorly understood. Genetic studies represent one approach to identify implicated biology for further investigation, but to date the lack of large cohorts for study has limited such efforts. We utilized the electronic health records of two large academic medical centers in Boston to identify individuals with fracture nonunion and control individuals with fracture but no evidence of nonunion. We conducted a genomewide association study among 1760 individuals of Northern European ancestry with upper or lower extremity fracture, including 131 with nonunion, to examine whether common variants were associated with nonunion in this cohort. In all, one locus in the Calcyon (CALY) gene exceeded a genomewide threshold for statistical significance (p = 1.95e-8), with eight additional loci associated with p < 5e-7. Previously reported candidate genes were not supported by this analysis. Electronic health records should facilitate identification of common genetic variations associated with adverse orthopedic outcomes. The loci we identified in this small cohort require replication and further study to characterize mechanism of action, but represent a starting point for the investigation of genetic liability for this costly outcome.

Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice

INTRODUCTION

One of the most challenging musculoskeletal complications in modern trauma surgery is infection after fracture fixation (IAFF). Although infections are clinically obvious in many cases, a clear definition of the term IAFF is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions used in the scientific literature to describe infectious complications after internal fixation of fractures. The hypothesis of this study was that the majority of fracture-related literature do not define IAFF.

MATERIAL AND METHODS

A comprehensive search was performed in Embase, Cochrane, Google Scholar, Medline (OvidSP), PubMed publisher and Web-of-Science for randomized controlled trials (RCTs) on fracture fixation. Data were collected on the definition of infectious complications after fracture fixation used in each study. Study selection was accomplished through two phases. During the first phase, titles and abstracts were reviewed for relevance, and the full texts of relevant articles were obtained. During the second phase, full-text articles were reviewed. All definitions were literally extracted and collected in a database. Then, a classification was designed to rate the quality of the description of IAFF.

RESULTS

A total of 100 RCT's were identified in the search. Of 100 studies, only two (2%) cited a validated definition to describe IAFF. In 28 (28%) RCTs, the authors used a self-designed definition. In the other 70 RCTs, (70%) there was no description of a definition in the Methods section, although all of the articles described infections as an outcome parameter in the Results section.

CONCLUSION

This systematic review shows that IAFF is not defined in a large majority of the fracture-related literature. To our knowledge, this is the first study conducted with the objective to explore this important issue. The lack of a consensus definition remains a problem in current orthopedic trauma research and treatment and this void should be addressed in the near future.

Biomechanical effects of angular stable locking in intramedullary nails for the fixation of distal tibia fractures

Treatment of distal tibia shaft fractures using intramedullary nailing requires stable fixation of the distal fragment to prevent malunion. Angular stable locking for intramedullary nails pledge to provide increased mechanical stability. This study tested the hypothesis that intramedullary nails with angular stable interlocking screws would have increased construct stiffness, reduced fracture gap movement and enhanced fatigue failure compared to nails with conventional locking having the same diameter. Biomechanical experiments were performed on 24 human cadaveric tibiae which obtained a distal fracture and were fixed by three different techniques: conventional locking with 8- and 10-mm-diameter nails and angular stable locking with 8-mm nails. Stiffness of the implant–bone construct and movement of the fragments were tested under axial loading and torsion. The constructs were tested to failure under cyclic fatigue loading. Analysis of variance and Kaplan–Meier survival analysis were used for statistical assessment. Axial stiffness of the 10-mm nail was about 50% larger compared to both 8-mm nail constructs independent of the type of locking mode (p < 0.01). No differences were found in axial performance between angular stable and conventional locking neither under static nor under cyclic testing conditions (p > 0.5). Angular stability significantly decreased the clearance under torsional load by more than 50% compared to both conventionally locked constructs (p = 0.03). However, due to the larger nail diameter, the total interfragmentary motion was still smallest for the 10-mm nail construct (p < 0.01). Although the 10-mm nail constructs survived slightly longer, differences between groups were minor and not statistically significant (p = 0.4). Our hypothesis that angular stable interlocking of intramedullary nails would improve mechanical performance of distal tibia fracture fixation was not confirmed in a physiologically realistic loading scenario. Whether minor mechanical advantages provided by angular stability of the locking screws would improve biological tissue response cannot be concluded from this biomechanical study.

