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Albushtra A, Mohsen AH, Alnozaili KA, Ahmed F, Aljobahi YMAA, Mohammed F, Badheeb M. External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach. Orthop Res Rev 2024; 16:75-84. [PMID: 38404536 PMCID: PMC10894515 DOI: 10.2147/orr.s450774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/18/2024] [Indexed: 02/27/2024] Open
Abstract
Background External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting. Materials and Methods A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient's demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated. Results The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05). Conclusion A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.
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Affiliation(s)
- Ahmed Albushtra
- Department of Orthopedic, School of Medicine, Ibb University, Ibb, Yemen
| | | | - Khaled Ali Alnozaili
- Department of Orthopedic, School of Medicine, 21 September University, Sana’a, Yemen
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University, Ibb, Yemen
| | | | - Fawaz Mohammed
- Department of Orthopedic, School of Medicine, Ibb University, Ibb, Yemen
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT, USA
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Kotsarinis G, Wakefield SM, Kanakaris NK, Giannoudis PV. Stabilization of Tibial Fractures at Risk of Complications With the Bactiguard Intramedullary Nail: Early to Medium Results With a Novel Metal-Coated Device. J Orthop Trauma 2023; 37:S12-S17. [PMID: 37828696 DOI: 10.1097/bot.0000000000002688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications. DESIGN This is a retrospective case series with prospectively collected data. SETTING Level I Trauma Centre in the United Kingdom. PATIENTS AND INTERVENTION Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up. MAIN OUTCOME MEASUREMENTS The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions. RESULTS Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; [19.3%]) required reinterventions [2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection). CONCLUSIONS The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Georgios Kotsarinis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Sophia M Wakefield
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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Younis M, Barnhill SW, Maguire J, Pretell-Mazzini J. Management of humeral impending or pathological fractures with intramedullary nailing: reaming versus non reaming technique-a retrospective comparative study. Musculoskelet Surg 2022; 106:35-41. [PMID: 32451845 DOI: 10.1007/s12306-020-00668-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/18/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE To compare reamed intramedullary nailing (RIM) versus un-reamed intramedullary nailing (URIM) for the treatment of impending and pathological fractures of the humeral shaft in terms of 24-h postoperative pain, blood transfusion requirements, surgical time, surgical complications, medical complications, length of stay and consolidation rates. METHODS A retrospective comparative study between January 2013 and December 2018 was conducted. Student's t test, Mann-Whitney U and Chi-square tests were used to detect differences within the two study groups. Multiple linear regression was done to adjust for possible confounders. RESULTS A total of 53 patients (33 RIM vs. 20 URIM) underwent humeral nailing. Fifteen (28%) were impending fractures (7 RIM vs. 8 URIM). Multiple myeloma (49%) and metastatic carcinoma (39.6%) were the most common etiologies. Pain score (5.13 ± 0.68 RIM vs. 6.78 ± 0.62 URIM; p = 0.082) and total dose of opioids (33.125 ± 27.6 RIM vs. 33.3 ± 22.28 URIM; p = 0.462) showed similar results. Blood transfusion was more prevalent within RIM group (34.48% RIM vs. 20% URIM; p = 0.044) with a clinical tendency of higher blood loss (207.86 ± 150.83RIM vs. 127.00 ± 179.98 URIM; p = 0.092). There was a consolidation rate of 71.05% (27/38) with no statistical difference (73.08% (19/26) RIM vs. 66.67% (8/12) URIM; p = 0.685). CONCLUSION Our study suggests possible benefit of URIM in terms of less blood transfusions with no difference in consolidation rates. Even though without significance, a tendency to less blood loss, less events of systemic complication and lower length of stay was observed with URIM. Despite its limitations, this study can be used to design future prospective ventures that quantify patient-reported outcomes and provide more clear evidence.
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Affiliation(s)
- M Younis
- Department of Orthopaedic Surgery, University of Miami Hospital, 1400 NW 12th Ave, Miami, FL, 33136, USA
| | - S W Barnhill
- Department of Orthopaedic Surgery, University of Miami Hospital, 1400 NW 12th Ave, Miami, FL, 33136, USA
| | - J Maguire
- Department of Education, University of Miami Leonard M. Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL, 33136, USA
| | - J Pretell-Mazzini
- Department of Orthopaedic Surgery, University of Miami Hospital, 1400 NW 12th Ave, Miami, FL, 33136, USA.
