Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study

Prevalence of Rotational Malalignment After Infrapatellar Versus Suprapatellar Intramedullary Nailing of Tibial Shaft Fractures

Background

Up to 30% of patients with a tibial shaft fracture sustain iatrogenic rotational malalignment (RM) after infrapatellar (IP) nailing. Although IP nailing remains the management of choice for most patients, suprapatellar (SP) nailing has been gaining popularity. It is currently unknown whether SP nailing can provide superior outcomes with regard to tibial RM. The aim of this study was to compare the differences in the prevalence of RM following IP versus SP nailing.

Methods

This retrospective study included 253 patients with a unilateral, closed tibial shaft fracture treated with either an IP or SP approach between January 2009 and April 2023 in a Level-I trauma center. All patients underwent a postoperative, protocolized, bilateral computed tomography (CT) scan for RM assessment.

Results

RM was observed in 30% and 33% of patients treated with IP and SP nailing, respectively. These results indicate no significant difference (p = 0.639) in the prevalence of RM between approaches. Furthermore, there were no significant differences in the distribution (p = 0.553) and direction of RM (p = 0.771) between the 2 approaches. With the IP and SP approaches, nailing of left-sided tibial shaft fractures resulted in predominantly internal RM (85% and 73%, respectively), while nailing of right-sided tibial shaft fractures resulted in predominantly external RM (90% and 80%, respectively). The intraobserver reliability for the CT measurements was 0.95.

Conclusions

The prevalence of RM was not influenced by the entry point of tibial nailing (i.e., IP versus SP). Hence, the choice of surgical approach should rely on factors other than the risk of RM.

Level of Evidence

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

The statistical fragility of intramedullary reaming in tibial nail fixation: a systematic review

PURPOSE

To report the statistical stability of prospective clinical trials evaluating the effect of intramedullary reaming on rates of non-union in tibial fractures through calculation of the fragility metrics for non-union rates and all other dichotomous outcomes.

METHODS

Literature search was conducted for prospective clinical trials evaluating the effect of intramedullary reaming on non-union rates in tibial nailing. All dichotomous outcomes were extracted from the manuscripts. The fragility index (FI) and reverse fragility index (RFI) were calculated by determining the number of event reversals required for a statistically significant outcome to lose significance and vice-versa. The fragility quotient (FQ) and reverse fragility quotient (RFQ) were calculated by dividing the FI or RFI by the sample size, respectively. Outcomes were defined as "fragile" if the FI or RFI was found to be less than or equal to the number of patients lost to follow-up.

RESULTS

Literature search identified 579 results which produced ten studies meeting the criteria for review. There were 111 outcomes identified for analysis, of which 89 (80%) exhibited statistical fragility. For reported outcomes across the studies the median and mean FI was 2, the median FQ was 0.019, the mean FQ was 0.030, the median RFI was 4, the mean RFI was 3.95, the median RFQ was 0.045, and the mean RFQ was 0.030. Four studies reported outcomes which were found to have an FI of 0.

CONCLUSIONS

The studies evaluating the effect of intramedullary reaming on tibial nail fixation demonstrate considerable fragility. On average, two event reversals for significant findings, and four event reversals for insignificant findings are sufficient to alter statistical significance.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and Level II studies.

Effects of intramedullary nailing and internal fixation plates on postoperative wound infection and pain in patients with distal tibia fractures: A meta-analysis

A meta-analysis was performed to assess the effects of intramedullary nailing (IMN) and internal fixation plates (IFP) on postoperative wound infection and pain in patients with distal tibia fractures, to provide evidence for the selection of surgical options for this group of patients. Computerised searches were performed on PubMed, Cochrane Library, EMBASE, MEDLINE, CNKI and Wanfang databases from the inception of each library to August 2023. All published randomised controlled trials (RCTs) comparing IMN with IFP for the treatment of patients with distal tibial fractures were selected. Literature screening, data extraction and literature evaluation were independently completed by two researchers. Data analysis was performed using the Review Manager 5.4 software. Overall, 25 RCTs with a total of 2011 patients were finally included, comprised by 1009 patients in the IMN group and 1002 patients in the IFP group. The rate of wound infection was significantly lower in the IMN group than that in the IFP group (5.05% vs. 9.58%, odds ratio [OR]: 0.52, 95% confidence intervals [CIs]: 0.37-0.73, p < 0.001). Meanwhile, the IMN group had a significantly higher rate of joint pain than that of the IFP group (14.57% vs. 2.90%, OR: 4.93, 95% CIs: 3.02-8.03, p < 0.00001), whereas the difference between the two surgical procedures in terms of operative time was not statistically significant (standardised mean differences: 0.08 95% CIs: -0.58-0.74, p = 0.82). Current clinical evidence suggests that both IMN and IFP are excellent treatments for distal tibial fractures. Although IMN is better in reducing postoperative wound infection, the risk of postoperative pain is higher. Thus, an appropriate surgical procedure should be selected in clinical practice in accordance with the actual situation of the patient, and IFP is used to reduce the incidence of postoperative joint pain when the anterior tibial soft tissue of the distal tibial fracture is in good condition, and vice versa. IMN is used to reduce the risk of infection.

Distal Tibial Metaphyseal Malunion Treated with Clamshell Osteotomy: A Case Report

CASE

Here, we describe a case of a 49-year-old female patient with a history of hypertension and polysubstance use disorder presenting with a distal tibial metaphyseal malunion treated with a clamshell osteotomy. Her follow-up was 2.5 years long.

CONCLUSION

Malunions in the tibial diaphysis and distal metaphysis can cause significantly increased joint reaction forces and altered gait mechanics leading to cosmetic dissatisfaction and decreased quality of life for these patients. Correction of these deformities can improve patient satisfaction and quality of life, along with decrease the risk of early arthritis. The clamshell osteotomy, although initially described to treat diaphyseal long bone malunions, can safely be performed for treatment of complex periarticular metaphyseal malunions.

