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

A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN)

INTRODUCTION

The aim of this study was to present clinical experience and outcomes of intramedullary nailing of proximal, midshaft and distal tibia fractures with the Expert Tibia Nail (ETN; Synthes GmbH, Switzerland), an implant offering a wide range of proximal and distal locking options in multiple planes to increase stability of the implant and bone construct.

PATIENTS AND METHODS

180 patients with 185 tibia fractures were enclosed between July 2004 and May 2005 from ten trauma units (Levels I, II and III) and treated with intramedullary reamed and unreamed nailing with the ETN. Patients attended examinations at 12 weeks and 1 year. The occurrence of postoperative complications was documented as well as the outcomes of fracture healing, primary and secondary malalignment, implant failure, rate of infection and the need for reoperation.

RESULTS

The 1-year follow-up rate was 81 %. At 1 year, the prevalence of delayed union was 12.2 % and higher for open fractures (18.2 %) compared to closed fractures (9.7 %). According to the fracture location, the percentage of delayed union was 5.9, 16.7 and 10.5 % in proximal third, midshaft and distal third cases, respectively. Patients with a plated fibula fracture had an eightfold higher risk of delayed union. The rate of malalignment >5° in any plane 1 year after surgery was 5.5 %. Proximal third fractures were at a higher risk of postoperative malalignment (17.6 %). The rate of secondary malalignment was 1.4 %. The risk of unplanned reoperation was 9.2 %.

CONCLUSION

Intramedullary ETN fixation of tibia fractures results in low rates of delayed union, primary and secondary malalignment, implant-related complications, and secondary surgery. Fibula plating had a negative effect on the healing of the tibia.

Factors influencing functional outcomes after distal tibia shaft fractures

OBJECTIVES

Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation. Comparative studies suggest more malalignment and nonunions with nails. Some studies have reported knee pain after tibial nailing. However, plates may be associated with soft tissue complications, such as infections or wound-healing problems. The purpose of this study was to assess functional outcomes after distal tibia shaft fractures treated with a plate or a nail. We hypothesized that tibial nails would be associated with more knee pain and that plates would be associated with pain from implant prominence, each of which would adversely affect functional outcome scores.

DESIGN

Randomized prospective study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred four patients with extra-articular distal tibia shaft fractures (OTA 42), mean age of 38 years (range, 18-95), and mean Injury Severity Score of 14.3 (range, 9-50).

INTERVENTION

Patients were randomized to treatment with a reamed intramedullary nail (n = 56) or standard large fragment medial plate (n = 48).

MAIN OUTCOME MEASUREMENTS

Ability to work was evaluated after a minimum of 12 months, with mean of 22 months. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were completed.

RESULTS

Mean MFA was 27.5, and mean total FFI was 0.26; P < 0.0001 versus an uninjured reference population. Sixty-one of 64 patients (95%) employed at the time of injury had returned to work, although 31% had modified their work duties because of injury. Three patients were unable to find work. None reported unemployment secondary to their tibial fracture. Forty percent of all patients described some persistent ankle pain, and 31% had knee pain after nailing, versus 32% and 22%, respectively after plating. Both knee and ankle pain were present in 27% with nails and 15% with plates (P = 0.08), and rates of implant removal were similar after nails versus plates. Patients with malunion ≥5 degrees were more likely to report knee or ankle pain (36% vs 20%, P < 0.05). Except 1 patient with knee pain when kneeling, none reported modifying activity because of persistent knee or ankle pain, although knee and ankle pain were more frequent in the unemployed (P = 0.03). Unemployed patients requested implant removal more frequently (24% vs 9.2%, P = 0.07) and continued to report pain afterward. Although FFI and MFA scores were not related to plate or nail fixation, open fracture, fracture pattern, multiple injuries, Injury Severity Score, or age, both MFA and FFI scores were worse when knee pain or ankle pain was present (all Ps < 0.004) and in patients who remained unemployed (P < 0.0001). All 4 patients with work-related injuries had returned to employment but had worse FFI scores (P = 0.01).

CONCLUSIONS

Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Mild ankle or knee pain was reported frequently after plate or nail fixation but was not limiting to activity in most. Angular malunion was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. No patients reported unemployment because of their tibia fracture, but unemployed people described knee and ankle pain more frequently and had the worst functional outcome scores.

Permanent antibiotic impregnated intramedullary nail in diabetic limb salvage: a case report and literature review

Managing complications after attempted hind foot and ankle arthrodesis with intramedullary nail fixation is a challenge. This situation becomes more problematic in the patient with diabetes mellitus and multiple comorbidities. Infection and subsequent osteomyelitis can be a devastating, limb threatening complication associated with these procedures. The surgeon must manage both the infectious process and the skeletal instability concurrently. This article provides a literature review and detailed management strategies for a modified technique of employing antibiotic impregnated polymethylmethacrylate-coated intramedullary nailing.

Intramedullary nailing for tibial shaft fractures in adults

BACKGROUND

Intramedullary nailing is commonly used for treating fractures of the tibial shaft. These fractures are one of the most common long bone fractures in adults.

OBJECTIVES

To assess the effects (benefits and harms) of different methods and types of intramedullary nailing for treating tibial shaft fractures in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and reference lists of articles to December 2009. The search was subsequently updated to September 2011 to assess the more recent literature.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical studies evaluating different methods and types of intramedullary nailing for treating tibial shaft fractures in adults were included. Primary outcomes were health-related quality of life, patient-reported function and re-operation for treatment failure or complications.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study selection, risk of bias assessment, and data collection and extraction.

