Intramedullary nailing for tibial shaft fractures in adults

Infrapatellar branch of the saphenous nerve lesion following tibial nailing: it is possible to avoid it?

BACKGROUND

Iatrogenic injury to the infrapatellar branches of saphenous nerve is a common complication following tibial nailing. This lesion seems to be directly related to the surgical approach adopted for nail insertion. The aim of the present study was to systematically review the current literature in order to assess the eventual superiority of one surgical approach for tibial nailing over the others in limiting the neurological impairment related to infrapatellar branch injury.

MATERIALS AND METHODS

The available literature was systematically screened searching papers dealing with iatrogenic injury to the infrapatellar branch of saphenous nerve after intramedullary tibial nailing. The terms "Saphenous" and "Infrapatellar branch" were used in combination with "intramedullary nailing" and "tibial fractures", supplying no limits regarding the publication year. Only publications in English were considered. Case reports, technical notes, instructional course, literature reviews, biomechanical and/ or in vitro studies were all excluded. Coleman methodological score was performed in all the retained articles.

RESULTS

Four articles matched the inclusion criteria. There were one original article and three retrospective study. Hypoesthesia and a larger extension of the area of sensory-loss were more frequently observed after vertical incision approach in three out of four articles. A trend towards a lower rate of iatrogenic nerve damage using a transverse incision was found in the remaining one, without any statistical significance.

CONCLUSIONS

In order to avoid infrapatellar nerve lesion, horizontal or oblique incisions or percutaneous approaches should be favored, although in some cases a longitudinal incision is required. Limited-extension incisions could minimize the risk and the incidence of this complication.

A retrospective investigation on clinical and radiographic outcomes of distal tibial fractures after intramedullary nailing using the lateral parapatellar extra-articular approach

INTRODUCTION

According to reports, the modified extra-articular parapatellar approach allows the performance of tibial nailing in the semi-extended position without the concern of joint violation. However, there remains no special study that has provided a detailed assessment of the benefits and risks of this approach for treating distal tibial fractures (DTFs). The aim of this retrospective study was to investigate the clinical and radiological outcomes of patients with DTFs after intramedullary nailing using a lateral parapatellar extra-articular (LPE) approach in comparison to using the suprapatellar (SP) and transpatellar (TP) approaches.

METHODS

Data were collected from 99 patients with a minimum follow-up period of 12 months. Comparisons were conducted between the groups regarding the number of intraoperative fluoroscopies, complications, knee pain, knee range of motion (ROM), the Lysholm Knee Scale (LKS), the Olerud-Molander Ankle Score (OMAS) and radiological findings.

RESULTS

The demographic characteristics were comparable between the groups. Fewer intraoperative fluoroscopies were performed in the LPE (27.47 ± 4.98) and SP (26.03 ± 5.12) groups than in the TP group (30.20 ± 7.42; P<0.001). When compared with the other two approaches, the LPE approach was associated with less knee pain (P<0.001) and better knee ROM (P<0.001) at one week postoperative. No significant intergroup differences were detected in the incidence of complications, LKS scores (P = 0.687) and OMAS (P = 0.926). Radiological findings demonstrated that postoperative tibial alignment (P = 0.853), the time of bony union and rate of non-union were similar between the groups.

CONCLUSION

The LPE approach can serve as a safe and effective option for tibial nailing, as it offers favourable outcomes in knee pain relief and knee ROM in the early postoperative period and is equivalent to the other two approaches in terms of the incidence of complications, fracture healing, functional recovery and postoperative alignment for patients with DTFs.

Simultaneous Surgical Management of Acute Tibial Shaft Fracture and Post-traumatic Ankle Arthritis

The simultaneous management of tibial shaft fractures and post-traumatic ankle arthritis with ankle pain as the chief complaint can be challenging. Herein, we present a case managed with closed reduction, internal fixation, and tibiotalocalcaneal arthrodesis using a retrograde femoral nail. The patient was able to actively ambulate with full weight bearing and no pain approximately three months after the procedure. Patient consent for this case report was obtained.

The relevance of the number of distal locking planes and nail to canal ratio in bone healing after intramedullary nailing in tibial shaft fractures

INTRODUCTION

The objective of this retrospective study was to assess the effect of the nail to canal ratio and the number and configuration of distal locking screws in bone healing in tibial shaft fractures.

METHODS

We analyzed 223 consecutive tibial shaft fractures treated with reamed intramedullary nailing between January 2014 and December 2020. We recorded and evaluated the nail to canal ratio (NCR) and the number and configuration of distal locking screws. Median NCR was 0.87 (IQR 0.82-0.94). Ten (4.48%) fractures were treated with one distal locking screw, 173 (77.57%) with two, and 40 (17.93%) with three. Uniplanar fixation was used in 63 (28.25%), biplanar in 150 (67.26%), and triplanar in 10 (4.48%) cases. Uni-, bi-, and multivariate analyses were performed to compare patients who achieved bone union with those who did not.

RESULTS

Bone union was achieved in 195 (87.44%) patients. Uni- and bivariate analyses showed that bone union increased significantly with larger NCR (p = 0.0001) and a greater number of locking planes (p = 0.001) and distal screws (p = 0.046). NCR > 0.78 (OR 48.77 CI 95% 15.39-154.56; p =  < 0.0001) and distal locking screw configuration (OR 2.91 CI 95% 1.12-9.91; p = 0.046) were identified as independent variables for union.

CONCLUSION

Our findings suggest that in tibial shaft fractures treated with intramedullary nailing, NCR should be equal to or greater than 0.79. Additionally, distal locking screws should be used with a biplanar or triplanar configuration.

Use of a Minimally Invasive Traction Repositor versus Conventional Manual Traction for the Treatment of Tibial Fractures: A Comparative Study from a Tertiary Hospital in China

Background

Closed reduction and intramedullary nail fixation of tibial fractures may not utilize a fracture table or reduction aids like a femoral distractor, and only manual traction will help aid the reduction process. This study aimed to describe and further investigate the effectiveness of an originally designed minimally invasive traction repositor (MITR) for the treatment of tibial fractures.

Methods

From January 2018 to April 2021, a total of 119 eligible patients with tibial shaft fractures were included and retrospectively assigned to two groups according to different reduction methods: MITR group vs conventional manual traction (CMT) group. The baseline characteristics between the two groups were comparable, including age, gender, BMI, residence, smoking history, drinking history, injury mechanism, fracture type, ASA, method of anesthesia, and surgical delay (all P > 0.05). The operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, number of intraoperative fluoroscopies, VAS, HSS, fracture healing time, and complications were compared.