Fractures in sport: Optimising their management and outcome

Fractures in sport are a specialised cohort of fracture injuries, occurring in a high functioning population, in which the goals are rapid restoration of function and return to play with the minimal symptom profile possible. While the general principles of fracture management, namely accurate fracture reduction, appropriate immobilisation and timely rehabilitation, guide the treatment of these injuries, management of fractures in athletic populations can differ significantly from those in the general population, due to the need to facilitate a rapid return to high demand activities. However, despite fractures comprising up to 10% of all of sporting injuries, dedicated research into the management and outcome of sport-related fractures is limited. In order to assess the optimal methods of treating such injuries, and so allow optimisation of their outcome, the evidence for the management of each specific sport-related fracture type requires assessment and analysis. We present and review the current evidence directing management of fractures in athletes with an aim to promote valid innovative methods and optimise the outcome of such injuries. From this, key recommendations are provided for the management of the common fracture types seen in the athlete. Six case reports are also presented to illustrate the management planning and application of sport-focussed fracture management in the clinical setting.

Return to Sport After Tibial Shaft Fractures: A Systematic Review

CONTEXT

Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods.

OBJECTIVE

To determine the current evidence for the treatment of and return to sport after tibial shaft fractures.

DATA SOURCES

OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014.

STUDY SELECTION

Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis.

RESULTS

A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01).

CONCLUSION

The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and compartment syndrome.

Reaming in treatment of non-unions in long bones: cytokine expression course as a tool for evaluation of non-union therapy

The analysis of peripheral serum cytokine expression patterns has been shown to be a possible method for demonstrating changes in bone metabolism. The aim of this study is to evaluate the effectiveness of this method within the treatment of long bone non-union with intramedullary reaming, a well-established non-union treatment concept.

MATERIALS AND METHODS

Three groups were added to this study: group one (G1) suffered from long bone non-unions, treated successfully with intramedullary reaming; group two (G2) consisted of long bone fractures with proper fracture healing; and group three (G3) included long bone fractures resulting in non-unions. We took blood samples on day 2, and after week 1, 4, 6, month 3 and 6 after initial treatment. Clinical and radiological follow-up were provided for 6 months. We measured transforming growth factor ß-1 (TGFß-1), platelet-derived growth factor (PDGF-AB), and insulin like growth factor-1 (IGF-1) at all-time points.

RESULTS

TGF-ß1 levels in G1 and G2 increased from day 2 to 6 weeks after surgery. In general, G1 and G2 showed parallel TGF-ß1 expression patterns, and G3 had a significant peak during first week compared to G1 (p = 0.023). PDGF peaked in G3 during first week after treatment, whereas G1 had its maximum after 4 weeks and G2 after 6 weeks. We were able to detect a significantly lower PDGF concentration at 3 months in G1 compared to G3 (p = 0.029). IGF-1 showed a peak concentration in G1 during the first 4 weeks. Afterwards, concentration levels in both G1 and G2 were higher.

CONCLUSIONS

Our study was able to show that the cytokine expression pattern in physiological bone healing is similar to that in successful non-union treatment with intramedullary reaming. Our results show that the effect of non-union therapy could be observed objectively by measuring cytokine expression patterns in peripheral blood even in a small group of patients.

Intramedullary Tibial Nailing Reduces the Attachment Area and Ultimate Load of the Anterior Medial Meniscal Root: A Potential Explanation for Anterior Knee Pain in Female Patients and Smaller Patients

BACKGROUND

Intramedullary (IM) nailing is the treatment of choice among orthopaedic surgeons for tibial shaft fractures. However, because of the close proximity of the nail's insertion site to the anterior medial (AM) meniscal root on the tibial plateau, there is increased risk of iatrogenic injury to the meniscal root during nailing.

PURPOSE

To quantify the area of the AM meniscal root footprint damaged by IM tibial reaming and determine its subsequent effects on the ultimate failure load in female versus male knees.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve matched pairs (6 male and 6 female pairs; average age, 50.2 years) of human cadaveric knees were randomly assigned to native and reamed groups. In the reamed group, knees were reamed within the "safe zone" according to current guidelines for IM tibial nail insertion (3 mm lateral to the center of the tibial tubercle and adjacent to the anterior margin of the tibial plateau). The attachment areas and ultimate failure load were quantified and compared with paired knees in the native group.

RESULTS

Intra-articular reaming within the "safe zone" for IM tibial nail insertion did not significantly decrease the AM root attachment area or ultimate failure load in male specimens, as only 2 of the 6 knees were damaged by reaming. In contrast, all 6 of the AM roots in the female knees were damaged by reaming, and on average, reaming decreased the female AM root attachment area by 19% and significantly decreased ultimate failure load by 37% (P = .028). There was a strong negative correlation (R(2) = 0.77) between reamed tunnel-AM root overlap area and medial-lateral width in female but not in male knees.