MAIN RESULTS

Nine randomised and two quasi-randomised clinical trials, involving a total of 2093 participants with 2123 fractures, were included. The evidence was dominated by one large multicentre trial of 1319 participants. Both quasi-randomised trials were at high risk of selection bias. Otherwise, the trials were generally at low or unclear risk of bias. There were very few data on functional outcomes; and often incomplete data on re-operations. The trials evaluated five different comparisons of interventions: reamed versus unreamed intramedullary nailing (six trials); Ender nail versus interlocking nail (two trials); expandable nail versus interlocking nail (one trial); interlocking nail with one distal screw versus with two distal screws (one trial); and closed nailing via the transtendinous approach versus the paratendinous approach (one trial).No statistically significant differences were found between the reamed and unreamed nailing groups in 'major' re-operations (66/789 versus 72/756; risk ratio (RR) 0.88, 95% confidence interval (CI) 0.64 to 1.21; 5 trials), or in the secondary outcomes of nonunion, pain, deep infection, malunion and compartment syndrome. While inconclusive, the evidence from a subgroup analysis suggests that reamed nailing is more likely to reduce the incidence of major re-operations related to non-union in closed fractures than in open fractures. Implant failure, such as broken screws, occurred less often in the reamed nailing group (35/789 versus 79/756; RR 0.42, 95% CI 0.28 to 0.61).There was insufficient evidence established to determine the effects of interlocking nail with one distal screw versus with two distal screws, interlocking nail versus expandable nail and paratendinous approach versus transtendinous approach for treating tibial shaft fractures in adults.Ender nails when compared with an interlocking nail in two trials resulted in a higher re-operation rate (12/110 versus 3/128; RR 4.43, 95% CI 1.37 to 14.32) and more malunions. There were no statistically significant differences between the two devices in the other reported secondary outcomes of nonunion, deep infection, and implant failure.One trial found a lower re-operation rate for an expandable nail when compared with an interlocking nail (1/27 versus 9/26; RR 0.11, 95% CI 0.01 to 0.79). The differences between the two nails in the incidence of deep infection or neurological defects were not statistically significant.The trial comparing one distal screw versus two distal screws found no statistically significant difference in nonunion between the two groups. However, it found significantly more implant failures in the one distal screw group (13/22 versus 1/20; RR 11.82, 95% CI 1.70 to 82.38).One trial found no statistically significant differences in functional outcomes or anterior knee pain at three year follow-up between the transtendinous approach and the paratendinous approach for nail insertion.

AUTHORS' CONCLUSIONS

Overall, there is insufficient evidence to draw definitive conclusions on the best type of, or technique for, intramedullary nailing for tibial shaft fractures in adults. 'Moderate' quality evidence suggests that there is no clear difference in the rate of major re-operations and complications between reamed and unreamed intramedullary nailing. Reamed intramedullary nailing has, however, a lower incidence of implant failure than unreamed nailing. 'Low' quality evidence suggests that reamed nailing may reduce the incidence of major re-operations related to non-union in closed fractures rather than in open fractures. 'Low' quality evidence suggests that the Ender nail has poorer results in terms of re-operation and malunion than an interlocking nail.

Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures

BACKGROUND

The objective of this study is to analyze the proximal tibiofibular joint in patients with knee pain after treatment of tibial shaft fractures with locked intramedullary nail.

FINDINGS

The proximal tibiofibular joint was analyzed in 30 patients, who reported knee pain after tibial nailing, and standard radiograph and computed tomography were performed to examine the proximal third of the tibia. Twenty patients (68.9%) presented the proximal screw crossing the proximal tibiofibular joint and 13 (44.8%) had already removed the nail and/or screw. Four patients (13.7%) reported complaint of knee pain. However, the screw did not reach the proximal tibiofibular joint. Five patients (17.2%) complained of knee pain although the screw toward the joint did not affect the proximal tibiofibular joint.

CONCLUSION

When using nails with oblique proximal lock, surgeons should be careful not to cause injury in the proximal tibiofibular joint, what may be one of the causes of knee pain. Thus, the authors suggest postoperative evaluation performing computed tomography when there is complaint of pain.

Knee pain correlates with union after tibial nailing

OBJECTIVES

The purpose of this study is to evaluate the change in quantitatively scored knee pain during union.

DESIGN

This is a retrospective review of prospectively collected data over a 15-year period.

SETTING

Academic medical center.

PATIENTS

All patients treated with an intramedullary nail were evaluated for knee pain and union. Four hundred twenty-eight patients with 443 tibia fractures were included.

INTERVENTION

All tibia fractures were treated with an intramedullary nail.

OUTCOMES

Patient-based knee pain was scored from 0 to 3. Fracture union was also graded using a modified Hammer score based on cortical bridging and remodeling.

RESULTS

We found a significant inverse association between pain and union score (P < 0.01). In contradistinction, there was not a correlation between time from surgery and pain (P = 0.13). Because union score and time were related, a model was created with both parameters. This model demonstrated a statistical correlation with union score (P < 0.01), but not for time from surgery (P = 0.18).

CONCLUSIONS

We postulated that knee pain may correlate with either union or time from surgery. We found a statistically significant, negative correlation between knee pain and fracture union. There was no such association between pain and time from surgery.

Are there any advantages in using a distal aiming device for tibial nailing? Comparing the Centro Nailing System with the Unreamed Tibia Nail

INTRODUCTION

The distal locking of an intramedullary tibial nail can be challenging and time consuming when performed freehand. This study was conducted to evaluate if a distal aiming device would reduce surgical time.

MATERIALS AND METHODS

A case-controlled study was performed between 2007 and 2009 with 30 patients receiving a reamed tibial nail (Centronail) with the use of a distal aiming device and 30 patients who were treated with an Unreamed Tibia Nail (UTN), with freehand distal locking, in the same period. The primary outcome in this study was operative time. Secondary outcomes were the need for fluoroscopy, time to consolidation and complications.