Results

All patients completed the follow-ups with an average of 18.5 months (range 12-42 months). The operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, and number of fluoroscopies were significantly decreased in the MITR group (all P < 0.05). At one month postoperatively, the VAS score was statistically lower in the MITR group (1.8±0.8) than in the CMT group (2.6±1.5). At 6 months postoperatively, the HHS score was statistically higher in the MITR group (90.8±2.3) than in the CMT group (86.4±3.8). We observed no statistical difference in the mean fracture healing time, bone nonunion, implant failure, and infection between the two groups (all P > 0.05).

Conclusion

Compared with CMT, MITR facilitates the minimally invasive treatment of tibial fractures and has the advantages of operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, number of fluoroscopies, and satisfactory VAS and HSS scores.

Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings

INTRODUCTION

Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes.

METHODS

We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier.

RESULTS

There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6 h. Mean duration of antibiotics therapy was 4.3 days, and the mean duration of hospital stay was 4.1 days. All patients were followed up to union. Mean time to radiographic union was 6.1 months for the tibia and 5.7 months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection.

CONCLUSION

The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

Antibiotic artificial bone implantation and external fixation for the treatment of infection after intramedullary nail fixation: a retrospective study of 33 cases

Objective

To explore the clinical effect of antibiotic artificial bone implantation and external fixation in the treatment of infection after intramedullary nail fixation.

Methods

We retrospectively reviewed the clinical data of patients with infection after intramedullary nail fixation treated from March 2010 to August 2020. There were 27 males and 6 female, aged from 12 to 67 years (average 42.27 years), 18 cases on the left side and 15 cases on the right side. Among them, 20 cases were open fractures with initial injury and 13 cases were closed fractures. All patients were treated with intramedullary nail removal, local debridement, antibiotic artificial bone implantation and external fixation. Because of bone defects, 19 patients underwent secondary autologous cancellous bone grafting after infection control. Postoperative wound healing, related inflammatory indicators, fixation time, and bone healing time were recorded and followed up.

Results

The 33 patients were followed up with period of 10 ~ 98 months (average 62.7 months). One patients failed to control the infection effectively after treatment, so received antibiotics artificial bone implantation again. Two patients also received antibiotic artificial bone implants again due to the recurrence of the infection. After treatment, infection was controlled and the fracture healed well. One patient received vacuum sealing drainage (VSD) due to persistent postoperative exudation, and five patients were also cured successfully after continuous dressing. Two patients had sinus tract after surgery, and the wound was cured by continuous dressing change. Nineteen patients received autogenous iliac bone grafts for healing due to bone defects ranging from 3 to 6.5 cm (average 4.15 cm) after infection control. The external fixation time of 33 patients ranged from 4 to 16 months (average 7.79 months), the bone healing time ranged from 4 to 13 months (average 6.67 months), and the related inflammatory indexes returned to normal within 2–8 weeks (average 4.48 weeks).

Conclusion

Antibiotic artificial bone implantation and external fixation is an effective method for the treatment of infection after intramedullary nail fixation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05161-8.

Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis

PURPOSE

Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing.

METHOD

This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis.

RESULTS

Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion.

CONCLUSION

The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.

Rates and timing of short-term complications following operative treatment of tibial shaft fractures

Introduction

Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures.

Methods

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications.

Results

A total of 4963 tibial shaft fracture were identified, with 3601 patients undergoing IMN (72.6%) and 1362 undergoing ORIF (27.4%). Patients undergoing IMN had a lower mean age of 48.8 compared with 53.9 for plate osteosynthesis (P < .001). IMN patients were also more likely to be male (53.5%) compared with ORIF patients (44.2%, P < .001). In multivariate analysis, ORIF patients were significantly more likely to experience surgical site complications, including dehiscence, superficial, and deep infections (OR 2.04, P = .003). There was no difference in probability of VTE between constructs; however, patients who underwent ORIF were diagnosed with VTE earlier than those who underwent IMN (relative rate 0.50, P < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications.

Conclusions

Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.

Pilot study of micromotion nailing for mechanical stimulation of tibial fracture healing

Aims

The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking.

Methods

Patients were treated in a single level I trauma centre over a 2.5-year period. Group allocation was not randomized; both the micromotion nail and standard-of-care static locking nails (control group) were commercially available and selected at the discretion of the treating surgeons. Injury risk levels were quantified using the Nonunion Risk Determination (NURD) score. Radiological healing was assessed until 24 weeks or clinical union. Low-dose CT scans were acquired at 12 weeks and virtual mechanical testing was performed to objectively assess structural bone healing.

Results

A total of 37 micromotion patients and 46 control patients were evaluated. There were no significant differences between groups in terms of age, sex, the proportion of open fractures, or NURD score. There were no nonunions (0%) in the micromotion group versus five (11%) in the control group. The proportion of fractures united was significantly higher in the micromotion group compared to control at 12 weeks (54% vs 30% united; p = 0.043), 18 weeks (81% vs 59%; p = 0.034), and 24 weeks (97% vs 74%; p = 0.005). Structural bone healing scores as assessed by CT scans tended to be higher with micromotion compared to control and this difference reached significance in patients who had biological comorbidities such as smoking.

Conclusion

In this pilot study, micromotion fixation was associated with improved healing compared to standard tibial nailing. Further prospective clinical studies will be needed to assess the strength and generalizability of any potential benefits of micromotion fixation.

Cite this article: Bone Jt Open 2021;2(10):825–833.

Effectiveness of Nail Dynamization in Delayed Union of Tibial Shaft Fractures: Relationship Between Fracture Morphology, Callus Diameter, and Union Rates

OBJECTIVE

Dynamization has already been described as a secondary intervention for delay unions of tibial shaft fractures treated with intramedullary nailing. Although it's a common procedure, it is not widely supported in the literature. The purpose of this study was to determine the union rate of nail dynamization in cases of delayed union of diaphyseal tibial fractures, and assess the effect of fracture morphology on union rates.

MATERIALS AND METHODS

We retrospectively analyzed a series of 199 consecutive tibial shaft fractures. We recorded the dynamization rate, period from nailing to dynamization, nailing to the union, the fracture pattern (according to AO/ASIF and whether it was closed or open), the callus diameter before dynamization (fracture healing index; FHI) and union/failure rates.

RESULTS

Out of a total of 199 fractures treated during the study period, 41 (20.6%) were dynamized. After applying inclusion and exclusion criteria, 39 patients with 39 fractures were included in the study. The mean time from nailing to dynamization was 18.4 ± 7.2 weeks. The union rate was 92.3% (n = 36) over a mean time of 14.1 ± 5.6 weeks as from dynamization. The overall failure rate was 6.7% (n = 3). There was no significant association between failure and AO/ASIF classification (p > 0.05) or fracture exposure (X ² = 0.19; p = 0.66). The pre-dynamization FHI of ≥ 1.17 was significantly associated with consolidation (p < 0.05).

CONCLUSION

In cases of delayed union of tibial fractures, dynamization offered a high union rate associated with pre-dynamization FHI, while fracture morphology did not affect the failure rate.