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Nicolaides M, Pafitanis G, Vris A. Open tibial fractures: An overview. J Clin Orthop Trauma 2021; 20:101483. [PMID: 34262849 PMCID: PMC8254044 DOI: 10.1016/j.jcot.2021.101483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/19/2021] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Marios Nicolaides
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgios Pafitanis
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Del Buono A, Zampogna B, Osti L, Fontanarosa A, Garofalo R, Papalia R. Pulsed electromagnetic fields after intramedullary nailing of tibial fractures: a case control study. INTERNATIONAL ORTHOPAEDICS 2021; 45:2945-2950. [PMID: 34448925 DOI: 10.1007/s00264-021-05125-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/20/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE To compare clinical and functional outcomes of two groups of patients undergoing reduction and nailing fixation for diaphyseal fractures of the tibia with (PEMF group) and without (control group) post-operative pulsed electromagnetic field (PEMF) application. METHODS This is a retrospective study on 50 patients (mean age 43.3 years, 28 males and 22 females) with diaphyseal tibial fractures managed between 2017 and 2019. Twenty-five patients underwent reduction, nailing fixation, and PEMF application post-operatively (PEMF group) and 25 patients underwent nailing fixation. Radiographic imaging assessment was performed every month until fracture healing had been evident. Use of analgesics, fracture healing time, post-operative lower limb alignment, and post-operative complications were recorded. Patients were asked about return to preinjury activity. All patients were assessed at 3 months and at an average follow-up of 13 months. The VAS scale and Johner-Wruhs criteria were used for pain assessment and functional recovery, respectively. RESULTS Comparing groups, VAS values were significantly lower in the PEMF group at three months and comparable at one year. The patients in the PEMF group took an average of 4.1 months to resume their preinjury activities, and control patients took an average of 5.3 months (P < 0.0001). According to the Johner-Wruhs score, the effective rate was 100% (25/25) in the PEMF group and 92% (23/25) in the control group (P = 0.14). CONCLUSIONS PEMF application after intramedullary nailing is safe and reduces post-operative pain, use of analgesics, and the time of healing fracture. At one year, there is no difference in outcome measures, regardless of PEMF application.
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Affiliation(s)
- Angelo Del Buono
- Unit of Orthopedics and Trauma Surgery, L. Curto Hospital, Polla, Italy
| | - Biagio Zampogna
- Department of Orthopedics and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Leonardo Osti
- Unit of Arthroscopy and Sports Medicine, Hesperia Hospital, Modena, Italy
| | - Alberto Fontanarosa
- Department of Shoulder Surgery and Sport Trauma Surgery, F. Miulli Hospital, Acquaviva Delle Fonti, BA, Italy
| | - Raffaele Garofalo
- Department of Shoulder Surgery and Sport Trauma Surgery, F. Miulli Hospital, Acquaviva Delle Fonti, BA, Italy
| | - Rocco Papalia
- Department of Orthopedics and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
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Clark D, Vo LU, Piscoya AS, Chan A, Dunn JC. Systematic Review and Analysis of the Quality of Randomized Controlled Trials Comparing Reamed and Unreamed Intramedullary Nailing of Tibial Fractures. J Orthop Trauma 2021; 35:59-64. [PMID: 33079845 DOI: 10.1097/bot.0000000000001910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems. DATA SOURCE PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail." Filters were applied for the years 1991-2019, full articles, human subjects, and English language. STUDY SELECTION Inclusion criteria were (1) prospective and randomized trials, (2) studies reported >80% follow-up, and (3) articles amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) skeletally immature patients or (2) incomplete data sets. DATA EXTRACTION Articles were assessed with the Coleman Methodology Score, the Consolidated Standards of Reporting Trials systems, and Cowan's Categorical Rating by 2 independent observers. DATA SYNTHESIS Scores for individual articles were averaged for the 2 observers. The total and subcategory scores for all included articles were also averaged with SD from both observers. Categories from the 2 grading systems with deficient reporting were measured as a percentage based on grading from both observers. Data were analyzed using kappa statistic and correlation coefficient to assess agreement and reliability. CONCLUSIONS All included articles supported the use of reamed tibial intramedullary nails, but the overall quality of the literature fell in the middle of both the modified Coleman Score and Consolidated Standards of Reporting Trials grading scheme ranges despite being Oxford Level 1. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- DesRaj Clark
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Loc-Uyen Vo
- Texas Tech University Health Sciences Center, El Paso, TX; and
| | - Andres S Piscoya
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Andrew Chan
- Department of Orthopedic Surgery, William Beaumont Army Medical Center, El Paso, TX
| | - John C Dunn
- Department of Orthopedic Surgery, William Beaumont Army Medical Center, El Paso, TX