RESULTS

Operation time was longer in the Centronail group compared with the UTN group (126 min vs. 96 min, p=0.000). Use of fluoroscopy for distal locking was needed in half of the cases (n=16) using a distal aiming device. No differences were found regarding time to consolidation, time to removal of the nail and complications.

CONCLUSION

The use of an aiming device for distal locking of a tibia nail lengthens operation time rather than reducing it. Fluoroscopy was still needed in about half of the cases. No difference was seen in clinical outcomes. The use of a distal aiming device to lock a tibial nail appears to have no benefit.

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

It is generally accepted that in tibial fractures the results of reamed intramedullary nailing are better than those of unreamed. However, it is not known whether the clinical effects of reaming are cumulative or if minimal reaming would induce the same beneficial effects as more extensive reaming. This international multicentre study has investigated the effects of different degrees of reaming. 100 patients with closed diaphyseal tibial fractures were prospectively randomised in two centres. Method of treatment was reamed nailing up to 12 mm inserting an 11 mm tibial nail (n: 50), and minimally reamed nailing up to 10 mm inserting a 9 mm tibial nail (n: 50). All patients included in the study had follow-up studies at 4,8,12,16,26 and 52 weeks after trauma. Sixty-six male and thirty-four female patients with an average age of 37.5 years were included in the study. Gender, age, and injury side were identical in both groups. There was no significant difference of complications in the two methods. The rate of deep wound infections was higher in the reamed group (n: 3) versus the minimally reamed group (n: 1). Union occurred earlier in the reamed group (17 wks) compared to patients with minimally reamed nailing (19 wks), and there were more patients with reamed nails in whom the fracture had healed by 16 weeks (57%) versus the minimally reamed group (43%), however, this was not statistically significant. Pain scales were similar for both groups from week 4 to week 52. A considerable number of outcome parameters including knee and ankle function, as well as the comparison of time intervals to restart certain activities, and return to work showed no significant statistical difference between the two groups. However, patients of the extensive reamed group returned earlier to running, training, and normal sports activities. This study found no significant evidence that more extensive reaming gave better results, however there seemed to be a tendency of more aggressive reaming to induce earlier fracture healing with a tendency of faster recovery times.

Treatment of acute tibial shaft fractures with an expandable nailing system: a systematic review of the literature

Locked Intramedullary Nailing is an established method of treatment for tibial shaft fractures. Locking of tibial nails is however not without its drawbacks. Locking is time consuming, and is associated with a noteworthy complication rate. The Fixion IM nailing system is an expandable nail designed to eliminate some of these drawbacks. We have performed a systematic review of the literature to determine the safety and efficacy of this system. Publications examining the use of the Fixion system were identified from the MEDLINE and the Cochrane databases. Forty-one citations were generated by the MEDLINE search. Of these, two quasi-randomised trials and eight case series satisfied our selection criteria and were reviewed. Overall the average reoperation rate for the Fixion nail was 10.2%. Shortening occurred in 3% of cases and fracture propagation was reported in 2% of cases. The Fixion cohort united at an average of 12.2 weeks and the average operative time was 54 minutes. The Fixion system eliminated complications and reoperations associated with the use of locking screws. Further studies in the form of randomised controlled trials are needed to evaluate the Fixion system against conventional locked nails.

TIBIAL SHAFT FRACTURES

The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures.

Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures

OBJECTIVE

To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique.

DESIGN

Prospective Cohort.

SETTING

Level I Trauma Centre.

PATIENTS/PARTICIPANTS

A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures.

INTERVENTION

All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken.

MAIN OUTCOME MEASURE(S)

Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >108.

RESULTS

A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.08 with a mean difference of 16.28(p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >108 from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.38 with a mean difference of 11.58 (p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >108 from the uninjured limb.

CONCLUSIONS

Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation.The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.

Systematic review shows lowered risk of nonunion after reamed nailing in patients with closed tibial shaft fractures

Nonunion after intramedullary nailing (IMN) in patients with tibial shaft fractures occurs up to 16%. There is no agreement whether reaming prior to IMN insertion would reduce the nonunion rate. We aimed to compare the nonunion rate between reamed and unreamed IMN in patients with tibial shaft fractures. A systematic search was conducted in Pubmed, Embase, and the Cochrane Library. The selected publications were: (1) randomised controlled trials; (2) comparing the nonunion rate; (3) in patients with tibial shaft fractures; (4) treated with either reamed or unreamed IMN. Seven studies that satisfied the criteria were identified. They showed that reamed IMN led to reduction of nonunion rate compared to unreamed IMN in closed tibial shaft fractures (risk difference ranging 7.0-20%, number needed to treat ranging 5-14), while the difference between compared treatments for open tibial shaft fractures was not clinically relevant. The evidence showed a consistent trend of reduced nonunion rate in closed tibial shaft fracture treated with reamed compared to unreamed IMN.

[Unreamed intramedullary nailing]

Reaming and non-reaming of intramedullary nails in long bone fractures was a controversial and even emotional topic in recent decades. This article gives an historical overview of the development in this field and presents the background to the need for unreamed nailing. Furthermore, the current state of knowledge is illustrated by describing the results of a series of randomised controlled trials. Before the year 2000 nearly all German handbooks on orthopaedic and trauma surgery recommended unreamed intramedullary nailing as a more "biological" treatment that causes less harm to vascularity with equal or even better results. Unreamed nailing was in particular advocated for the treatment of open fractures. The tide turned as randomised controlled trials conducted since 2000 gave evidence that unreamed nailing leads to a higher rate of delayed or non-union, while the advantages to blood supply and infection rate could not be proven. According to evidence based medicine isolated femur and tibia fractures should be nailed in a reamed procedure. In a severe multiple injury setting it is safer to stabilize long bone fractures with external fixators, as adverse events are described for reamed and unreamed nailing.