CONCLUSION

Standard reaming for an IM tibial nail induced significant damage to the AM meniscal root in smaller, female specimens, whereas larger, male specimens were not affected.

CLINICAL RELEVANCE

These findings may suggest that improvements in current guidelines and surgical techniques are warranted to prevent iatrogenic injury to the AM meniscal root during intramedullary reaming for tibial shaft fractures in females and in smaller patients.

Locking plate versus retrograde intramedullary nail fixation for tibiotalocalcaneal arthrodesis: A retrospective analysis

BACKGROUND

Tibiotalocalcaneal arthrodesis (TTCA) surgery is indicated for the end-stage disease of the tibiotalar and subtalar joints. Although different fixation technique of TTCA has been proposed to achieve high fusion rate and low complication rate, there is still no consensus upon this point. The purpose of this study is to compare the clinical efficacy of retrograde intramedullary nail fixation (RINF) and locking plate fixation (LPF) for TTCA.

MATERIALS AND METHODS

Fifty four patients who underwent TTCA through the lateral approach with lateral fibular osteotomy using RINF (32 patients, 18 male/14 female, mean age: 48) or LPF (22 patients, 12 male/10 female, mean age: 51) between January 2007 and January 2010 were retrospectively analyzed. Demographic and clinical characteristics, surgery (operation time, blood loss) outcomes (postoperative fusion rates, visual analog scale and foot and ankle surgery score and complications) were compared.

RESULTS

The LPF group had a shorter operation time (72.3 ± 9.2 vs. 102.8 ± 11.1 min, P < 0.001), less blood loss (75.9 ± 20.2 vs. 140.0 ± 23.8 ml, P < 0.001) and less intraoperative fluoroscopy sessions (3.6 ± 0.9 vs. 8.4 ± 1.3, P < 0.001) than the RINF group. Patients were followed up for 12-24 months (mean of 16.2 months). Both groups had similar postoperative fusion rates (90.6% and 95.4%) and the LPF group showed a nonsignificant lower complication rate (18.2% vs. 28.1% respectively). Patients at higher risk on nonunion due to rheumatoid diseases may have a lower nonunion rate with LPF than RINF (one out of eight vs. three out of nine, P < 0.001).

CONCLUSIONS

The LPF for TTCA was simpler to perform compared with RINF, but with similar postoperative outcomes and complication rates.

Fracture near press-on interlocking enhances callus mineralisation in a sheep midshaft tibia osteotomy model

INTRODUCTION

Factors which impair fracture healing after intramedullary (IM) nailing of long bone fractures range from surgical and biological factors to mechanical parameters. Mechanical parameters known to prolong bony consolidation are share forces at the site of the fracture. Fracture near press-on interlocking reduces share forces directly at the fracture site and is hypothesised to enhance callus mineralisation. A sheep model of midshaft tibia osteotomies evaluates the technique.

MATERIALS AND METHODS

Fracture near interlocking was achieved by surfacing a custom made nail with special hutches that enable firm screw seating on top of the nail ("golf ball" structure). Virtual (fine element analysis (FEA)) and biomechanical pilot tests were completed before in vivo application in 12 adult female German black sheep. Midshaft tibia osteotomy was performed creating a subcritical 7 mm gap for delay in union. One group (n=6) was treated with reamed IM nailing employing the custom made nail and in addition to proximal and distal standard interlocking a fracture near press on interlocking was employed. A second group of six sheep without additional press on interlocking served as control. 10 weeks after operation the quality of fracture healing was determined by micro-CT.

RESULTS

The FEA showed that axial loading up to 4000N did not lead to implant fatigue. Fracture near press on interlocking led to significantly more callus mineralisation compared to the conventional interlocking procedure (0.567 g/cm(3) ± 0.106 g/cm(3) versus 0.434 g/cm(3) ± 0.0836 g/cm(3), p=0.043).

CONCLUSIONS

Fracture near press on interlocking increases callus mineralisation in a subcritical osteotomy model in sheep. The results indicate that the reduction of share forces at the fracture site after nailing procedures may be effective in reducing the time until bony consolidation.

Genetic predisposition to non-union: evidence today

Atrophic non-union represents a complex clinical condition and research is ongoing in an effort to elucidate its pathophysiology and to offer new and more efficient treatment modalities. Differences seen in fracture healing responses and final outcome may be attributed among other factors to biological variations between patients resulting in a "disturbed" signalling pathway and an "inert or deficient local biology with reduced potentials for bone regeneration". The genetic contribution with or without the interaction of other exogenous factors in cases of impaired fracture healing, is yet to be elucidated. However, preliminary animal and human studies demonstrate the molecular basis of fracture non-unions and correlate genetic variants of the molecules regulating fracture healing and their expression patterns with impaired bone healing and fracture non-union. Further research is needed to clarify the genetic component and its role and interaction with other risk factors that may result in increased susceptibility of a patient to develop this complication.