Open tibial fractures: An overview

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

Tibial alignment following intramedullary nailing via three approaches

PURPOSE

The purpose of this study is to evaluate the incidence of malalignment in patients undergoing IMN for tibial shaft fractures treated with the extra-articular lateral parapatellar, suprapatellar, and infrapatellar approaches.

METHODS

A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical centre. Quality of reduction was assessed using the following three parameters: (1) < 10°of angulation in orthogonal radiographic views (2) < 5 mm of displacement between the major fracture fragments (3) < 5 mm of gap between the major fracture fragments. A good reduction was one that met all 3 criteria, an acceptable reduction met 2 criteria, and a bad reduction met one or none of the criteria. All patients treated consecutively for tibial shaft fractures between June 1, 2019 and June 1, 2020 were identified. The final cohort included 57 tibia fractures in 56 patients. Of the 57 tibia fractures, 8 (14%) were proximal third, 32 (56%) were middle third, and 17 (30%) were distal third fractures.

RESULTS

We found no significant difference in angulation, displacement, or gapping with respect to surgical approach utilized or location of fracture (proximal or distal tibia fractures) on one-way ANOVA. Quality of reduction was rated as "good" in 48 (84%) of the cases (19 supra, 13 infra, and 16 lateral). Nine reductions (16%) met only two of the three reduction quality criteria and were considered acceptable reductions. These included 2 suprapatellar (1 > 5 mm displacement, 1 > 5 mm gapping), 4 infrapatellar (4 > 5 mm displacement), and 3 lateral extra-articular parapatellar (2 > 5 mm displacement and 1 > 5 mm gapping). No reductions were determined to be bad according the Baumgaertner et al. criteria. There was no significant difference in the rate of combined fibula fractures or the rate of fibular fixation between the three cohorts.

CONCLUSIONS

In conclusion, no significant difference was found in fracture reduction angulation, displacement, and gapping in patients treated with an IMN with respect to approach for diaphyseal or metadiaphyseal tibial shaft fractures.

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.

The economic burden of infections following intramedullary nailing for a tibial shaft fracture in England

OBJECTIVES

Determine the impact of infections on direct costs and healthcare resource use in England for patients undergoing intramedullary nailing (IMN) for tibial shaft fractures.

DESIGN

Non-concurrent cohort based on retrospectively collected data with 2-year follow-up.

SETTING

England.

PARTICIPANTS

The study population included adult patients (≥18 years) in England with a diagnosis of tibial shaft fracture (International Classification of Diseases-10, S822) in the inpatient setting between May 2003 and June 2017 followed by a procedure for IMN for tibial shaft fracture within 30 days. Patient data were derived from the Clinical Practice Research Datalink linked to National Health Service Hospital Episode Statistics datasets.

PRIMARY INDEPENDENT VARIABLE

Infection.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was total inpatient costs from index stay admission through 1 year of follow-up. Secondary outcome included cumulative total healthcare costs, and resource utilisation at 30 days, 90 days, 1 year and 2 years.

RESULTS

Overall, 805 patients met the inclusion criteria. At index inpatient stay, 3.7% had a post-IMN infection, rising to 11.7% at 1 year. One-year inpatient costs were 80% higher for patients with infection (p<0.001). Total costs were estimated to be £14 756 (95% CI £13 123 to £16 593) for patients with infection versus £8279 (95% CI £7946 to £8626). Length of stay (LOS), readmission and reoperation were the key drivers of healthcare costs (all p<0.001). After adjustment, LOS was higher by 109% (95% CI 62% to 169%), from 10.5 days to 21.9 days, for patients with infection. The odds of being readmitted or requiring reoperation were higher by 5.18 times (95% CI 3.01 to 9.13) and 2.47 times (95% CI 1.48 to 4.09), respectively, for patients with infection versus those without infection.

CONCLUSIONS

Post-IMN infection significantly increases inpatient costs, LOS, readmissions and reoperations associated with tibial fracture fixation. Healthcare burden could be reduced through novel surgical site infection prevention strategies.

Laser Ablated Periodic Nanostructures on Titanium and Steel Implants Influence Adhesion and Osteogenic Differentiation of Mesenchymal Stem Cells

Metal implants used in trauma surgeries are sometimes difficult to remove after the completion of the healing process due to the strong integration with the bone tissue. Periodic surface micro- and nanostructures can directly influence cell adhesion and differentiation on metallic implant materials. However, the fabrication of such structures with classical lithographic methods is too slow and cost-intensive to be of practical relevance. Therefore, we used laser beam interference ablation structuring to systematically generate periodic nanostructures on titanium and steel plates. The newly developed laser process uses a special grating interferometer in combination with an industrial laser scanner and ultrashort pulse laser source, allowing for fast, precise, and cost-effective modification of metal surfaces in a single step process. A total of 30 different periodic topologies reaching from linear over crossed to complex crossed nanostructures with varying depths were generated on steel and titanium plates and tested in bone cell culture. Reduced cell adhesion was found for four different structure types, while cell morphology was influenced by two different structures. Furthermore, we observed impaired osteogenic differentiation for three structures, indicating reduced bone formation around the implant. This efficient way of surface structuring in combination with new insights about its influence on bone cells could lead to newly designed implant surfaces for trauma surgeries with reduced adhesion, resulting in faster removal times, reduced operation times, and reduced complication rates.

Association of Three-Month Radiographic Union Score for Tibia Fractures (RUST) with Nonunion in Tibial Shaft Fracture Patients

Objectives Nonunions of tibial shaft fractures have profound implications on patient quality of life and are associated with physical and mental suffering. Radiographic Union Score for Tibia Fractures (RUST) may serve as an important prognostic tool for identifying patients at a high risk of nonunion. Design We used data from the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) and Fluid Lavage of Open Wounds (FLOW) trials to explore the association of three-month RUST scores with nonunion in patients with tibial shaft fractures treated with intramedullary nailing. We performed a retrospective cohort study nested within two multi-center, randomized controlled trials. Participants The patients included in the current study: (1) sustained a tibial shaft fracture and were enrolled in the SPRINT or FLOW randomized trials, (2) had initial operative management with intramedullary nailing, (3) showed radiographic evidence of an unhealed fracture at the three-month follow-up, and (4) their healing status (union or nonunion) was captured at 12-months postoperatively. Intervention Multivariable binary logistic regression was carried out to identify factors associated with nonunion, including open versus closed injury, fracture severity, fracture gap, and three-month RUST score. We determined the concordance statistic (c statistic) for our regression model both with and without the RUST score. Outcome Measurements and Results Of the 155 tibial fracture patients with complete data available for analysis, the overall rate of nonunion at 12 months was 30% (n=47). The mean three-month RUST score in patients with nonunion at 12 months was 4.8 (standard deviation (SD) 1.1) as compared to 6.3 (SD 1.7) for those healed at 12 months. In our multivariable regression analysis, open fractures conferred five-fold greater odds of nonunion at 12 months as compared to closed fractures (odds ratio (OR) 4.76, 95% confidence interval (CI):1.71-13.30). Further, three-month RUST scores of 4 and 5-6 were associated with a 47% (95% CI: 18%-73%) and 23% (4.5-51.5%) absolute risk increase of nonunion as compared to a score of ≥ 7, respectively. The addition of RUST scores to our adjusted regression model improved the c statistic from 0.70 (95%CI: 0.61-0.79) to 0.81 (95%CI: 0.74-0.88). Conclusion A third of patients with tibial shaft fractures who have failed to heal by three months will show nonunion at one year. Open fractures and lower three-month RUST scores are strongly associated with a higher risk of nonunion at one year. Further research is needed to establish whether prognosis in this high-risk group can be modified.