Proximal tibiofibular joint pain after insertion of a tibial intramedullary nail: two case reports with accompanying computed tomography and cadaveric studies

Intramedullary nail (IMN) fixation is a proven, efficient, and effective surgical intervention for diaphyseal tibia fractures. We present a case report of two patients who sustained diaphyseal tibial fractures, were treated with IMN fixation, and subsequently developed lateral and posterolateral knee pain secondary to interlocking screw penetration into the proximal tibiofibular joint (PTFJ). We performed a retrospective radiographic review of 50 consecutive knee computed tomographic scans to define the fibula's respective anatomic relationship to the tibia on axial computed tomographic images in addition to a cadaveric study of four IMN implants to evaluate the orientation of the medial inserted proximal oblique interlock screw with three-dimensional reconstructive fluoroscopy. The "danger zone" was found to be from 44.7 degrees to 72.1 degrees on the right and from 40.6 degrees to 73.0 degrees on the left. The cadaveric computed tomographic study showed the projected screw placement angles to be 45 degrees for the Synthes IMN, 45 degrees for the Stryker IMN, 48 degrees for the DePuy IMN, and 63 degrees for the Smith & Nephew IMN. These findings were correlated to an anatomically based "clock face" guide. To our knowledge, this report is the first to illuminate a PTFJ injury with the initial presenting complaint of lateral and posterolateral knee pain from a medially inserted proximal oblique interlocking screw after IMN for a diaphyseal tibia fracture. Using the proposed reproducible "clock face" diagram and understanding the computed tomography-derived PTFJ "danger zone" for placement of proximal oblique interlock screws for IMN fixation of tibia fractures, surgeons can avoid violation of the PTFJ.

Minimally invasive locked plating of distal tibia fractures is safe and effective

Distal tibial fractures are difficult to manage. Limited soft tissue and poor vascularity impose limitations for traditional plating techniques that require large exposures. The nature of the limitations for traditional plating techniques is intrinsic to the large exposure required to approach distal tibia, a bone characterized by limited soft tissue coverage and poor vascularity. The locking plate (LP) is a new device for treatment of fractures. We assessed the bone union rate, deformity, leg-length discrepancy, ankle range of motion, return to preinjury activities, infection, and complication rate in 21 selected patients who underwent minimally invasive osteosynthesis of closed distal tibia fractures with an LP. According to the AO classification, there were 12 Type A, 5 Type B, and 4 Type C fractures. The minimum followup was 2 years (average, 2.8 years; range, 2-4 years). Two patients were lost to followup. Union was achieved in all but one patient by the 24th postoperative week. Four patients had angular deformity less than 7 degrees . No patient had a leg-length discrepancy more than 1.1 cm. Five patients had ankle range of motion less than 20 degrees compared with the contralateral side. Sixteen patients had not returned to their preinjury sporting or leisure activities. Three patients developed a delayed infection. We judge the LP a reasonable device for treating distal tibia fractures. The level of physical activities appears permanently reduced in most patients.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A critical appraisal of the SPRINT trial

The Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) was a randomized controlled trial to evaluate rates of reoperation and complications resulting from reamed versus unreamed intramedullary nailing for the treatment of tibial shaft fractures. The trial found a possible benefit for reamed intramedullary nailing in patients with closed tibial fractures, but no difference was found between the 2 approaches in patients with open fractures. This article is a review and critique of the methodology used in the SPRINT trial. Numerous aspects of the trial's design served to greatly reduce the potential bias, producing sound and reliable results. Overall, the SPRINT trial should provide recommendations for change in clinical practice and also set a benchmark for the conduct of randomized controlled trials in orthopedic surgery.

Reaming does not add significant time to intramedullary nailing of diaphyseal fractures of the tibia and femur

BACKGROUND

Reamed intramedullary nailing is the current gold standard for the treatment of diaphyseal fractures of the femur and tibia. Current concepts of orthopedic damage control surgery for patients with multiple injuries have placed an emphasis on appropriate surgical timing, limiting blood loss, and the duration of the initial operative procedure(s). Proponents of unreamed nailing have stated that reaming places polytraumatized patients "at risk," in part because it adds to the length of the surgical procedure and may exacerbate the severity of a patient's pulmonary injury. The purpose of this study was to determine how many minutes reaming actually takes and what percentage of operative time reaming comprises during intramedullary nailing of femoral and tibial shaft fractures.

METHODS

Intraoperative timing data were collected prospectively on a total of 52 patients with 54 fractures (21 femoral and 33 tibial) who underwent reamed intramedullary nailing of acute closed or open femoral or tibial shaft fractures over a 10-month period. Total operating room, surgical, and reaming times were collected.

RESULTS

The average reaming time for femur and tibia fractures was 6.9 minutes and 7 minutes, respectively. On average, reaming accounted for 4.9% of the surgical time and 3.2% of the total operating room time for femur fractures and 4.9% of the surgical time and 3.4% of the total operating room for tibia fractures.

CONCLUSION

Our results show that reaming comprises a small percentage of the operative time and the total time a patient spends in the operating room.

Reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures: a subgroup analysis of randomised trials

The choice between reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures is an ongoing controversy. We carried out a comprehensive search strategy. Six eligible randomised controlled trials were included. Three reviewers independently assessed methodological quality and extracted outcome data. Analyses were performed using Review Manager 5.0. The results showed lower risks of tibial fracture nonunion and implant failures with reamed nails compared to unreamed nails in closed tibial fractures [relative risk (RR): 0.41, 95% confidence interval (CI): 0.21-0.89, P = 0.008 for nonunion and RR: 0.35, 95% CI: 0.22-0.56, P < 0.0001 for implant failures], but no statistical differences in risk reduction of malunion, compartment syndrome, embolism and infection. Our results suggested no statistical differences in risk reduction of all the complications evaluated between reamed and unreamed nails in open tibial fractures. In conclusion, our study recommended reamed nails for the treatment of closed tibial fractures. But the choice for open tibial fractures remains uncertain.

Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result?

The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.

Lower limb deformity due to failed trauma treatment corrected with the Ilizarov technique: factors affecting the complication rate in 52 patients

BACKGROUND AND PURPOSE

Failed treatment of fractures may be corrected by the Ilizarov technique but complications are common. In 52 patients with compromised healing of femoral and tibial fractures, the results of secondary reconstruction with Ilizarov treatment were investigated retrospectively in order to identify the factors that contribute to the risk of complications.

METHODS

52 consecutive patients was analyzed. The median interval between injury and secondary reconstruction was 3 (0.1-27) years. The patients had failed fracture treatment resulting in bone defects, pseudarthrosis, infection, limb length discrepancy (LLD) caused by bone consolidation after bone loss, malunion, soft-tissue loss, and stiff joints. Most patients had a combination of these deformities. The results were analyzed by using logistic regression in a polytomous universal mode (PLUM) logistic regression model.

RESULTS

The median treatment time was 9 (4-30) months, and the obstacle and complication rate was 105% per corrected bone segment. In 2 patients treatment failed, which resulted in amputation. In all other patients healing of nonunion could be established, malunion could be corrected, and infections were successfully treated. The statistical analysis revealed that relative bone loss of the affected bone was the only predictor for occurrence of complications. From these data, we constructed a simple graph that shows the relationship between relative bone loss of the affected bone and risk of complications.

INTERPRETATION

Relative bone loss of the affected bone segment is the main predictor of complications after Ilizarov treatment of previously failed fracture treatment. The visualization of the analysis in a simple graph may assist comparison of the complication rates in the literature.

Clinical and radiological midterm results from using the Fixion expandable intramedullary nail in transverse and short oblique fractures of femur and tibia

Background

A locked nail is the principal method used to eliminate rotatory components in femoral and tibial fractures. Nevertheless, weight bearing is not directed onto the fracture site, slowing down the healing process; another possibility is to use a large-diameter nail and ream the canal to obtain as much adherence as possible and increase the grip, but this can cause a number of complications. The expandable nail is a new option that in theory should remove some problems with previous techniques.

Materials and methods

This was a retrospective nonrandomized study encompassing 21 femoral fractures and 27 tibial fractures in 45 patients. They were classified according to the AO classification. Clinical and radiological checks were done at one, three, and six months and at one year from the surgery in order to check for signs of clinical and radiological healing. A good alignment was considered to be the presence of a deformity of less than 5° in the sagittal and lateral planes and the absence of rotatory clinically evident problems. This protocol was adhered to up to six months after surgery by all of the patients, while only 62.2% performed the last control. The mean follow-up was 15 months. A second group of 48 consecutive fractures (24 femural and 24 tibial) treated with locked nail was created to compare surgical times.

Results

Appropriate alignment was observed in all cases; the healing process appeared slower: radiological healing occurred in most cases at six months. The following complications were reported: a case of intraoperative fracture widening with no effect on the treatment; a case of a lesion of the tip of the nail with pneumatic system rupture that necessitated nail substitution; two cases of retarded consolidation at six months, with both tibial fractures treated successfully by intralesion platelet gel; a case of incarcerated nail on 17 removals, resolved by shearing. We had no cases of clinically evident compartment syndrome or pulmonary embolism.

Conclusions

The expandable Fixion nail presents significant advantages in the treatment of transverse and short oblique fractures of femur and tibia because it is easy to use, involves minimal X-ray exposure and can control rotations. Nevertheless, it high cost limits its use. We consider it as an alternative to locked nail.

Unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third tibial fractures

PURPOSE

To assess the outcome of unreamed intramedullary nailing through the lateralised entry point using oblique proximal and biplanar distal interlocking screws.

METHODS

15 men and 3 women aged 25 to 58 (mean, 37) years underwent unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third metaphyseal tibial fractures. The entry point was kept proximal to the tibial tuberosity and slightly lateral to midline. Proximal locking was at 45 degrees to the coronal and sagittal planes. Biplanar distal locking was in the coronal and sagittal planes.

RESULTS

16 patients had bone union within 20 (mean, 17; range, 14-27) weeks; 2 underwent dynamisation for delayed union. Three patients had valgus angulation of less than 5 degrees; 2 had a loss of terminal knee flexion; 3 had a loss of ankle dorsiflexion; and 3 had shortening of more than 0.5 cm. Functional outcomes were excellent in 13, good in 4, and fair in one patient. No patient endured neurovascular injury, compartment syndrome or implant failure.

CONCLUSION

Unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third tibial fractures was effective in preventing malalignment.

Early dynamization by reduced fixation stiffness does not improve fracture healing in a rat femoral osteotomy model

Dynamization of fracture fixation is used clinically to improve the bone healing process. However, the effect of early dynamization remains controversial. This study evaluated the effect of early dynamization, by reduced stiffness of fixation on callus stiffness and size after 5 weeks of healing in a rat diaphyseal femoral osteotomy. An external unilateral fixator allowed either a rigid (R-group; n = 8) or a flexible (F-group; n = 8) fixation. The dynamized group (D-group: n = 8) had a rigid fixation for 1 week, and then a flexible fixation for the remaining 4 weeks. The pre- and postoperative activity of the rats was measured. After 5 weeks, the rats were sacrificed, and healing was evaluated by biomechanical and densitometric methods. The R-group had a higher activity more closely approaching preoperative levels, compared to the D-group throughout all time points measured. This difference was significant after 14 days and 21 days. The flexural rigidity of the R-group was 82% (tested in the anterior-posterior direction; p = 0.01) and 93% (tested in the medial-lateral direction; p = 0.002) greater than the flexural rigidity of the D-group. The rigid fixation led to a stiffer callus with a smaller callus volume, but better mineralized tissue in the whole callus and at the level of the osteotomy gap than the flexible or the dynamized fixation. Early dynamization did not improve healing compared to rigid or flexible fixation in a rat femoral osteotomy model.

Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation

BACKGROUND

The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation.

METHODS

A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed.

RESULTS

A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5 degrees of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days).

CONCLUSIONS

Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.

Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures

BACKGROUND

There remains a compelling biological rationale for both reamed and unreamed intramedullary nailing for the treatment of tibial shaft fractures. Previous small trials have left the evidence for either approach inconclusive. We compared reamed and unreamed intramedullary nailing with regard to the rates of reoperations and complications in patients with tibial shaft fractures.

METHODS

We conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. Perioperative care was standardized, and reoperations for nonunion before six months were disallowed. The primary composite outcome measured at twelve months postoperatively included bone-grafting, implant exchange, and dynamization in patients with a fracture gap of <1 cm. Infection and fasciotomy were considered as part of the composite outcome, irrespective of the postoperative gap.

RESULTS

One thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized to unreamed nailing. Among all patients, fifty-seven (4.6%) required implant exchange or bone-grafting because of nonunion. Among all patients, 105 in the reamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event (relative risk, 0.90; 95% confidence interval, 0.71 to 1.15). In patients with closed fractures, forty-five (11%) of 416 in the reamed nailing group and sixty-eight (17%) of 410 in the unreamed nailing group experienced a primary event (relative risk, 0.67; 95% confidence interval, 0.47 to 0.96; p = 0.03). This difference was largely due to differences in dynamization. In patients with open fractures, sixty of 206 in the reamed nailing group and forty-six of 194 in the unreamed nailing group experienced a primary event (relative risk, 1.27; 95% confidence interval, 0.91 to 1.78; p = 0.16).

CONCLUSIONS

The present study demonstrates a possible benefit for reamed intramedullary nailing in patients with closed fractures. We found no difference between approaches in patients with open fractures. Delaying reoperation for nonunion for at least six months may substantially decrease the need for reoperation.

Thermal necrosis complicating reamed intramedullary nailing of a closed tibial diaphysis fracture: a case report

A case report of thermal necrosis of the tibia after reamed intramedullary nailing is presented. Given the consequences of this complication, the proper use of reaming technique and equipment is emphasized.

Long-term follow-up of tibial shaft fractures treated with intramedullary nailing

OBJECTIVE

We conducted a study to evaluate the long-term functional outcomes of patients with an isolated tibial shaft fracture treated with locked intramedullary nailing.

DESIGN

Prospective cohort and retrospective clinical and radiographic assessment.

SETTING

A level 1 trauma and tertiary referral center.

PATIENTS/PARTICIPANTS

We identified 250 eligible patients with isolated tibia fractures from the Center's prospectively enrolled orthopaedic trauma database between 1987 and 1992. A total of 56 patients agreed to participate. We had a median follow-up of 14 years, with a range from 12 to 17 years.

INTERVENTION

All enrolled patients were initially acutely treated with locked intramedullary nailing of their tibia.

MAIN OUTCOME MEASUREMENTS

All enrolled patients were evaluated with the SF-36 and Short Musculoskeletal Functional Assessment functional questionnaires and an injury-specific questionnaire focusing on knee pain and symptoms of venous insufficiency. A subgroup of patients were evaluated radiographically and by physical examination.

RESULTS

The mean normalized SF-36 scores (physical composite score-PCS 48.9, mental composite score-MCS 51.8) and the mean normalized Short Musculoskeletal Functional Assessment scores (50.7) (bothersome index, functional index) were not statistically different (P > 0.05) from reference population norms. Of the questionnaire group (n = 56), only 15 (26.7%) denied knee pain with any activity whereas 41 patients (73.2%) had at least moderate knee pain. With respect to swelling, 19 (33.9%) reported asymmetrical swelling affecting the injured limb. However, of the 33 physically examined patients, only 6 (18.2%) had objective evidence of venous stasis. Knee range of motion was equivalent to the unaffected side in all but two patients (93.9%) whereas 14 (42.4%) had a restricted range of motion of the ankle. Nine patients (27.3%) had persistent quadriceps atrophy, and the same rate was observed for calf atrophy. Twenty-five patients (75.8%) had no tenderness to anterior knee palpation. Of the 31 radiographically examined patients, 11 patients (35.4%) showed evidence of arthritis despite the absence of radiographic malalignment. Five patients (16.1%) had at least mild osteoarthritis of at least one knee compartment, 5 (16.1%) had at least mild osteoarthritis of the tibio-talar joint, and 1 (3.2%) had osteoarthritis of both, despite the absence of malunion. Self-reported knee pain was not correlated with the presence of a tibial nail or radiographic nail prominence. Similarly, knee tenderness on examination was not correlated with these factors.

CONCLUSIONS

At a median 14 years after tibial nailing of isolated tibial fractures, patients' function is comparable to population norms, but objective and subjective evaluation shows persistent sequelae which are not insignificant. This study is the first to describe the long-term functional outcomes after tibial shaft fractures treated with intramedullary nailing nails. It may allow surgeons to better inform patients on the expected long-term function after intramedullary nailing of a tibia fracture. It may also prove useful when comparing intramedullary nailing nailing to other treatment techniques.

The effect of retained intramedullary nails on tibial bone mineral density

BACKGROUND

Intramedullary nailing has become a standard treatment for adult tibial shaft fractures. Retained intramedullary nails have been associated with stress shielding, although their long-term effect on decreasing tibial bone mineral density is currently unclear. The purpose of this study was to determine if retained tibial intramedullary nails decrease tibial mineral density in patients with successfully treated fractures.