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Li H, Yu D, Wu S, Zhang Y, Ma L. Multiple Comparisons of the Efficacy and Safety for Seven Treatments in Tibia Shaft Fracture Patients. Front Pharmacol 2019; 10:197. [PMID: 31024295 PMCID: PMC6467001 DOI: 10.3389/fphar.2019.00197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/15/2019] [Indexed: 11/13/2022] Open
Abstract
Background: A tibia shaft fracture is one of the most common long bone fractures, with two general types, open fracture and close fracture. However, there is no universally accepted guideline suggesting which treatment to use under certain circumstances. Therefore, a comprehensive network meta-analysis (NMA) is needed to summarize existing studies and to provide more credible data-based medical guidelines. Methods: Available literature was identified by searching medical databases with relevant key terms. Studies that met the inclusion and exclusion criteria, baseline, intervention, and the outcome of treatments, were extracted. A comparative connection of these studies was demonstrated through net plots. Continuous variables and binary variables were reported as mean difference (MD) and odds ratio (OR) with a 95% credible interval (CrI), respectively. The comparison of direct and indirect outcome and their P-value were listed in the node-splitting table. Treatments for each endpoint were ranked by their surface under the cumulative ranking curve (SUCRA) value. A heat plot was created to illustrate the contribution of raw data and the inconsistency between direct and indirect comparisons. Results: According to the search strategy, 697 publications were identified, and 25 records were included, involving 3,032 patients with tibia shaft fractures. Seven common surgical or non-surgical treatments, including reamed intramedullary nailing (RIN), un-reamed intramedullary nailing (UIN), minimally reamed intramedullary nailing (MIN), ender nailing (EN), external fixation (EF), plate, and cast, were compared, in terms of time to union, reoperation, non-union, malunion, infection and implant failure. Plate performed relatively better for time to union, while cast might be the best choice in close cases to reduce the risks of reoperation, non-union, malunion, and infection. To prevent implant failure, EN seemed to be better. Conclusion: Cast might have the highest probability of the most optimal choice for tibia shaft fracture in close cases, while reamed intramedullary nailing ranked second.
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Affiliation(s)
- Haibo Li
- Department of Orthopaedic, Tianjin Hospital, Tianjin, China
| | - Dapeng Yu
- Department of Emergency Trauma Surgery, the Wendeng Osteopathic Hospital, Weihai, China
| | - Shaobin Wu
- Department of Orthopaedic, Weifang Traditional Chinese Hospital, Weifang, China
| | - Yihang Zhang
- Graduate Student Education Center, Shandong Academy of Medical Sciences, Jinan, China
| | - Liang Ma
- Department of Orthopaedic, Affiliated Hospital of Shandong University of Chinese Medicine, Jinan, China
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Cereijo C, Attum B, Rodriguez-Buitrago A, Jahangir AA, Obremskey W. Intramedullary Nail Fixation of Tibial Shaft Fractures: Suprapatellar Approach. JBJS Essent Surg Tech 2018; 8:e24. [PMID: 30588369 DOI: 10.2106/jbjs.st.17.00063] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Cesar Cereijo
- Vanderbilt Orthopedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | - Basem Attum
- Vanderbilt Orthopedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | | | - A Alex Jahangir
- Vanderbilt Orthopedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | - William Obremskey
- Vanderbilt Orthopedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
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Hierholzer C, Friederichs J, Glowalla C, Woltmann A, Bühren V, von Rüden C. Reamed intramedullary exchange nailing in the operative treatment of aseptic tibial shaft nonunion. INTERNATIONAL ORTHOPAEDICS 2016; 41:1647-1653. [PMID: 27796484 DOI: 10.1007/s00264-016-3317-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 10/12/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this study was to evaluate a standardized treatment protocol regarding the rate of secondary bone union, complications, and functional outcome. METHODS This study was started as a prospective study in a single Level I Trauma Centre between 2003 and 2012. The study group consisted of 188 patients with the diagnosis of an aseptic tibial shaft nonunion. Exchange nailing was performed following a standardized surgical protocol. Long-term follow-up was analyzed for rate of bone healing and functional outcome. RESULTS Osseous healing was achieved in 182 out of 188 patients (97 %). In 165 out of 188 patients (88 %), bone healing was observed timely and uneventfully after a single exchange nailing procedure. An open approach was necessary in 32 patients (17 %). Twenty-three patients (12 %) required additional therapy such as extracorporeal shock wave therapy. Post-operative complications were observed in seven patients (4 %). Almost all patients demonstrated osseous healing within 12 months, with the majority of osseous healing occurring within six months. A relevant shortening of the fractured tibia was observed in 20 out of 188 patients (11 %). After a median follow-up of 23 months (range 12-45 months), outcome was evaluated using the assessment system of Friedman/Wyman. In summary, 154 out of 188 patients (82 %) had a good functional long-term result. DISCUSSION Reamed intramedullary exchange nailing including correction of axis alignment is a safe and effective treatment of aseptic tibial shaft nonunion with a high rate of bone healing and a good radiological and functional long-term outcome.