Reaming the intramedullary canal during tibial nailing does not affect in vivo intramuscular pH of the anterior tibialis

Many investigations have evaluated local and systemic consequences of intramedullary (IM) reaming and suggest that reaming may cause, or exacerbate, injury to the soft tissues adjacent to fractures. To date, no study has examined the effect on local muscular physiology as measured by intramuscular pH (IpH). Here, we observe in vivo IpH during IM reaming for tibia fractures.

Methods

Adults with acute tibia shaft fractures (level 1, academic, 2019-2021) were offered enrollment in an observational cohort. During IM nailing, a sterile, validated IpH probe was placed into the anterior tibialis (<5 cm from fracture, continuous sampling, independent research team). IpH before, during, and after reaming was averaged and compared through repeated measures ANOVA. As the appropriate period to analyze IpH during reaming is unknown, the analysis was repeated over periods of 0.5, 1, 2, 5, 10, and 15 minutes prereaming and postreaming time intervals.

Results

Sixteen subjects with tibia shaft fractures were observed during nailing. Average time from injury to surgery was 35.0 hours (SD, 31.8). Starting and ending perioperative IpH was acidic, averaging 6.64 (SD, 0.21) and 6.74 (SD, 0.17), respectively. Average reaming time lasted 15 minutes. Average IpH during reaming was 6.73 (SD, 0.15). There was no difference in IpH between prereaming, intrareaming, and postreaming periods. IpH did not differ regardless of analysis over short or long time domains compared with the duration of reaming.

Conclusions

Reaming does not affect IpH. Both granular and broad time domains were tested, revealing no observable local impact.

Conversion of External Fixator to Intramedullary Nail in Tibial fractures

INTRODUCTION

Conversion of provisional external fixation to intramedullary nail (IMN) in femur fractures has been reported to be safe within 14 days of initial surgery. However, there is no current literature guiding this practice in tibial fractures. The purpose of this study was to identify the time period when conversion of external fixation to nail in tibial fractures is safe.

METHODS

After obtaining IRB approval, tibial fractures (OTA 41A, 42, 43A) that received provisional ex-fix and were converted to IMN from 2009 to 2019 were retrospectively reviewed. Skeletally mature patients with minimum 6 months of follow-up were included. The primary outcome was deep infection. External fixation days were categorized as less than 7, 8 to 14, and 15+ days. Risk ratios of infection were estimated using generalized linear regression with a Poisson distribution. A separate regression model evaluated risk factors for infection using both the external fixation and non-external fixation tibial cohorts.

RESULTS

Twenty-eight patients (32%) were treated for deep infection. The infection rate for closed fractures was 28% (11 of 39 patients) and for open fractures was 35% (17 of 49 patients) ( P = 0.56). Examining both tibial cohorts, external fixation (odds ratio [OR] = 2.39, P = 0.017), open fracture (OR = 3.13, P = 0.002), and compartment syndrome (OR = 2.58, P = 0.01) were all associated with infection in regression modeling. Median external fixation days for patients with deep infection was 8 days (Inter-quartile range, 3 to 18 days) as compared with 4 days (IQR, 2 to 9 days) in patients without infection ( P = 0.06). While controlling for open fractures, the 8- to 14-day group had RR = 1.81 ( P = 0.2), and the 15+-day group had RR = 2.67 ( P = 0.003) as compared with the <7-day group.

DISCUSSION

Infection rates of tibial fracture patients treated with external fixation and converted to IMN were high. Surgeons should strongly consider the necessity of external fixation for these fractures. Earlier conversion of external fixation to definitive fixation reduced infection rates.

LEVEL OF EVIDENCE

Level IV-case series.

Are small-diameter intramedullary nails enough for treating simple diaphyseal tibial fractures? A comparative study between small versus large nails

PURPOSE

The aim of our study was to compare the results of using small-diameter versus large-diameter interlocking reamed intramedullary nails in treatment of simple tibial shaft fractures.

METHODS

This prospective randomized control trial involved 60 patients, divided into two groups, Group A (Small IMN) (10 mm in males and 9 mm in females) and Group B (Large IMN) (12 mm in males and 11 mm in females). All patients were followed up for at least 1 year.

RESULTS

The mean operative time in Group A was 79 min versus 94.6 min in Group B. The mean time of radiological exposure in Group A was 2.27 min compared to 3.73 min in Group B. The mean union time in Group A was 15.2 weeks, while in Group B, the mean union time was 12.8 weeks. Implant failure (screw breakage or nail breakage) or nonunion did not occur in any case in the two groups.

CONCLUSION

Small IMN showed comparable clinical and radiological results to large IMN with lesser operative and radioscopic time. We can recommend that small IMN should be used more often in treating simple stable tibial fractures.

Intraoperative Fluoroscopy for Correcting Rotational Malalignment After Fixation of Tibial Shaft Fracture: A Case Report

CASE

A 29-year-old man previously treated with closed reduction and intramedullary nail (IMN) fixation for a right tibial shaft fracture presented with complaint of the foot pointing outward compared with uninjured side. He was diagnosed with tibial malrotation, and a novel intraoperative imaging technique was used for correction.

CONCLUSION

Literature suggests that the prevalence of tibial malrotation after IMN fixation is greater than previously thought. This case highlights the need for a simple and reliable intraoperative approach to guide and confirm correction of tibial malrotation after IMN fixation, and it demonstrates a technique that can be implemented with immediate results.

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.

Suprapatellar versus infrapatellar nailing for tibial shaft fractures: A comparison of surgical and clinical outcomes between two approaches

BACKGROUND

Tibial shaft fractures are a relatively common injury and contemporary treatment includes on-axis fixation with a locked intramedullary nail in the majority of cases. The conventional technique is via an infrapatellar approach but currently there is a trend towards the use of a suprapatellar approach. We compared key variables including operative time, radiation exposure and early patient reported outcomes when adopting a suprapatellar approach to tibial nailing in our unit versus our previous experience of infrapatellar tibial nailing.