Nonunion in Patients with Tibial Shaft Fractures: Is Early Physical Status Associated with Fracture Healing?

Background

Nonunions of tibial shaft fractures have devastating physical and psychological consequences for patients. It remains unknown if early functional status can identify patients at risk for nonunion.

Questions/Purposes

To determine if functional status at three months after surgery, as measured by either the short form 36 (SF-36) or the short form 12 (SF-12) health survey physical component summary (SF-12 PCS) score, can serve as a prognostic indicator for nonunion at one year in patients with fractures of the tibial shaft.

Patients/Methods

This study was an observational cohort study nested within two multicenter, randomized controlled trials. Patients who met the following eligibility criteria were included: (1) sustained a tibial shaft fracture that was treated with intramedullary nailing, (2) were unhealed at the three-month follow-up, (3) had a reported SF-36 or SF-12 PCS score at three months, (4) had the final 12-month follow-up with a reported radiographic healing status (bone union or nonunion), and (5) were enrolled in either the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Shaft Fractures (SPRINT) or Fluid Lavage of Open Wounds (FLOW) randomized trials. Multivariable logistic regression was performed to evaluate the association between healing status at 12 months and seven prognostic variables (open fracture, fracture pattern, nailing technique, smoking, fracture gap, three-month PCS score, and FLOW vs. SPRINT trial).

Results

A total of 940 patients were included in this study with an overall rate of radiographic nonunion of 13.3% (n=125) at the 12-month follow-up. Absolute nonunion risk increased with incrementally lower PCS scores (8.2%, 12.8%, 15.9%, 23.7% for scores ≥ 40, 30.0-39.99, 20.0-29.99, and < 20, respectively). In the multivariable regression analysis, PCS scores of < 20 were associated with a 2.6-times greater odds and 10% absolute risk increase of non-union, as compared to scores of ≥ 40 (OR 2.58, 95%CI: 1.02-6.53, ARI: 10.3, 95% CI: 0.1 - 28.2), whereas scores between 20 and 30 were associated with a nearly two-times greater odds of nonunion and a 6.4% absolute risk increase of nonunion (OR 1.94, 95%CI: 1.08-3.49, ARI: 6.4, 95% CI 0.6 - 15.3). Open fractures also conferred a 2.8-fold increase in odds of nonunion as compared to closed injuries (OR 2.77, 95%CI: 1.58-4.83), as did complex fractures when compared to simple fractures (OR 2.57, 95%CI: 1.64-4.02).

Conclusion

A considerable portion of patients with fractures of the tibial shaft treated with intramedullary nailing will experience nonunion at one-year postoperatively. Nonunion can be accurately predicted by patient functional recovery at three months as measured by the PCS of the SF-36 and SF-12 instruments.

Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients

Background

Studies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN).

Methods

A noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up.

Results

After 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection.

Conclusion

This study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur.

Trial registration

ISRCTN82233198. Retroactively registered on July 29, 2019.

Oblique proximal locking screw in tibial fracture intramedullary nailing: a clinical imaging study of proximity to common peroneal nerve

Intramedullary nailing (IMN) is the treatment of choice in the surgical management of most tibia shaft fractures. The aim of the study was to evaluate the proximity of the common peroneal nerve (CPN) to the oblique proximal locking screw inserted from the anteromedial to the posterolateral direction. We identified all the patients who underwent the IMN of the tibia between 2008 and 2018. Patients who underwent post-operative computed tomography for any reason were identified. Patients were included if the CPN was visible on the axial slices, the proximal oblique locking screw was used, or the line of the drilling could be reconstructed. Twenty-nine patients met the inclusion criteria. The median length of the intramedullary nail was 345 mm. The median nail diameter was 10 mm. The median number of proximal interlocking screws was 2. All scans were reviewed by the musculoskeletal radiologist for verifying the visibility and marking of the CPN. The mean screw trajectory angle to the CPN was 9° (± 9°). Most of the drilling trajectories passed posterior to the CPN (79%). The depth of the intramedullary nail was on average - 8 mm (± 10 mm). A negative correlation was observed between the depth of the nail and the distance from the CPN (P < 0.001). During the insertion of the oblique proximal locking screw from the anteromedial to the posterolateral direction, the CPN is potentially at risk if the drill is allowed to plunge or an incorrectly long screw is used. Sinking the nail provides a better margin of safety.

Semiextended Tibial Nail Insertion Using an Extraarticular Lateral Parapatellar Approach: A 24-Month Follow-up Prospective Cohort Study

OBJECTIVE

To analyze the outcomes of tibial shaft fractures treated with a lateral parapatellar approach in the semiextended position for intramedullary nail insertion.

DESIGN

Prospective cohort study.

SETTING

Level I trauma center.

PATIENTS AND METHODS

Seventy patients treated from March 2012 to July 2015 with intramedullary nailing (IMN) using an extraarticular lateral parapatellar approach in the semiextended position were reviewed. Patients were clinically and radiographically checked at a minimum follow-up of 24 months, and the following data were recorded: fracture healing, any residual deformity, nail-apex distance, range of motion of the treated knee together with the contralateral side, knee functional outcome, and residual knee pain.

RESULTS

Twenty-four months after surgery, all patients were clinically and radiographically healed, with 2 cases of malalignment (angular deformity <10 degrees). The average range of motion of the treated knee was 0-130.6 degrees (±8.6 degrees) compared with 0-131.1 degree (±7.9 degrees) of the contralateral. Lysholm knee score was excellent for 57 patients, good for 11, and fair for 2. The mean residual pain was 0.6 (±1.1) according to the visual analogue scale.

CONCLUSIONS

The described technique represents an effective option for IMN of tibial fractures. It is suitable for all tibial fractures, including proximal and distal. The results of our series demonstrate the effectiveness of this technique with nearly complete recovery of knee function and negligible incidence of anterior knee pain at a minimum follow-up of 24 months.