METHODS

Patients treated with statically locked intramedullary nails for isolated, unilateral tibia shaft fractures were studied. Inclusion required that fracture had healed radiographically and that the patient returned to the pre-injury activity level. Data on patient demographic, fracture type, surgical technique, implant, and post-operative functional status were tabulated. Dual energy X-ray absorptiometry was used to measure bone mineral density in selected regions of the affected tibia and the contralateral intact tibia. Image reconstruction software was employed to ensure symmetry of the studied regions.

FINDINGS

Twenty patients (mean age 43; range 22-77 years) were studied at a mean of 29 months (range 5-60 months) following intramedullary nailing. There was statistically significant reduction of mean bone mineral density in tibiae with retained intramedullary nails (1.02 g/cm(2) versus 1.06 g/cm(2); P=0.04). A significantly greater decrease in bone mineral density was detected in the reamed versus non-reamed tibiae (-7% versus +6%, respectively; P<0.05).

INTERPRETATION

The present study demonstrates a small, but statistically significant overall bone mineral density decrease in healed tibiae with retained nails. Intramedullary reaming appears to be a factor potentiating the reduction of tibia bone mineral density in long-term nail retention.

Study to prospectively evaluate reamed intramedually nails in patients with tibial fractures (S.P.R.I.N.T.): study rationale and design

BACKGROUND

Surgeons agree on the benefits of operative treatment of tibial fractures - the most common of long bone fractures - with an intramedullary rod or nail. Rates of re-operation remain high - between 23% and 60% in prior trials - and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better.

METHODS/DESIGN

The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0-3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes.

DISCUSSION

The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following re-operations: bone grafts, implant exchanges, and dynamizations, in patients with fracture gaps less than 1 cm post intramedullary nail insertion. Infections and fasciotomies were considered events irrespective of the fracture gap. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. S.P.R.I.N.T is the largest collaborative trial evaluating alternative orthopaedic surgical interventions in patients with tibial shaft fractures. The methodological rigor will set new benchmarks for future trials in the field and its results will have important impact on patient care. The S.P.R.I.N.T trial was registered [ID NCT00038129] and received research ethics approval (REB#99-077).

Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing

OBJECTIVE

The purposes of this study were to review distal tibia shaft fractures treated with a plate or a nail and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures.

DESIGN

Retrospective review.

SETTING

Two Level I trauma centers.

PATIENT/PARTICIPANTS

We retrospectively reviewed 111 patients with 113 extra-articular distal tibia fractures between 4 and 11 cm proximal to the plafond. Seventy-six were treated with an intramedullary nail and 37 were treated with a medial plate. Twenty-nine (27%) of the concomitant fibula fractures were fixed.

MAIN OUTCOME MEASUREMENTS

Complications and secondary procedures were evaluated in 111 patients after a mean of 24 months (range, 12-84 months).

RESULTS

A total of 111 patients with 113 fractures of the distal tibia were reviewed. Their mean age was 39.1 years, 69% were men, and 30% had open fractures. Four patients underwent additional procedures for soft tissue coverage. None of these had infection. Five patients (4.4%) developed osteomyelitis: four after intramedullary nailing (5.3%) and one after plating (2.7%). Nine patients (12%) had delayed union or nonunion after nailing. One patient (2.7%) had a nonunion after plating (P = 0.10). Nonunion was more common after concurrent fixation of the fibula (14% versus 2.6%, P = 0.04). Angular malalignment of > or =5 degrees occurred in 22 patients with nails (29%) and 2 with plates (5.4%, P = 0.003). Eight patients had malunions of > or =10 degrees. Valgus was the most common deformity (n = 16). Malunion was more common after open fracture (38%, P = 0.006) but was not related to fibula fixation. Painful hardware was removed in six patients (7.9%) with nails and in two patients (5.4%) with plates.

CONCLUSIONS

Distal tibia fractures may be treated successfully with plates or nails. Delayed union, malunion, and secondary procedures were more frequent after nailing. Randomized prospective assessment may further clarify these issues and provide information about costs associated with these fractures.

Are inflatable nails an alternative to interlocked nails in tibial fractures?

Recently developed inflatable nails avoid reaming and interlocking screws in tibial fractures and reflect a new principle for stabilization of long bone fractures. We asked if the bending stiffness, rotational rigidity, or play (looseness of rotation) differed between an inflatable versus large-diameter reamed interlocked nails, and whether the maximal torque to failure of the two bone-implant constructs differed. In a cadaveric model, we compared the biomechanical properties with those of an interlocked nail in eight pairs of fractured tibial bones. Bending stiffness, rotational rigidity, play (looseness in rotation), and torsional strength within 20 degrees rotation were investigated using a biaxial servohydraulic testing system. For all biomechanical variables, we found a large interindividual variance between the pairs attributable to bone quality (osteoporosis) for both fixation methods. The inflatable nail had a higher bending stiffness, with a mean difference of 58 N/mm, and a lower torsional strength, with a mean difference of 13.5 Nm, compared with the locked nail. During torsional testing we noted slippage between the inflatable nail and bone. We observed no differences in play or rotational rigidity. Given the lower torsional strength we recommend caution with weightbearing until there are signs of fracture consolidation.

The effectiveness of the external distal aiming device in intramedullary fixation of tibial shaft fractures

INTRODUCTION

Intramedullary nailing has become a popular and effective procedure for the treatment of most fractures of the tibial diaphysis. However, distal interlocking screw placement under fluoroscopic control is responsible for the majority of the radiation exposure and a significant loss of surgical time in the entire nailing procedure. To limit fluoroscopy use, during distal interlocking screw placement, Orthofix has developed a distal targeting device which compensates for the inevitable deformation of the nail in the sagittal plane during its insertion. This prospective clinical study evaluates the efficacy of this distal targeting device for distal locking.