METHOD

Twenty-eight consecutive patients with tibial fracture underwent tibial nailing via the suprapatellar (SPN) approach. Six patients in the study group were excluded due polytrauma and need for dual orthopaedic and plastic surgery management. We compared outcomes with our most recent 20 consecutive patients who had undergone tibial nailing via an infrapatellar (IPN) approach. Primary surgical outcomes were: operative time, radiation exposure and accuracy of entry point of the nail on both anteroposterior and lateral radiographs. Clinical outcomes included time to weightbearing, time to radiographic union and patient-reported outcome score (Lysholm score).

RESULTS

Forty-eight consecutive patients underwent intramedullary nail fixation for tibial shaft fractures and 42 were eligible for inclusion in our study (22 SPN vs 20 IPN). There were no significant differences in patient demographics or injury patterns between the two groups. Operative time and radiation exposure were significantly lower in the SPN group when compared to the IPN group (115 min vs 139 min ± 12.5) (36 cGY/cm² vs 76.33 cGY/cm² +/- 20.1). Furthermore, patients in the SPN group reported superior outcome scores at a mean follow up of 3 months (8-24 weeks) There were no observed differences in complication rate between groups and time of final clinical follow up at a minimum of 6 months.

CONCLUSION

Our study shows that adoption of the SPN approach requires minimal learning curve, and has the potential benefits of reduced operative time, radiation exposure and superior patient reported outcomes when compared to the conventional infrapatellar approach.

Prognostic factors for predicting health-related quality of life after intramedullary nailing of tibial fractures: a randomized controlled trial

Aims

Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Methods

The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL.

Results

For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing.

Conclusion

We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL.

Cite this article: Bone Jt Open 2021;2(1):22–32.

Suprapatellar tibial nailing: a learning curve analysis

PURPOSE

The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure.

METHODS

Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning.

RESULTS

Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period.

CONCLUSIONS

Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.

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.

Extra-articular distal tibial fractures, is interlocking nailing an option? A prospective study of 147 cases

PURPOSE

Distal tibia fractures comprise about 7%-10% of lower extremity trauma. Because of the peculiarity of the soft tissue and subcutaneous location of the bone there are many controversies in the ideal treatment of distal tibia fractures especially extra articular pilon fractures. Plating is fraught with complications of wound dehiscence and infection. There are limited studies which document outcomes in such cases using intramedullary interlocking nail. We intend to study the outcome and complications of extra articular distal tibial fractures treated with interlocking nailing.

METHODS

This is a prospective study conducted in a tertiary care orthopaedic hospital in southern India. There are 147 patients of distal tibia extra-articular fractures managed by IM nailing with follow up of more than one year were included in this study. Only cases with fresh injury (less than 1 week), fracture below the isthmus, closed and open Gustilo Anderson type 1 and 2 fractures were included in the study. Patients were reviewed at 3, 6, 12 and 24 weeks after surgery and thereafter at one year and were assessed for clinical and radiological signs of healing, any complications, time to union and functional outcome.

RESULTS

There were 102 males and 45 females (male/female ratio is 2.3:1) with a mean age of 38.96 (range 23-65) years. According to AO classification, there were 78 cases (53.06%) of 43-A1, 39 cases (26.53%) of 43-A2 and 30 cases of 43-A3 constituting 20.40%. The fracture united in all the patients at an average of 18 weeks (range 16-22 weeks), none of the patient in our series had a delayed or non-union. Two patients (1.47%) had the fracture united in mild valgus but it was well within the acceptable limits (<5°). The functional outcome was assessed in all the patients at final follow up using Olerud and Molander score all the patients fared an excellent to good score, there were no cases with poor score.

CONCLUSION

Intramedullary nailing is a viable option to treat distal tibial fractures with excellent outcome. Wound complications related to plating can be avoided but meticulous surgical technique is key to avoid malunion.

Avoiding Neurovascular Risk During Percutaneous Clamp Reduction of Spiral Tibial Shaft Fractures: An Anatomic Correlation With Computed Tomography

The use of percutaneous clamps is often a helpful tool to aid reduction and intramedullary nailing of distal tibial spiral diaphyseal fractures. However, the anterior and posterior neurovascular bundles are at risk without careful clamp placement. We describe our preferred technique of percutaneous clamp reduction for distal spiral tibial fractures with a distal posterolateral fracture spike, with care to protect the adjacent neurovascular structures. We also investigated the relationship between these neurovascular structures and the site of common percutaneous clamp placement. Preoperative computed tomography images of surgically managed patients who sustained this specific common fracture pattern (distal third spiral diaphyseal tibia fracture with a posterolateral fragment) were retrospectively reviewed. On computed tomography, we extrapolated the ideal virtual clamp site on the posterolateral fracture fragment to facilitate reduction. The average distance of this clamp position from the anterior neurovascular bundle was 14 mm (SD = 7.6), with a range of 6-32 mm. The average distance of the clamp site from the posterior neurovascular bundle was 19 mm (SD = 6.1), with a range of 11-30 mm. In 31% of patients, the distal fragment's apex extended anterior to the interosseous membrane, and in 69% of patients, the apex was posterior to the interosseous membrane. We also describe our preferred surgical technique with percutaneous clamping and tibial nailing, which involves sliding the posterolateral tine of the percutaneous clamp along the lateral tibial cortex to prevent neurovascular bundle injury.

Deficits in preference-based health-related quality of life after complications associated with tibial fracture

Aims

The aims of this study were to quantify health state utility values (HSUVs) after a tibial fracture, investigate the effect of complications, to determine the trajectory in HSUVs that result in these differences and to quantify the quality-adjusted life years (QALYs) experienced by patients.

Patients and Methods

This is an analysis of 2138 tibial fractures enrolled in the Fluid Lavage of Open Wounds (FLOW) and Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trials. Patients returned for follow-up at two and six weeks and three, six, nine and 12 months. Short-Form Six-Dimension (SF-6D) values were calculated and used to calculate QALYs.

Results

Compared with those who did not have a complication, those with a complication treated either nonoperatively or operatively had lower HSUVs at all times after two weeks. The HSUVs improved in all patients with the passage of time. However, they did not return to the remembered baseline preinjury values nor to US age-adjusted normal values by 12 months after the injury.