LEVEL OF EVIDENCE

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

Bifocal Bone Transport over a Preexisting Nail to Treat a Septic Femoral Shaft Nonunion

Intramedullary nailing is the method of choice for the treatment of most femoral shaft fractures. However, it is not always an easy procedure with predictable results as leg length discrepancy as well as rotational and angular malunion may occur. Lengthening over an intramedullary nail (IMN) has become very common as it allows early removal of the external fixator. This report presents a case of an open femoral shaft fracture initially treated with an IMN and subsequently complicated by a septic nonunion. Union was obtained by bifocal bone transport with a circular external fixator over the preexisting nail without exchange or removal of the previously inserted IMN. In conclusion, the presence of an IMN supports osteotomy and regenerates bone during bone healing, prevents fracture and/or deformation of the regenerated bone, and reduces the time needed for the external fixator.

Decrease surgery time by using an alternative lateral parapatellar approach for tibia shaft fracture nailing

INTRODUCTION

Medial parapatellar or transpatellar ligament approaches are commonly used for nail osteosynthesis in tibia shaft fractures. The lower leg is normally in a hanging position to allow guide wire insertion and reaming of the tibia. However, this position complicates fracture reduction and retention, as well as image intensification throughout the procedure. A lateral parapatellar approach with the lower leg in a semi-extended, horizontal position has been previously described for proximal tibial fracture fixation. The purpose of the presented study was to share the lateral parapatellar approach technique used in our institution and to analyse its feasibility for tibia shaft fracture fixation when compared to a medial parapatellar and transpatellar incision technique.

MATERIALS AND METHODS

All patients with tibial shaft fractures treated at our institution between 2009 and 2012 by intramedullary nailing through either a transpatellar, a medial parapatellar or a lateral parapatellar approach were reviewed. Demographics, injury pattern and the operative procedure, especially operation and fluoroscopy time, were analysed.

RESULTS

73 patients were enrolled into the study. Twenty-six patients were treated by use of a lateral parapatellar approach, whilst a transpatellar or a medial parapatellar approach was chosen in 29 and 18 cases, respectively. Patients' characteristics were similar regarding gender and body mass index. When compared to the transpatellar (126 ± 30 min) or the medial parapatellar approach (105 ± 29 min), surgical time was significantly shorter in the lateral parapatellar approach group (96 ± 29 min). Likewise, shorter image intensifier time was documented when a lateral parapatellar approach was chosen (211 ± 189 s) compared to the transpatellar (347 ± 204 s) or the medial parapatellar approach (241 ± 222 s).

CONCLUSION

The extra-articular semi-extended tibial nailing technique using a lateral parapatellar approach was associated with a significant decrease in time of surgery, while fluoroscopy time was shorter but not significantly different between the three groups.

Carbon-Fiber-Reinforced Polymer Intramedullary Nails Perform Poorly in Long-Bone Surgery

BACKGROUND

Carbon-fiber-reinforced (CFR) polymer has produced great excitement in the orthopedic community as a material that will reduce bone healing times and provide improved image quality. Osteotomy stabilized with an intramedullary (IM) nail has become a common technique to address post-traumatic malalignment of the lower extremity.

PURPOSES/QUESTIONS

The following questions were asked: (1) Did CFR polymer nails provide a rapid healing time after long bone osteotomy, shortening, or fracture? (2) Did the CFR polymer nails produce unexpected complications?

METHODS

A retrospective review was conducted in patients who received CFR polymer IM nails for various indications, from April 2016 to January 2017 in a deformity and trauma practice, using patient charts and radiographs. The primary outcomes were time to union and incidence of complications including nonunion, hardware failure, neurovascular injury, venous thromboembolism, and infection.

RESULTS

Twelve patients who received CFR polymer IM nails in 16 limbs for various indications were included in our analysis. Patients were followed for an average of 16.9 months. Eleven limbs underwent realignment and were corrected an average of 23° through a diaphyseal osteotomy. Three limbs underwent limb-shortening surgery, an average of 25 mm, through an open, excisional osteotomy of the femoral diaphysis. Two diaphyseal, closed tibia fractures underwent routine IM nailing. The average time to union was 107.6 days, which included all limbs that united (11/16, 69%). Nonunion occurred in 5/16 (31%) of limbs. Complications recorded included nonunion and hardware failure, most of which resulted in unplanned surgery.

CONCLUSIONS

The use of the CFR polymer IM nail was associated with loss of fixation and nonunion after surgeries that have traditionally healed uneventfully. The increased elasticity of the CFR polymer allows for more motion at the osteotomy/fracture interface than the stiffer titanium counterparts, exposing long-bone osteotomies to delayed union and nonunion, a finding seen with CFR polymer plates. The overwhelmingly poor early results of this device applied to a long-bone deformity practice have led these authors to abandon the use of this implant.

Preoperative Evaluation of Intramedullary Tibial Nail Measurements-A Review of the Literature and a New Technique Using Contralateral Radiographs and Digital Planning

Introduction:

An accurate selection of tibial nail and screws measurements is paramount in purpose to achieve proper tibial fracture reduction and fixation, avoid irritation of the soft-tissue envelope, and enable extraction of the nail in the future, if needed. To this date, many methods were suggested to determine the length and diameter of an intramedullary tibial nail, preoperatively and intraoperatively. Each method has its disadvantages, and most are lacking in accuracy. Digital aids are currently available for preoperative planning for many types of surgeries.

Methods:

Retrospectively, 27 patients operated for diaphysial tibial fracture intramedullary nailing were selected. The contralateral leg was imaged using AP and lateral radiograph views. Six orthopaedic trauma surgeons used the TraumaCad program (Voyant Health) to plan the appropriate nail and distal locking screws measurements, while blinded from the actual hardware used in the operation. Later, they also conducted quality review regarding the operation carried out and suggested correction in measurements of the hardware. Intra-observer and inter-observer reliability was calculated.

Results:

The inter-correlation coefficient for the planned nails was 0.97 and 0.84 (P < 0.001) in AP view for length and diameter, respectively, and similarly 0.98 and 0.86 (P < 0.001) in lateral view. The interclass correlation coefficient (ICC) for the locking screws length was 0.7 (P < 0.02) and 0.82 (P < 0.01) for the proximal and distal medio-lateral screws, respectively, and 0.9 (P < 0.001). The ICC between AP and lateral views was 0.98 for length and 0.96 for diameter (P < 0.001). The scores and corrections given by the examiners to the actual selected nail were ICC of 0.98 and 0.96 (P < 0.001) for length and diameter, respectively. The examiners suggested they would correct, post-factum, the length of the nail in average 28% and the diameter in average 30%. The average observer resulted in ICC of 0.94 and 0.91 (P < 0.001) in length and only 0.77 and 0.67 (P < 0.001) in diameter (AP and lateral views, respectively) when comparing the actual nail used and the post-factum plan.