MATERIALS AND METHODS

One hundred and fifteen fresh tibial fractures in the same number of patients with a mean age of 37.5 years (17-85 years) were treated with operative stabilization using the Orthofix tibial nailing system.

RESULTS

The mean duration of the operation was 38 min (20-55 min). A mean of four intra-operative plain X-rays (2-6 X-rays) were used in 103 cases to confirm guide wire placement, final nail insertion and accuracy of screws placement. The mean duration of the use of the image intensifier utilized in the remaining 12 fractures was 5 s (3-8 s). The distal targeting device failed in 12 (5.2%) distal locking screws.

CONCLUSION

This study demonstrates that distal locking can be performed easily and successfully with minimal exposure to radiation, once the surgeon develops a reasonable experience with the use of this distal targeting device.

Comparative study of the locked intramedullary nail and Ender pins in the treatment of tibial diaphyseal fractures

OBJECTIVE

To compare the locked, unreamed intramedullary nail with Ender pins in the treatment of open Gustilo grade I or II or closed tibial diaphyseal fractures of type A, B, or C2 of the AO classification.

MATERIALS AND METHODS

Forty-four patients with unilateral tibial diaphyseal fractures were treated with intramedullary nails or Ender pins. Twenty patients were treated with an unreamed intramedullary nail with access via the patellar tendon with static locking. Twenty-four patients were treated with Ender pins introduced medially and laterally with respect to the tuberosity of the tibia. The main parameters analyzed were type of reduction, complications, union rate, deformities, joint mobility, pain, gait, effort capacity, presence of neurovascular disorders, and complaints related to the synthesis material.

RESULTS

During 1 year of follow-up, the fractures of 90.0% of the patients with intramedullary nails and 95.7% of patients with Ender pins healed within an average of 21.5 weeks and 20.9 weeks, respectively. The significant findings were as follows: patients treated with Ender pins had less mobility of the subtalar joint; patients treated with intramedullary nails were more likely to have pain in the knee; both groups showed shortening of the tibia at the end of 1 year of treatment.

CONCLUSIONS

The two methods are similar in the treatment of type A, B, and C2 tibial diaphyseal fractures.

Peroneal nerve damage by oblique proximal locking screw in tibial fracture nailing: a new emerging complication?

Interlocking intramedullary nailing currently is the preferred treatment for most tibial fractures requiring operative treatment. Good results with a relative low complication rate have been reported in large clinical series, as well as in comparative series. The reported incidence of neurological complications after tibial nailing varies, involving mainly the peroneal nerve. The mechanism of peroneal nerve damage in tibial fracture nailing is usually indirect, caused by leg traction or compartment syndrome. Direct peroneal nerve damage related to the proximal locking screw seems to be very rare since we were able to identify only one report in the English literature. We report a case of partial peroneal nerve damage caused by a long oblique proximal locking screw. Removal of the proximal locking screw leaded to a gradual improvement of the nerve function and a complete resolution at one year. This seems to be a new emerging iatrogenic complication related to nails designed with oblique proximal locking screws. We feel that the placement of the oblique proximal screw from medial to lateral side needs an extra care. Even fluoroscopy, does not give enough safety due to the spatial geometry of the proximal tibia and the known problems of viewing oblique interlocking screws with a two-dimensional image-intensifier.

Prevalence of long-bone non-unions

Despite the enormous progress made during recent decades in the treatment of long-bone fractures, fracture healing is still haunted by complications and above all non-unions. Non-unions represent a particular challenge, and the difficulties surrounding their management are frequently underestimated. Knowledge of the epidemiology of long-bone non-union can assist the treating surgeon in the application of the optimum fracture treatment.

Intramedullary fixation of tibial shaft fractures using an expandable nail

Interlocking intramedullary nails are the gold standard for treating tibial fractures. We compared the clinical and economic factors associated with tibial fracture fixation using either interlocking intramedullary or expandable nails. From 2000 to 2002, 53 patients with 53 diaphyseal tibial fractures of similar characteristics (AO/OTA 42A1-B3) were randomly and prospectively treated with either interlocking (n = 26) or expandable nails (n = 27). Patients were followed for a minimum of 2 years. The mean surgical duration was 104 minutes with interlocking nails and 52.9 minutes with expandable nails. Rehospitalizations were required in 12 patients (46%) and reoperations were required in nine patients (35%) with interlocking nails. Only one patient (3%) with an expandable nail required rehospitalization and reoperation. Union was achieved after 17 weeks (mean) with interlocking nails and 11.5 weeks with expandable nails. The beneficial economic ramifications of using expandable nails were a 39% reduction in overall surgical and hospital expenses. Expandable nails showed important clinical advantages for tibial fracture fixation, and complications related to lengthy operations, reoperations, and rehospitalizations were substantially reduced. Overall treatment cost was substantially lower with expandable nails. Based on these advantages, simplicity in use, and short surgical time, we recommend an expandable nail for treating tibial (AO Type A, B) shaft fractures.

Computational comparison of reamed versus unreamed intramedullary tibial nails

We compared, via a computational model, the biomechanical performance of reamed versus unreamed intramedullary tibial nails to treat fractures in three different locations: proximal, mid-diaphyseal, and distal. Two finite element models were analyzed for the two nail types and the three kinds of fractures. Several biomechanical variables were determined: interfragmentary strains in the fracture site, von Mises stresses in nails and bolts, and strain distributions in the tibia and fibula. Although good mechanical stabilization was achieved in all the simulated fractures, the best results were obtained in the proximal fracture for the unreamed nail and in the mid-diaphyseal and distal fractures for the reamed nail. The interlocking bolts, in general, were subjected to higher stresses in the unreamed tibial nail than in the reamed one; thus the former stabilization technique is more likely to fail due to fatigue.