Conclusion

While the acute fracture and complications may have resolved clinically, the detrimental effect on a patient’s quality of life persists up to 12 months after the injury. Cite this article: Bone Joint J 2018;100-B:1227–33.

Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis

Osteosynthesis has evolved theoretically and practically throughout its evolution. Similar to trends in other surgical fields, surgical techniques in fracture fixation, such as minimally invasive plate osteosynthesis (MIPO), have moved from large dissections to more tissue sparing methods. These plating techniques have been developed for a variety of bones, but more universal clinical adoption will rely upon improved clinical outcomes. The current review will describe minimally invasive techniques, evaluate their rationale, and summarize evidence for their efficacy.

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.

Does Provisional Plating of Closed Tibia Fractures Have Higher Complication Rates?

OBJECTIVES

To compare infection and nonunion rates after provisional plating (PP) with standard reduction (SR) techniques for closed tibia fractures treated with an intramedullary nail.

DESIGN

Retrospective comparative study.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Of the 348 closed tibia fractures (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 42) treated using an intramedullary nail from January 2007 through June 2015, 231 (40 PP and 191 SR) patients met inclusion/exclusion criteria.

INTERVENTION

The patients received either a provisional plate or an SR before intramedullary nail placement.

MAIN OUTCOME MEASUREMENT

Infection and nonunion.

RESULTS

The PP cohort had a significantly higher proportion of high-energy injury mechanism and a significantly higher proportion of diabetes than the SR cohort. We were unable to demonstrate a difference in rates of infection [PP cohort (1/40, 2.5%) vs. SR cohort (6/191, 3.1%), P = 1.0], nonunion [PP cohort (3/40, 7.5%) vs. SR cohort (9/191, 4.7%), P = 0.44], or malunion [PP cohort (0/40, 0%) vs. SR cohort (8/191, 4.2%), P = 0.36]. Symptomatic implant removal was similar between the 2 groups [PP cohort (4/40, 10%) vs. SR cohort (27/191, 14%), P = 0.61].

CONCLUSION

PP can be used for complex, closed tibia fractures without an increased risk of infection, nonunion, and malunion compared with standard closed reduction techniques.

LEVEL OF EVIDENCE

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

Trajectory of Short- and Long-Term Recovery of Tibial Shaft Fractures After Intramedullary Nail Fixation

OBJECTIVE

To determine the trajectory of recovery after tibial shaft fracture treated with intramedullary nail over the first 5 years and to evaluate the magnitude of the changes in functional outcome at various time intervals.

DESIGN

Prospective cohort study.

SETTING

A Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred thirty-two patients with tibial shaft fracture (OTA 42-A, B, C) were enrolled into the Center's prospective orthopaedic trauma database between January 2005 and February 2010. Functional outcome data were collected at baseline, 6 months, 1 year, and 5 years.

INTERVENTION

Enrolled patients were treated acutely with intramedullary nailing of their tibia.

MAIN OUTCOME MEASUREMENTS

Evaluation was performed using the Short Form-36 and Short Musculoskeletal Function Assessment (SMFA).

RESULTS

Mean SF-36 physical component scores improved between 6 and 12 months (P = 0.0008) and between 1 and 5 years (P = 0.0029). Similarly, mean SMFA dysfunction index scores improved between 6 and 12 months (P = 0.0254) and between 1 and 5 years (P = 0.0106). In both scores, the rate or slope of this improvement is flatter between 1 and 5 years than it is between 6 and 12 months. Furthermore, SF-36 and SMFA scores did not reach baseline at 5 years (SF-36 P < 0.0001, SMFA P = 0.0026). A significant proportion of patients were still achieving a minimal clinically important difference in function between 1 and 5 years (SF-36 = 54%, SMFA = 44%).

CONCLUSIONS

The trajectory of functional recovery after tibial shaft fracture is characterized by an initial decline in function, followed by improvement between 6 and 12 months. There is still further improvement beyond 1 year, but this is of flatter trajectory. The 5-year results indicate that function does not improve to baseline by 5 years after injury.

LEVEL OF EVIDENCE

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

Biocompatibility, bone healing, and safety evaluation in rabbits with an IlluminOss bone stabilization system

Bone healing, biocompatibility, and safety employing the IlluminOss System (IS), comprised of an inflatable balloon filled with photopolymerizable liquid monomer, was evaluated in New Zealand white rabbits. Successful bone healing and callus remodeling over 6 months was demonstrated radiologically and histologically with IS implants in fenestrated femoral cortices. Biocompatibility was demonstrated with IS implants in brushed, flushed femoral intramedullary spaces, eliciting no adverse, local, or systemic responses and with similar biocompatibility to K-wires in contralateral femurs up to 1 year post-implant. Lastly simulated clinical failures demonstrated the safety of IS implants up to 1 year in the presence of liquid or polymerized polymer within the intramedullary space. Polymerized material displayed cortical bone and vasculature effects comparable to mechanical disruption of the endosteum. In the clinically unlikely scenario with no remediation or polymerization, a high dose monomer injection resulted in marked necrosis of cortical bone, as well as associated vasculature, endosteum, and bone marrow. Overall, when polymerized and hardened within bone intramedullary spaces, this light curable monomer system may provide a safe and effective method for fracture stabilization. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2181-2190, 2017.

Salvage of an osteocutaneous thermonecrosis secondary to tibial reaming by the induced membrane procedure

Osteocutaneous thermonecrosis is a rare but devastating complication of tibial reaming, which can cause large and infected bone and cutaneous defects. The case presented here illustrates that the induced membrane technique described by Masquelet is a valuable option in treating this complication.

Percutaneous or Open Reduction of Closed Tibial Shaft Fractures During Intramedullary Nailing Does Not Increase Wound Complications, Infection or Nonunion Rates

OBJECTIVE

To compare the incidence of complications (wound, infection, and nonunion) among those patients treated with closed, percutaneous, and open intramedullary nailing for closed tibial shaft fractures.