Conclusion:

Preoperative planning of tibial fractures' nailing using imaging of the contralateral leg and a digital graphic planning program is an accurate and reliable method. It may serve to reduce errors, surgical time, and radiation dose in the operating room. This method could also be applied for surgical debriefing.

Resection Arthroplasty Treatment Possibility for a Patient with Fibrous Dysplasia, Chronic Osteomyelitis, and Recurrent Periprosthetic Hip Joint Infection: A Case Report

Introduction:

Fibrous dysplasia (FD) is a rare congenital abnormality, in which parts of bone are replaced with fibrous stroma and woven bone, making it susceptible to pathological fractures. Osteomyelitis following intramedullary nailing of such fractures of the femur and periprosthetic joint infection (PJI) after hip arthroplasty is one of the most devastating complications and a true challenge for the orthopedic surgeon. To the best of our knowledge, this is the 1st time, such complications are reported in a patient with monostotic FD.

Case Report:

We present a 30-year-old male patient with FD of the left femur, chronic osteomyelitis, recurrent periprosthetic hip joint infection after multiple revision arthroplasties, and two episodes of axillary vein thrombosis. Due to the severe structural changes and a large medial wall defect in the proximal femur with impairment of a large soft tissue zone, it was decided during operation not to put any other implants in the hip joint and perform only a resection hip arthroplasty procedure.

Conclusion:

Managing a recurrent PJI in a patient with poor bone quality, severe bone defects, soft tissue compromise, and thromboembolic events is challenging even for the most experienced orthopedic surgeon. Resection arthroplasty is a salvage treatment option that should be considered in such complex cases.

Intramedullary Nail Fixation of Tibial Shaft Fractures: Suprapatellar Approach

Intramedullary nailing is the most popular and widely used method for treating tibial shaft fractures. Intramedullary nailing involves minimal surgical dissection, allowing preservation of blood supply by not disrupting the soft tissue around the fracture. The procedure is performed with the following steps: (1) the patient is positioned supine on the radiolucent operating table with a bump under the ipsilateral hip; (2) a 4 to 6-cm longitudinal incision is made 2 to 4 cm directly proximal to the superior pole of the patella; (3) the quadriceps tendon is sharply incised at its midline and split longitudinally; (4) a cannula device with a blunt trocar and protective sleeve is inserted into the knee joint between the articular surface of the patella and the trochlea of the distal part of the femur, after which a second pin can be inserted through the cannula device and into the distal part of the femur to stabilize the cannula and keep it from backing out; (5) a 3.2-mm guide pin is inserted and placed resting at the junction of the articular surface and the anterior cortex of the tibia at the appropriate starting point in line with the intramedullary canal; (6) the guide pin is advanced 8 to 10 cm into the proximal part of the tibia, the inner centering sleeve is removed, and the cannulated entry drill is passed over the pin through the outer protective sleeve and used to ream down to the metadiaphyseal level of the proximal part of the tibia; (7) the fracture is reduced; (8) a ball-tipped guidewire is centrally passed across the fracture down to the level of the distal tibial physeal scar; (9) incremental reaming is performed, and the appropriate-size tibial nail is inserted down the tibial canal; (10) the appropriate nail position is confirmed radiographically, and distal interlocking screws are placed with a freehand technique, after which the proximal aiming arm is attached to the insertion handle and interlocking screws are drilled, measured, and placed into the proximal part of the tibia as well; and (11) all incisions as well as the quadriceps tendon are closed. Intramedullary nail fixation is a safe and effective method for treating tibial shaft fractures, and with appropriate surgical technique good outcomes and reproducible results can be expected. This soft-tissue-sparing method of fracture fixation achieves biomechanical stabilization of the fracture using a load-sharing device that allows for earlier postoperative ambulation.

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.

Suprapatellar versus infrapatellar intramedullary nailing for tibal shaft fractures: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

The aim of this study was to compare the outcome of using tibial nails inserted by the suprapatellar approach with tibial nails inserted by the infrapatellar approach in a meta-analysis of randomized controlled trials (RCTs).

METHODS

The following electronic databases were searched: PubMed (1966 to January 2018), EMBASE (1974 to January 2018), Cochrane Library (January 2018), Web of Science (1990 to January 2018). We also used Google Search Engine to search more potentially eligible studies until January 2018. The methodological qualities of included studies were assessed in accordance with the guidelines provided by the Cochrane Collaboration for Systematic Reviews. The statistical analysis all of included studies were performed by STATA 13.0 software. The outcomes were total blood loss, postoperative pain, range of motion (ROM), Lysholm knee score, fluoroscopy time, operation time, and postoperative complications.

RESULTS

Four RCTs published between 2015 and 2017 were selected in the meta-analysis. There was a significant difference between suprapatellar and infrapatellar approach surgery in total blood loss, postoperative pain, ROM, Lysholm knee scores, and fluoroscopy times.

CONCLUSIONS

The suprapatellar approach for intramedullary nailing appears superior to the infrapatellar approach, with a reduction in total blood loss, improved postoperative pain, shorter fluoroscopy time, and better knee functionality outcomes. There was no increased incidence of postoperative complications between the 2 groups. Further research remains necessary.

Open fractures of the lower extremity: Current management and clinical outcomes

Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate.

This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management.

The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility.

Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type.

Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality.

Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072

Complications during removal of stainless steel versus titanium nails used for intramedullary nailing of diaphyseal fractures of the tibia

Objectives

Intramedullary nailing is the treatment of choice for fractures of the tibial shaft, which might necessitate the nail removal due to complications in the long-term. Although considered as a low-risk procedure, intramedullary nail removal is also associated with certain complications. Here, we compared the most commonly used stainless steel and titanium nails with respect to the complications during removal and clinical outcome for intramedullary nailing of diaphyseal fractures of the tibia.

Patients and methods

Sixty-two patients (26 females, 36 males) were included in this retrospective study. Of the removed nails, 24 were of stainless steel and 38 of titanium. Preoperative and intraoperative parameters, such as implant discomfort, anterior knee pain, operating time and amount of bleeding, and postoperative outcomes were evaluated for each patient.

Results

Titanium nail group had more, but not statistically significant, intraoperative complications than stainless steel group during the removal of nails (p = .4498). Operating time and amount of intraoperative bleeding were significantly higher in titanium group than stainless steel group (p = .0306 and p < .001, respectively). Preoperative SF-36 physical component and KSS scores were significantly lower in patients who had removal of titanium nails than those of stainless steel nails, whereas there was no difference in terms of postoperative SF-36 and KSS scores.

Conclusion

In conclusion, although greater bone contact with titanium increases implant stability, nail removal is more difficult, resulting in more longer surgical operation and more intraoperative bleeding. Therefore, we do not recommend titanium nail removal in asymptomatic patients.