How many distal bolts should be used in unreamed intramedullary nailing for diaphyseal tibial fractures?

INTRODUCTION

Unreamed intramedullary nailing (UIMN) is an effective treatment procedure for the majority of tibial fractures, with locking constituting the technical support for the buttressing and neutralisation principles underlying intramedullary nailing. It has been claimed that the added versatility obtained from the use of more bolts in distal locking is very important. Several studies have been made concerning the optimum number of locking bolts in distal tibial fractures; however, to the best of our knowledge, no study has dealt with the question of whether two or three bolts should be used in diaphyseal fractures.

MATERIAL AND METHODS

In this paper, we evaluate the results of treating 86 diaphyseal tibial fractures (type 42 according to the AO classification) with Expert Tibial UIMN (Synthes™, West Chester, PA, USA) and distal blocking with either two or three bolts. Mean patient age was 35 years (21-51).

RESULTS

We found that the consolidation time is shorter, less radiation time is needed and the material cost is lower when two bolts are used. No other differences were found regarding mean operative time, wound healing, pain at fracture site, joint function, angular deviation or rotation.

CONCLUSIONS

For type 42 AO tibial fractures treated with Expert Tibial UIMN, distal blocking should be performed with only two bolts.

Dynamisation and early weight-bearing in tibial reamed intramedullary nailing: its safety and effect on fracture union

AIM

To compare the safety and effect on tibial diaphyseal fracture bone union of two intramedullary nailing techniques: (1) dynamic locking with early, full weight bearing, and (2) static locking with delayed weight bearing until bone union.

PATIENTS AND METHODS

This is a retrospective case-control study of closed or type I open tibial diaphyseal fractures (types A and B according to the AO classification) treated with dynamic nailing (32 cases) or static nailing (35 cases). The type of intramedullary nail, the surgical technique and the postoperative protocol were similar for both groups, with the exception of the locking mode and the time of weight bearing. Time to union, mechanical and biological complications, and the number and type of re-operations needed until union were recorded and analysed.

RESULTS

Mean union time was 21 weeks in the dynamic group and 26 in the static group (p = 0.051). In both groups 3 cases of nonunion were noted. In the dynamic group there was 1 case of delayed union and 1 case of malunion. In the static group, 5 cases of delayed union and 5 cases of malunion were found. Four reoperations were required in the dynamic group, whereas 10 were needed in the static group (p >0.05). Initial degree of interfragmentary gaps had an impact on the mean time to union and the appearance of biological complications in both groups.

CONCLUSION

Dynamic nailing assembly in intramedullary nailing in closed or type I open tibial diaphyseal fractures with limited comminution (types A and B according to the AO classification) is safe when used for these fracture types. A dynamic mode of nailing should be encouraged in these fracture patterns.

Management of simple (types A and B) closed tibial shaft fractures using percutaneous lag-screw fixation and Ilizarov external fixation in adults

PURPOSE

Although intramedullary fixation of closed simple (type A or B) diaphyseal tibial fractures in adults is well tolerated by patients, providing lower morbidity rates and better mobility, it is associated with some complications. This study evaluated the results of managing these fractures using percutaneous minimal internal fixation using one or more lag screws, and Ilizarov external fixation.

METHODS

This method was tested to evaluate its efficacy in immediate weight bearing, fracture healing and prevention of any post-immobilisation stiffness of the ankle and knee joints. This randomised blinded study was performed at a referral, academically supervised, level III trauma centre. Three hundred and twenty-four of the initial 351 patients completed this study and were followed up for a minimum of 12 (12-88) months. Patient ages ranged from 20 to 51 years, with a mean of 39 years. Ankle and knee movements and full weight bearing were encouraged immediately postoperatively. Solid union was assessed clinically and radiographically. Active and passive ankle and knee ranges of motion were measured and compared with the normal side using the Wilcoxon signed rank test for matched pairs. Subjective Olerud and Molander Ankle Score was used to detect any ankle joint symptoms at the final follow-up.

RESULTS

No patient showed delayed or nonunion. All fractures healed within 95-129 days.

CONCLUSIONS

Based on final clinical and radiographic outcomes, this technique proves to be adequate for managing simple diaphyseal tibial fractures. On the other hand, it is relatively expensive, technically demanding, necessitates exposure to radiation and patients are expected to be frame friendly.