DESIGN

Retrospective review.

SETTING

Multiple trauma centers.

PATIENTS

Skeletally mature patients with closed tibia fractures amenable to treatment with an intramedullary device.

INTERVENTION

Intramedullary fixation with closed, percutaneous, or open reduction.

MAIN OUTCOME MEASUREMENTS

Superficial wound complication, deep infection, nonunion.

RESULTS

A total of 317 tibial shaft fractures in 315 patients were included in the study. Two-hundred fractures in 198 patients were treated with closed reduction, 61 fractures in 61 patients were treated with percutaneous reduction, and 56 fractures in 56 patients were treated with formal open reduction. The superficial wound complication rate was 1% (2/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 3.6% (2/56) for the open group with no statistical difference between the groups (P = 0.179). The deep infection rate was 2% (4/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 7.1% (4/56) for the open group with no significant difference between the groups (P = 0.133). Nonunion rate was 5.0% (10/200) for the closed group, 4.9% (3/61) for the percutaneous group, and 7.1% (4/56) for the open group, with no statistical difference between the groups (P = 0.492).

CONCLUSIONS

This is the largest reported series of closed tibial shaft fractures nailed with percutaneous and open reduction. Percutaneous or open reduction did not result in increased wound complications, infection, or nonunion rates. Carefully performed percutaneous or open approaches can be safely used in obtaining reduction of difficult tibial shaft fractures treated with intramedullary devices.

LEVEL OF EVIDENCE

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

Does weight-bearing assignment after intramedullary nail placement alter healing of tibial shaft fractures?

INTRODUCTION

There is no consensus regarding postoperative weight-bearing (WB) assignment after treatment of tibial shaft fractures with an intramedullary nail. This study aims to determine if the postoperative WB assignment after tibia intramedullary nail placement alters healing.

METHODS

Closed AO type 42A fractures treated with a reamed statically-locked intramedullary nail over a 10-year period were retrospectively reviewed from injury at 2, 3, 6, 9 and 12 month intervals until union or revision. Patients were categorized according to postoperative weight-bearing assignment: weight-bearing-as-tolerated (WBAT) or non-weight-bearing (NWB). Patients with additional diagnoses that confound routine fracture healing were excluded. Postoperative radiographic union scores for tibial fractures (RUST), coronal/sagittal angulations, and length were compared between different weight-bearing groups. Union was defined as a RUST≥10 at a painless fracture site.

RESULTS

A total of 83 patients achieved union (32 WBAT, 51 NWB). Both WB groups had similar preoperative demographics. Average age was 37±13 years and follow-up averaged 1.3±0.2 years. There were no significant differences in average time to radiographic union between NWB versus WBAT groups (5.5 vs. 6.1 months, respectively; P=0.208) nor radiographic healing at 2, 3, and 6-month intervals (P=0.631). There were two nonunions and one fracture shortened in the NWB group. There were no reoperations for symptomatic or broken hardware in either cohort.

CONCLUSION

Immediate WBAT after statically-locked intramedullary nail placement in simple tibial shaft fractures does not alter the time until or course of radiographic union.

LEVEL OF EVIDENCE

IV.

Does Participation in a Randomized Clinical Trial Change Outcomes? An Evaluation of Patients Not Enrolled in the SPRINT Trial

OBJECTIVES

To determine the extent to which knowledge from clinical trial protocols is transferred to nonparticipating patients.

DESIGN

Retrospective review of prospectively collected data from a large clinical trial.

SETTING

Six level-1 international trauma centers.

METHODS

We compared rates and timing of reoperation in a subset of patients enrolled in the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) to concurrent patients who were eligible but not enrolled. This was a retrospective review of prospectively collected trial data. The records of 6 of the original SPRINT centers were searched for non-SPRINT patients who underwent intramedullary nailing of a closed tibial fracture. The rate and timing of reoperation were compared. A P < 0.05 was considered significant.

RESULTS

One hundred fourteen non-SPRINT patients were compared with 328 patients enrolled in SPRINT from those same sites. There were 7 reoperations (6.1%) in non-SPRINT patients versus 18 (5.2%) in SPRINT patients [odds ratio (OR) 1.19, 95% confidence interval (CI) 0.41 to 3.13; P = 0.811]. There was no difference in the time to reoperation between the SPRINT and non-SPRINT patients (6.2 vs. 6.8 months, 95% CI of the difference -3.8 to 2.6; P = 0.685) or in the proportion of patients who underwent reoperation before 6 months (29% vs. 43%; OR 1.75; 95% CI 0.18 to 15.41; P = 0.647).

CONCLUSIONS

Patients not enrolled in SPRINT had similarly low rates of reoperation for nonunion, and the average time to reoperation for both groups was longer than 6 months. A 6-month waiting period may have allowed slow-to-heal fractures adequate time to heal, thereby reducing the rate of diagnosis of nonunion. As such, this waiting period could contribute to lower-than-expected reoperation rates for nonunion. It is possible that clinical trials may beneficially influence the care of nonenrolled patients.

Safe surgical technique: intramedullary nail fixation of tibial shaft fractures

Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.

Histopathological examination of bone debris from reaming of interlocking intra-medullary nail fixation of long bone fractures with concomitant head injury

BACKGROUD/AIM

The aim of study was to test, for the presence of osteoblasts in the reaming debris of intramedullary nailing of femoral and tibial fracture in patients with and without severe head injury.

METHODS

Two groups of patients were studied. Group A (n = 32) had long bone fractures in addition to having head injuries. Group B (n = 35) had only long bone fractures. The fractures in the 2 groups of patients was treated by inter medullary nailing. Osteoblasts in the debris of the inter medullary nailing was compared between the 2 groups of patients.

RESULTS

The results demonstrated that histopathological specimens from reaming debris of fractured femur and tibia in patients with head injury showed osteoblasts in (82.9%) and in (27.5%) of patients with isolated long bone fractures (p < 0.001).