Determinants of re-operation following tibia intramedullary nailing at a tertiary hospital in south-west Nigeria

Introduction

intramedullary nailing is a method of choice in the management of long bone diaphyseal fractures. However, complications necessitating re-operation may arise. This study was aimed at determining the rate and indications for re-operation following intramedullary nailing of tibia shaft fractures.

Methods

it was a cross-sectional study done at Orthopaedic Department of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife in Southwest Nigeria. Records of patients who had interlocking nailing for tibia shaft fracture between 2005 and March 2013 were retrieved. Variables of interest extracted included aetiology of fracture, type of fracture, cadre of surgeon and indication for re-operation. Frequency distribution and chi-square analysis were done using SPSS version 22. Level of statistical significance was determined at p-value <0.05

Results

One hundred and forty-six patients had tibia nailing done during the study period. Eighty-six patients met the study criteria with male to female ratio of 2.6:1. There were 51 (59.3%) with open fractures and 35 (40.7%) with closed fractures. Ten patients had re-operation giving a re-operation rate of 11.6 %. Two most common indications for re-operation included loose screw 3 (25%) and surgical site infection (SSI) 3 (25%). There was no statistically significant association between rate of re-operation and the cadre of surgeon (p=0.741) and type of fracture whether closed or open (p=0.190).

Conclusion

Re-operation following tibia intramedullary nailing is an ever present risk. Precautions should be taken to prevent the common indications such as loose screw and surgical site infections.

Prevalence and risk factors for re-interventions following reamed intramedullary tibia nailing

INTRODUCTION

This study aimed to identify the prevalence and the risk factors for re-interventions following reamed intramedullary nailing (IMN) of tibial shaft fractures.

PATIENTS AND METHODS

We retrospectively analysed a prospectively populated data of adult patients that underwent reamed intramedullary nailing for stabilization of tibial shaft fractures over a period of three years. Exclusion criteria were immature patients, pathological and periarticular fractures. Data collected included patient demographics, mechanism of injury, open or closed injury pattern, ISS, perioperative complications, reintervention characteristics (time, cause, number), smoking habits, medical co-morbidities and progress to radiological fracture union. Fractures were classified according to AO/OTA system. The cohort of these patients was divided in two groups: Group 1 included the patients who healed uneventfully and Group 2 included the patients who underwent a re-intervention for the healing of the fracture. A logistic regression analysis model was used to assess the odds ratio (OR) of identified risk factors predicting the necessity of re-interventions.

RESULTS

181 (129 male) patients with a mean age of 37 (range 16-87) met the inclusion criteria. 30 patients were excluded due to inadequate follow up, leaving 151 patients for the study group. 119 patients were included in Group 1. 32 (21.2%) patients who had at least one re-intervention (range 1-3) were included in Group 2. The most common causes for re-intervention were aseptic non-union (31.3%) and removal of implants due to soft tissue irritation/anterior knee pain (31.3%), followed by early metalwork failure (12.5%), infected non-union (9.4%), correction of rotational deformities (9.4%) and canal intramedullary sepsis with evident fracture healing (6.3%). 29 (25.8%) from the study cohort patients sustained an open fracture and 8 of them underwent a re-intervention (20.5% of interventions). Incidence of fracture pattern 42-B, C was statistically significant greater in the reintervention (40.6%) compared to the non-re-intervention group (23.53%) (p = 0.026). Risk factors predicting the need for re-interventions included the type of fracture B, C (p = 0.026 OR: 2.528, range: 1.117-5.721) and increased alcohol consumption (p = 0.027/OR: 2.618, range: 1.116-6.141).

CONCLUSION

Fracture pattern and alcohol abuse were highly predictive for re-interventions following reamed IM nailing for stabilization of acute tibial shaft fractures.

A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures

Background

The purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting.

Materials and methods

We performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento’s criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months.

Results

At 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months.

Conclusions

Patients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion.

Level of evidence

Level-II prognostic.

Minimally invasive surgical treatment for unstable fractures of the proximal phalanx: intramedullary screw

OBJECTIVE

To analyze the clinical-functional parameters and quality of life of patients undergoing minimally invasive surgical treatment for extra-articular fractures of the proximal phalanx, using an intramedullary screw (Acutrak(®)).

METHODS

Between January 2011 and September 2014, a prospective study was conducted on 41 patients (48 fingers) with unstable extra-articular fractures of the proximal phalanx, who underwent minimally invasive surgical treatment using an intramedullary screw (Acutrak(®)). These patients were evaluated 12 months after the surgery by means of the DASH quality-of-life questionnaire, VAS pain scale, measurement of range of motion (ROM, in degrees) and radiographic assessment.

RESULTS

All the patients achieved adequate reduction and consolidation of their fractures. There were statistically significant improvements in quality of life on the DASH scale, pain on the VAS scale and range of motion.

CONCLUSION

The minimally invasive technique for treating unstable extra-articular fractures of the proximal phalanx using an intramedullary screw (Acutrak(®)) is effective and safe, and it presents satisfactory clinical-functional results.

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.

Bone Morphogenetic Protein for the Healing of Tibial Fracture: A Meta-Analysis of Randomized Controlled Trials

PURPOSE

To review the evidence from RCTs on clinical outcomes and benefit of acute tibial fracture and nonunion treated with and without BMPs.

MATERIAL

We searched multiple databases (MEDLINE, EMABSE, BIOSIS and Cochrane central) as well as reference lists of articles and contacted authors. Evaluated outcomes included union rate, revision rate, hardware failure and infection. The weighted and standard mean difference (WMD and SMD) or the relative risk (RR) was calculated for continuous or dichotomous data respectively. The quality of the trial was assessed, and meta-analyses were performed with the Cochrane Collaboration's REVMAN 5.0 software.

RESULTS

Eight RCTs involving 1113 patients were included. For acute tibial fracture, BMP group was associated with a higher rate of union (RR, 1.16; 95% CI, 1.04 to 1.30) and a lower rate of revision (RR, 0.68; 95% CI, 0.54 to 0.85) compared with control group. No significant differences were found in rate of hardware failure and infection. The pooled RR for achieving union for tibial fracture nonunion was 0.98 (95% CI, 0.86 to 1.13). There was no significant difference between the two groups in the rate of revision (RR, 0.48; 95% CI, 0.13 to 1.85) and infection (RR, 0.61; 95% CI, 0.37 to 1.02).

CONCLUSION

Study on acute tibial fractures suggests that BMP is more effective that controls, for bone union and for decreasing the rate of surgical revision to achieve union. For the treatment of tibial fracture nonunion, BMP leads to similar results to as autogenous bone grafting. Finally, well-designed RCTs of BMP for tibial fracture treatment are also needed.

Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

BACKGROUND

Open tibial shaft fractures are one of the most devastating orthopaedic injuries. Surgical treatment options include reamed or unreamed nailing, plating, Ender nails, Ilizarov fixation, and external fixation. Using a network meta-analysis allows comparison and facilitates pooling of a diverse population of randomized trials across these approaches in ways that a traditional meta-analysis does not.

QUESTIONS/PURPOSES

Our aim was to perform a network meta-analysis using evidence from randomized trials on the relative effect of alternative approaches on the risk of unplanned reoperation after open fractures of the tibial diaphysis. Our secondary study endpoints included malunion, deep infection, and superficial infection.

METHODS

A network meta-analysis allows for simultaneous consideration of the relative effectiveness of multiple treatment alternatives. To do this on the subject of surgical treatments for open tibial fractures, we began with systematic searches of databases (including EMBASE and MEDLINE) and performed hand searches of orthopaedic journals, bibliographies, abstracts from orthopaedic conferences, and orthopaedic textbooks, for all relevant material published between 1980 and 2013. Two authors independently screened abstracts and manuscripts and extracted the data, three evaluated the risk of bias in individual studies, and two applied Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria to bodies of evidence. We included all randomized and quasirandomized trials comparing two (or more) surgical treatment options for open tibial shaft fractures in predominantly (ie, > 80%) adult patients. We calculated pooled estimates for all direct comparisons and conducted a network meta-analysis combining direct and indirect evidence for all 15 comparisons between six stabilization strategies. Fourteen trials published between 1989 and November 2011 met our inclusion criteria; the trials comprised a total of 1279 patients surgically treated for open tibial shaft fractures.

RESULTS

Moderate confidence evidence showed that unreamed nailing may reduce the likelihood of reoperation compared with external fixation (network odds ratio [OR], 0.38; 95% CI, 0.23-0.62; p < 0.05), although not necessarily compared with reamed nailing (direct OR, 0.74; 95% CI, 0.45-1.24; p = 0.25). Only low- or very low-quality evidence informed the primary outcome for other treatment comparisons, such as those involving internal plate fixation, Ilizarov external fixation, and Ender nailing. Method ranking based on reoperation data showed that unreamed nailing had the highest probability of being the best treatment, followed by reamed nailing, external fixation, and plate fixation. CIs around pooled estimates of malunion and infection risk were very wide, and therefore no conclusive results could be made based on these data.

CONCLUSION

Current evidence suggests that intramedullary nailing may be superior to other fixation strategies for open tibial shaft fractures. Use of unreamed nails over reamed nails also may be advantageous in the setting of open fractures, but this remains to be confirmed. Unfortunately, these conclusions are based on trials that have had high risk of bias and poor precision. Larger and higher-quality head-to-head randomized controlled trials are required to confirm these conclusions and better inform clinical decision-making.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Searching ClinicalTrials.gov and the International Clinical Trials Registry Platform to inform systematic reviews: what are the optimal search approaches?

BACKGROUND

Since 2005, International Committee of Medical Journal Editors (ICMJE) member journals have required that clinical trials be registered in publicly available trials registers before they are considered for publication.

OBJECTIVES

The research explores whether it is adequate, when searching to inform systematic reviews, to search for relevant clinical trials using only public trials registers and to identify the optimal search approaches in trials registers.

METHODS

A search was conducted in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) for research studies that had been included in eight systematic reviews. Four search approaches (highly sensitive, sensitive, precise, and highly precise) were performed using the basic and advanced interfaces in both resources.

RESULTS

On average, 84% of studies were not listed in either resource. The largest number of included studies was retrieved in ClinicalTrials.gov and ICTRP when a sensitive search approach was used in the basic interface. The use of the advanced interface maintained or improved sensitivity in 16 of 19 strategies for Clinicaltrials.gov and 8 of 18 for ICTRP. No single search approach was sensitive enough to identify all studies included in the 6 reviews.

CONCLUSIONS

Trials registers cannot yet be relied upon as the sole means to locate trials for systematic reviews. Trials registers lag behind the major bibliographic databases in terms of their search interfaces.

IMPLICATIONS

For systematic reviews, trials registers and major bibliographic databases should be searched. Trials registers should be searched using sensitive approaches, and both the registers consulted in this study should be searched.

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.

[Distal tibia peri-implant fracture with an intramedullary nail: a case report]

Peri-implant fractures of the distal tibia after intramedullary nailing are rare. We present a case of a fracture of the distal tibia at the site of the distal interlocking screw. We found two cases reported in the world literature. There are no cases reported in the Spanish literature.

Freehand 'figure 4' technique for tibial intramedullary nailing: introduction of technique and review of 87 cases

Intramedullary nailing of tibial fractures is commonplace, and freehand operative techniques are increasingly popular. The standard freehand method has the knee of the injured leg flexed over a radiolucent bolster. This requires the theatre fluoroscope to swing from antero-posterior to lateral position several times. Furthermore, guide wire placement, reaming and nail insertion are all performed well above most surgeons' shoulder height. Alternatively the leg is hung over the edge of the table, and the assistant must crouch and hold the leg until the nail is passed beyond the fracture. We describe a freehand figure 4 position technique for tibial nailing which is easier both for the surgeons and the radiographer, and present a series of 87 consecutive cases utilising this method.

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.

Is a magnetic-manual targeting device an appealing alternative for distal locking of tibial intramedullary nails?

Background

In order to enable a radiation-free, accurate and simple positioning of distal locking screws, a combined magnetic and manual targeting system has been developed by Sanatmetal®. Where a low-frequency magnetic field is initially used to detect the position of the first drill hole and three more holes can be found with a mechanical template.

Objectives

Our cadaver study was performed to evaluate the accuracy and efficiency of this device.

Materials and Methods

In two runs, 30 probands (group 1: 10 students; group 2: 10 residents; group 3: 10 attendings), none of who being familiar with the device, tested the radiation-free system using 60 intact cadaver tibias. Each proband performed the surgical procedure twice in succession.

Results

Referring to the first attempts, 9.6, 7.2 and 7.1 minutes were the time periods required to insert the four distal screws and the relevant values for the second attempts were 8.6, 6.3 and 6.2 minutes; in both cases revealing a significant difference between group 1 and 2 and group 1 and 3. Furthermore, the mean values within each group indicated a significant decrease of the test duration. Out of the 240 drillings, only one failure (group 1) occurred, representing an accuracy of 99.58 %. Of the probands, 90 % rated the targeting device better than the free-hand technique and 77 % at least attested a high user-friendliness.

Conclusions

Due to our satisfactory test results, the brief training, the steep learning curve and the radiation-free technique the new device has to be considered an appealing alternative for distal locking.

Peri-implant fracture of the distal tibia after intra-medullary nailing of a tibial fracture: a report of two cases

Fracture of the tibia in the area of a pre-existing implant is not common. We report two cases of a fracture of the distal tibia at the distal interlocking screw site. We are not aware of any similar reports in the literature.