Flexible medullary nailing of tibial shaft fractures

Minimally Invasive Plate Osteosynthesis in Open Pediatric Tibial Fractures

OBJECTIVES

The aim of this study is to investigate the effectiveness and reliability of limited-contact locking plates in minimally invasive percutaneous osteosynthesis (MIPO) of the lateral tibia.

DESIGN

A retrospective study.

PATIENTS AND METHODS

The retrospective study included 14 patients who were operatively treated with an MIPO technique due to open tibial fractures between 2006 and 2012. The patients were 11 males and 3 females with a mean age of 13.2 (range, 9 to 16) years. The patients were followed up for a mean period of 2.4 (range, 1 to 5) years. The mechanism of the injuries included a motor vehicle accident (n=11), a shotgun injury (n=2), and a fall from height (n=1). According to the Gustilo-Anderson classification, 10 patients had type I (72%), 2 had type II (14%), and 2 had type III (14%) open fractures.

RESULTS

The mean time to radiologic union was 18 (range, 11 to 32) weeks. No infection was detected that would require implant removal. No complications such as early epiphyseal closure, angulation, or limb-length inequality were observed.

CONCLUSIONS

Limited-contact locking plates in MIPO of the lateral tibia is an effective alternative method in the treatment of open pediatric tibial fractures.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Open unstable metaphyseo-diaphyseal fractures of the tibia in adolescents: treatment by flexible intramedullary nails augmented by external fixator

INTRODUCTION

The treatment of open and unstable metaphyseo-diaphyseal fractures of the tibia in adolescents is challenging. It is important to choose a fixation method that can maintain alignment, allow wound care and not violate the growth plate. The aim of this work was to evaluate the efficacy of using flexible intramedullary nails (FIN) augmented by external fixator (EF) in the management of such fractures.

PATIENTS AND METHODS

A total of 26 males, with a mean age of 14.08 years and average body weight of 49.8 kg, presented with open metaphyseo-diaphyseal tibial fractures. All cases were treated using FIN augmented by mono-lateral EF. The fractures were located at the upper third in 17 cases and at the lower third in nine cases. The fracture pattern was spiral in eight cases, oblique in seven and multi-fragmentary in 11. The results were evaluated according to the scoring system for femoral TENs.

RESULTS

All fractures united primarily after an average eight to 12 weeks with no evident angular deformity or limb-length discrepancy. None of the cases required cast immobilization or revision procedure. Twenty patients had excellent results, six patients showed good results and none had poor results. Fracture characteristics as well as patients' characteristics had no statistically significant effect (p > 0.005) on the final end results.

CONCLUSIONS

The use of FIN augmented by EF is a good alternative in the management of open metaphyseo-diaphyseal tibial fractures in adolescents. This fixation provides more stability, allows easy access to the wound and early patients' ambulation.

Flexible intramedullary nails for unstable fractures of the tibia in children

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children.

We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails.

Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome.

We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children.

Intramedullary flexible nail fixation of unstable pediatric tibial diaphyseal fractures

Flexible intramedullary nail fixation provides excellent fixation in children with unstable tibial shaft fractures, but few published series demonstrate the results and complications with this technique in children. A retrospective review of 19 patients was performed, as well as a biomechanical analysis of two implant configurations. Outcome measures included union rates, residual deformity, and complications. Union occurred in all cases. Five patients (26%) had complications. None required repeat operation. Two (11%) angular deformities (>/=10 degrees) occurred with the medial C and S construct, versus none with the double C. The C and S construct was more stable to mechanical testing with axial and torsional loading. Flexible intramedullary nail fixation is a straightforward technique that reliably produces good results. While the C and S construct was superior in biomechanical testing, the double C construct is more reliable and straightforward and remains by far the authors' preferred technique.

Unstable closed tibial shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE

To define the roles of the rigid interlocking nail and the semirigid Ender nail in the treatment of closed unstable tibia] shaft fractures.

DESIGN

Randomized, clinical, prospectively study with detailed comparison of parameters.

MATERIALS AND METHODS

Data on 116 unstable closed tibial shaft fractures were collected. Randomly, 60 tibiae were fixed with interlocking nails and 56 tibiae were fixed with Ender nails. The follow-up period was 24 (16-32) months.

MEASUREMENTS AND MAIN RESULTS

In the interlocking nail group, the average blood loss was 189 cc, operation time was 51 minutes, length of hospital stay was 7 days, and union time was 14.2 weeks. In the Ender nail group, the average blood loss was 95 cc, operation time was 30 minutes, length of hospital stay was 5.0 days, and union time was 16.9 weeks. Student's t test was used for statistical significance.

CONCLUSIONS

For more comminuted unstable tibial shaft fractures, an interlocking nail is undoubtedly a better choice, but an Ender nail still is effective in some aspects of treatment in the less comminuted unstable tibial shaft fractures.

Biomechanical analysis of the mechanism of interlocking nail failure

From December 1986 to May 1989, 412 patients with 274 femoral and 144 tibial fractures were treated with Grosse-Kempf interlocking nails at our hospital. 324 cases (78.6%) were followed-up for at least 1 year (average 23 months). There were 13 breakages in the locking nails in femora and none in tibiae. The recorded incidence of breakage in the femur is therefore 4.7% (13/274). The mechanisms of locking nail failure are stress concentration around screw hole and nail slot, nicking of the nail during drilling of the screw holes, too close proximity of the screw hole to the fracture, and larger loading over the proximal femur. The incidence of failure is 4.9% in the upper third, 1.9% in the mid-third, and 8.2% in the distal third (P greater than 0.05, chi 2 test). The site most at risk is the first screw hole of the distal third, especially if it is near the fracture site. Prevention of failure involves using a nail of larger diameter and sufficient length, improving the surgical drilling technique, and allowing only protected weight bearing. Management of nail breakage by insertion of a new implant and supplementary cancellous bone grafting can gain satisfactory results.