CONCLUSION

Healing indicators in diaphyseal fractures and concomitant head injury confirm fast and adequate healing in these patients and the presence of plenty of osteoblasts in their reaming debris may reflect a proof of accelerated fracture healing environment.

The healing stages of an intramedullary implanted tibia: A stress strain comparative analysis of the calcification process

AIMS

The extended usage of unreamed tibial nailing resulted in reports of an increased rate of complications, especially for the distal portion of the tibia. Unreamed nailing favours biology at the expense of the achievable mechanical stability, it is therefore of interest to define the limits of the clinical indications for this method. Extra-articular fractures of the distal tibial metaphysis, meta-diaphyseal junction, and adjacent diaphysis are distinct in their management from impaction derived ''pilon'' type fractures and mid-diaphyseal fractures. The goals of this work were to gain a thorough understanding of the load-sharing mechanism between unreamed nail and bones in a fractured tibia. With this purpose a complete model of the human leg was realised, simulating a mid-diaphyseal fracture, classified as A2 type 1, according to the AO classification. The analysis of the entire chain allows to have a complete picture of the stress distribution and of the most stressed bones and soft tissues, but, more importantly can overcome problems connected with boundary conditions imposed at single bony components.

METHODS

Model consists of six bony structures: pelvis, femur, patella, fibula, tibia, and a simplified lump of the feet, configured in a standing up position. Their articular cartilage layers, were simulated by 3D membranes of opportune stiffness connecting the different segments. Moreover an unreamed intra-medullary nail Expert Tibial Nail (DePuy Synthes(®)) stabilized the fractured tibia. A load of 700 N has been applied at the top of pelvis and a part the feet, at the tip, was rigidly fixed. Five different contact interfaces have been imposed at the different bony surfaces in contact.

RESULTS

Three different conditions were analysed: the initially healthy tibia, the A2 type 1 fractured tibia with the Expert tibial nail implanted, and the follow up stage after complete healing of tibia. Non-linear finite element analysis of the models were performed with Abaqus version 5.4 (Hibbitt, Karlsson and Sorensen, Inc., Pawtucket, RI) using the geometric non linearity and automatic time stepping options.

CONCLUSION

The obtained results reveal interesting consequences deriving by taking into account how the stress shielding can influence the integrity and resistance of bones, in order to identify the mechanical reasons for the unfavourable clinical results, and to identify borderline indications due to biomechanical factors. The evolution of treatment options for these fractures has been closely linked to developments in implant technology and surgical technique. Further developments in this area, particularly with respect to minimally invasive plating techniques and nail design are ongoing.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures

OBJECTIVES

To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails.

DESIGN

Retrospective analysis.

SETTING

Level I trauma center with follow-up in a private orthopaedic practice.

MAIN OUTCOME MEASUREMENTS

Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation.

PATIENTS

A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing.

RESULTS

Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal.

CONCLUSIONS

Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases.

LEVEL OF EVIDENCE

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

Percutaneous clamping of spiral and oblique fractures of the tibial shaft: a safe and effective reduction aid during intramedullary nailing

The reduction of tibial shaft fractures during intramedullary nailing is important if limb alignment is to be restored and successful clinical outcomes are expected. We have used a percutaneously applied (or open) clamp or clamps to achieve and maintain reduction during nailing of all amendable tibial shaft fractures. In this article, we describe the technique and preliminary results comparing closed, simple spiral and oblique tibial shaft fractures (OTA 42-A1 and A2) managed with percutaneous clamp-assisted nailing (CAN) versus nailing using manual reduction (MRN) held by the surgical team. In the MRN group, there were an increased fracture gap (P = 0.04) and trends toward malalignment (P = 0.07) and healing time (P = 0.06) compared with the CAN group. There were also trends in clinical; no wound complications occurred in either group. We have found that percutaneous CAN of closed, simple spiral and oblique tibial shaft fractures seems safe and allows for early predictable union with reproducible alignment compared with nailing using MRN.

Risk factors for acute compartment syndrome of the leg associated with tibial diaphyseal fractures in adults

Background

We sought to examine the occurrence of acute compartment syndrome (ACS) in the cohort of patients with tibial diaphyseal fractures and to detect associated risk factors that could predict this occurrence.

Materials and methods

A total of 1,125 patients with tibial diaphyseal fractures that were treated in our centre were included into this retrospective cohort study. All patients were treated with surgical fixation. Among them some were complicated by ACS of the leg. Age, gender, year and mechanism of injury, injury severity score (ISS), fracture characteristics and classifications and the type of fixation, as well as ACS characteristics in affected patients were studied.

Results

Of the cohort of patients 772 (69 %) were male (mean age 39.60 ± 15.97 years) and the rest were women (mean age 45.08 ± 19.04 years). ACS of the leg occurred in 87 (7.73 %) of all tibial diaphyseal fractures. The mean age of those patients that developed ACS (33.08 ± 12.8) was significantly lower than those who did not develop it (42.01 ± 17.3, P < 0.001). No significant difference in incidence of ACS was found in open versus closed fractures, between anatomic sites and following IM nailing (P = 0.67). Increasing pain was the most common symptom in 71 % of cases with ACS.

Conclusions

We found that younger patients are definitely at a significantly higher risk of ACS following acute tibial diaphyseal fractures. Male gender, open fracture and IM nailing were not risk factors for ACS of the leg associated with tibial diaphyseal fractures in adults.

Level of evidence

Level IV.

Intramedullary nailing of tibial shaft fractures distal to total knee arthroplasty

Tibial shaft fractures distal to total knee arthroplasty are rare, but they are likely to become more common with the increasing number of arthroplasty procedures being performed. These fracture patterns have been treated in the past either with closed reduction and casting/bracing or with open reduction internal fixation using plates. Weight-bearing precautions in the elderly patient population can affect patient disposition, and weight bearing on extramedullary fixation can lead to early hardware failure. We present a series of nailing techniques that can be used for tibial fractures distal to a well-fixed total knee arthroplasty that avoids the tibial baseplate, provides stable fracture fixation, and allows for early weight bearing.

Semi-extended nailing of metaphyseal tibia fractures: alignment and incidence of postoperative knee pain

OBJECTIVES

To review a large series of tibial metaphyseal fractures treated with nailing in semi-extension (20-30 degrees) using a superomedial portal. To report on the quality and maintenance of reduction. To compare knee pain at final follow-up with a group nailed in hyperflexion (>90 degrees) with a standard inferior incision and parapatellar approach.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENTS

One hundred eighty-five consecutive tibia fractures were treated with intramedullary nails. Eighty-four patients with fractures affecting the proximal (50) or distal (34) metaphysis were nailed with the knee in semi-extension. One hundred one with diaphyseal fractures were nailed in standard hyperflexion and were used as a comparison group.

OUTCOME MEASURES

Knee pain was recorded at the final follow-up and graded on a 0-3 scale as per Court-Brown. Alignment was measured on full-length biplanar radiographs immediately postoperative and compared with the same radiographs at union.

RESULTS

There was no statistical difference in the number of patients without knee pain at union (P = 0.7). Radiographic angulation at the fracture was <5 degrees in all patients immediately postoperative, and no patient lost reduction. The average follow-up was 2.3 years.

CONCLUSIONS

Knee pain after semi-extended tibial nailing was similar in frequency compared with standard nailing. There were no significant angulatory deformities, and no losses of reduction for both proximal and distal metaphyseal fractures nailed with the semi-extended technique.

LEVEL OF EVIDENCE

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

A meta-analysis of reamed versus unreamed intramedullary nailing for the treatment of closed tibial fractures

Controversy exists regarding the clinical outcomes of reamed vs unreamed intramedullary nailing in the treatment of closed tibial fractures. This study assessed the effects of reamed vs unreamed intramedullary nailing for closed tibial fractures. The authors searched PubMed, EMBASE, BIOSIS, and the Cochrane Controlled Trials Register for randomized and quasi-randomized controlled clinical trials from January 1980 to June 2012 comparing reamed with unreamed intramedullary nailing for closed tibial fracture in adults. Primary outcomes were nonunion, delayed union, malunion, secondary procedure, failure of implants, compartment syndrome, infection, and knee pain. Eight randomized and 1 quasi-randomized clinical trials (1229 fractures) were included. No statistically significant differences were found between reamed and unreamed nailing groups in delayed union (P=.20), malunion (P=.28), infection (P=.36), compartment syndrome (P=.36), and knee pain (P=.93). The unreamed group had a higher rate of fracture nonunion than the reamed group (P=.02). The subgroup analysis of implant failures (broken screws vs broken nails) indicated that reamed nailing significantly reduced the risk of screw breakage (P<.001); however, there was no significant difference between reamed and unreamed intramedullary nailing in nail breakage (P=.94). The subgroup analysis of a secondary procedure showed that the reamed intramedullary nailing resulted in significantly lower risks of implant exchange (P=.01) and dynamization (P=.04); however, there was no significant difference in bone grafting rate (P=.73). Evidence comparing reamed with unreamed intramedullary nailing for closed tibial fractures indicates that reamed intramedullary nailing may lead to significantly lower risks of nonunion, screw failure, implant exchange, and dynamization without increasing operative complications.

Minimizing the complications of intramedullary nailing for distal third tibial shaft and metaphyseal fractures

BACKGROUND

The complications of intramedullary nailing of distal third tibial shaft and metaphyseal fractures have a direct impact on ankle and hind foot function.

METHODS

We retrospectively evaluated 28 patients. Unreamed nail was negotiated across the well reduced fracture till subchondral bone and fixed with 2 to 3 distal locking screws in different planes.

RESULTS

Fracture union rate was 85%. Three out of 28 patients had malalignment. Mean ankle, hindfoot functional score was 85.

CONCLUSION

Complications can be minimized by impacting the unreamed nail till the subchondral bone while maintaining the fracture well reduced and by using multiple distal locking screws in different planes.

Reamed versus unreamed intramedullary locked nailing in tibial fractures

The purpose of this prospective observational study is to identify whether or not reaming of tibial shaft fractures has benefits over unreamed intramedullary locked nailing. Eighty-four adult patients with recent open and closed tibial shaft fractures were treated with reamed or unreamed intramedullary locked nail fixation. We followed up for 12 months 39 of 43 patients in the unreamed and 38 of 41 patients in the reamed group, respectively. There were no significant differences between the two groups regarding the average time to healing for both clinical (3.2 vs 3.4 months, p = 0.65) and radiological (4.1 vs 4.5 months, p = 0.43) evaluations. The mean duration of surgery was shorter (p = 0.025) for the unreamed group 43 min (SD 18) compared to 55 (SD 27), but the main determinants were the fracture type and the surgeon's experience. We conclude that reamed nailing proved beneficial, but the impact on overall outcome is not superior to unreamed nailing.

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.

Can tibial nonunion be predicted at 3 months after intramedullary nailing?

OBJECTIVE

The purpose of this study was to determine if surgeons could reliably predict if patients with tibia fractures treated with intramedullary nails will proceed to nonunion based on their clinical scenario and radiographs at 3 months.

DESIGN

Blinded randomized questionnaire based on a retrospective cohort.

SETTING

University level 1 trauma center.

PATIENTS/PARTICIPANTS

Fifty-six patients who underwent intramedullary fixation for tibia fractures with incomplete healing at 3 months.

METHODS

A questionnaire was applied to 56 consecutive patients treated between 2005 and 2009 with intramedullary fixation for tibia fractures who had incomplete healing at 3 months. Each case was developed into a vignette that included the 3-month radiographs and detailed clinical histories. The questionnaire was distributed to 3 fellowship-trained trauma surgeons who were asked to predict if the fracture would go onto nonunion.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy of predicting nonunion in patients with incomplete healing of their tibia fracture at 3 months.

RESULTS

The combined overall diagnostic accuracy of all 3 surgeons was 74%. Sensitivity and specificity was 62% and 77%, respectively. Radiographic features and injury mechanism were the most commonly cited clinical information used to predict fracture healing. The average positive predictive value was 73%. In 9 patients with diabetes, the diagnostic accuracy was 88%.

CONCLUSIONS

Clinical judgment at 3 months allows for correct prediction of eventual nonunion development in a majority of patients. We suggest that analysis of the entire clinical picture be used to predict fracture healing at 3 months. A protocol of waiting for 6 months before reoperation in all patients treated with intramedullary nailing for tibia fractures may subject patients to prolonged disability and discomfort.

LEVEL OF EVIDENCE

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

System evaluation on reamed and non-reamed intramedullary nailing in the treatment of closed tibial fracture

PURPOSE

To systematically evaluate the clinical efficacy of reamed and nonreamed intramedullary nailing in treatment of closed tibial fractures with Cochrane systematic review methods.

METHODS

According to the Cochrane systematic review methods, literatures were retrieved from Cochrane library, PubMed, EMbase and other database. Randomized controlled trials (RCTs) and quasi-randomized controlled clinical trials about reamed and nonreamed intramedullary nailing in the treatment of closed tibial fractures were collected and RevMan 5.0 was chosen for meta-analysis.

RESULTS

A total of seven studies were included in this meta-analysis. Reamed intramedullary nailing was better than nonreamed intramedullary nailing in nonunion rate [P = 0.02, RR = 0.46, 95% CI: (0.24, 0.91)] and implant failure rate [P <0.0001, RR = 0.36, 95% CI: (0.22, 0.57)]. No statistically significant difference was observed in malunion rate, compartment syndrome rate, postoperative infection [P = 0.18, RR = 0.50, 95% CI: (0.18, 1.383); P = 0 43, RR = 0.77, 95% CI: (0.40, 1.48); P = 0.27, RR = 0.38, 95% CI: (0.01, 7.87)].

CONCLUSION

Compared with the nonreamed intramedullary nailing, reamed intramedullary nailing can lead to better outcome in the treatment of closed tibial fractures.

Unreamed intramedullary nailing in distal tibial fractures

PURPOSE

Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial.

METHODS

In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised.

RESULTS

Union occurred after a mean time of 23.9 (range, 11-134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases).

CONCLUSIONS

Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.

Management of infection after intramedullary nailing of long bone fractures: treatment protocols and outcomes

Implant related sepsis is a relatively unusual complication of intra-medullary nail fixation of long bone fractures. Depending on the extent of infection, timing of diagnosis and progress of fracture union, different treatment strategies have been developed. The aim of this review article is to collect and analyze the existing evidence about the incidence and management of infection following IM nailing of long bone fractures and to recommend treatment algorithms that could be valuable in everyday clinical practice. After searching the P u b M e d /Medline databases, 1270 articles were found related to the topic during the last 20 years. The final review included 28 articles that fulfilled the inclusion criteria.

Only a few prospective studies exist to report on the management of infection following IM nailing of long-bone fractures. In general, stage I (early) infections only require antibiotic administration with/without debridement. Stage II (delayed) infections can be successfully treated with debridement, IM reaming, antibiotic nails, and administration of antibiotics. Infected non-unions are best treated with exchange nailing, antibiotic administration and when infection has been eradicated with graft implantation if it is needed. Debridement, exchange nailing and systemic administration of antibiotics is the best indication for stage III (late) infections, while stage III infected non-unions can successfully be treated with nail removal and Ilizarov frame, especially when large bone defects exist.

Expandable intramedullary nails in lower limb trauma: a systematic review of clinical and radiological outcomes

This study systematically reviews the evidence-base for the use of expandable nails in the treatment of acute diaphyseal fractures of the lower limb. Both electronic and hand searches were undertaken of the published and grey literature to 1 December 2011. A total of 154 citations were identified, of which 15 were deemed suitable and assessed with the Critical Appraisals Skills Programme tool. A total of 625 nailing procedures were performed in 620 patients: 279 femoral and 346 tibial nails. The expandable nail was found to be significantly quicker to insert than interlocked nails (p < 0.05), and the total incidence of non-union or other complication was 13 and 14 % for expandable femoral and tibial nails, respectively. Notable complications with the expandable nail included fracture propagation on nail inflation in 2.5 % and post-operative shortening in 3.3 %. Device failure secondary to problems with the expansion mechanism was seen in 2.9 %. The rate of non-union and infection following expandable nailing was 3.1 and 1.4 %, respectively. Despite promising initial results, there remains a paucity of good quality studies to support the use of expandable nails over interlocked nails for the treatment of acute diaphyseal fractures of the lower limb.

A Prospective Comparative Study of Reamed vs. Unreamed Nailing in Fractures Shaft of Tibia

ABSTRACT

BACKGROUND

Although the tibia is one of the most commonly fractured long bones in the body, there are two accepted management techniques: reamed and unreamed nailing. There is not a general consensus as to which technique is more advantageous to the patient.

PATIENTS AND METHODS

This was a single centre prospective randomized trial of 38 adults with a tibial shaft fracture who were treated with either reamed or unreamed nailing.

RESULTS

Overall fracture healing time was 23 weeks in the reamed group and 25 weeks in the unreamed group. Differences in rate of clinical union, clinical outcome, time for weight bearing and complications in both the groups were not statistically significant.

CONCLUSION

There are no clear indications or contraindications to favour either reamed or unreamed nailing over the other. Technique, fracture union, functional outcome and complications are similar in both groups. Considering the ease of technique application and the decreased operative time, unreamed interlocking nailing has an edge over reamed interlocking nailing.

KEY WORDS

Reamed, unreamed, interlocking nailing, fracture shaft of tibia.

Critical analysis of tibial fracture healing following unreamed nailing

PURPOSE

Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing.

METHODS

One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing.

RESULTS

Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p=0.005), fracture site gap (p=0.01), degree of comminution (p=0.0003), associated soft tissue injuries (p=0.02) and the time to dynamisation (p=0.0001).

CONCLUSIONS

High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.