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Affiliation(s)
| | - Jan Friederichs
- Department of Trauma Surgery, Trauma Center Murnau, Professor Küntscher Str. 8, 82418 Murnau, Germany
| | - Claudio Glowalla
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Woltmann
- Department of Trauma Surgery, Trauma Center Murnau, Professor Küntscher Str. 8, 82418 Murnau, Germany
| | - Volker Bühren
- Department of Trauma Surgery, Trauma Center Murnau, Professor Küntscher Str. 8, 82418 Murnau, Germany
| | - Christian von Rüden
- Department of Trauma Surgery, Trauma Center Murnau, Professor Küntscher Str. 8, 82418 Murnau, Germany. .,Institute of Biomechanics, Paracelsus Medical University, Salzburg, Austria.
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Is There an Impact of Concomitant Injuries and Timing of Fixation of Major Fractures on Fracture Healing? A Focused Review of Clinical and Experimental Evidence. J Orthop Trauma 2016; 30:104-12. [PMID: 26606600 DOI: 10.1097/bot.0000000000000489] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This review aims to summarize current knowledge regarding the underlying patho-mechanisms of delayed fracture healing in polytraumatized patients. DATA SOURCES AND STUDY SELECTION The following search terms were used: "fracture", "hemorrhage," "chest trauma," "inflammation," "inflammatory response," "fracture healing," "delayed healing," "nonunion," "fracture stabilisation," "intramedullary nailing," "external fixation," "early total care," and "damage control." Medline, Embase, and Cochrane Library were searched for studies published between January 1, 1990 through March 30, 2014. Of 1322 publications, 68 were included in the current summary. CONCLUSION Concomitant injuries and the strategy for fracture stabilization seem to affect bone metabolism and fracture healing. Among the relevant patho-mechanisms, interactions between the local and systemic inflammatory response seem to play a role. However, the consequences of fracture fixation strategies in case of severe concomitant injuries on local inflammation and bone healing remain unknown. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Zelle BA, Boni G. Safe surgical technique: intramedullary nail fixation of tibial shaft fractures. Patient Saf Surg 2015; 9:40. [PMID: 26692899 PMCID: PMC4676866 DOI: 10.1186/s13037-015-0086-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/22/2015] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Boris A Zelle
- Department of Orthopaedic Surgery, Division of Orthopaedic Traumatology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229 USA
| | - Guilherme Boni
- Department of Orthopaedics and Traumatology, Federal University of São Paulo, Rua Borges Lagoa, 783-50 Andar, São Paulo, 04038032 Brazil
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Foote CJ, Guyatt GH, Vignesh KN, Mundi R, Chaudhry H, Heels-Ansdell D, Thabane L, Tornetta P, Bhandari M. Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis. Clin Orthop Relat Res 2015; 473:2179-92. [PMID: 25724836 PMCID: PMC4457757 DOI: 10.1007/s11999-015-4224-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/20/2015] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Clary J. Foote
- Division of Orthopaedics, McMaster University, Hamilton, ON Canada ,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
| | - Gordon H. Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada ,Department of Medicine, McMaster University, Hamilton, ON Canada
| | | | - Raman Mundi
- Division of Orthopaedics, McMaster University, Hamilton, ON Canada
| | - Harman Chaudhry
- Division of Orthopaedics, McMaster University, Hamilton, ON Canada
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
| | - Paul Tornetta
- Department of Orthopedics, Boston University, Boston, MA USA
| | - Mohit Bhandari
- Division of Orthopaedics, McMaster University, Hamilton, ON Canada ,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada ,Centre for Evidence-based Orthopaedics, Division of Orthopaedics, McMaster University, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7 Canada
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Hofmann A, Dietz SO, Pairon P, Rommens PM. The role of intramedullary nailing in treatment of open fractures. Eur J Trauma Emerg Surg 2014; 41:39-47. [DOI: 10.1007/s00068-014-0485-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 11/30/2014] [Indexed: 10/24/2022]
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Shao Y, Zou H, Chen S, Shan J. Meta-analysis of reamed versus unreamed intramedullary nailing for open tibial fractures. J Orthop Surg Res 2014; 9:74. [PMID: 25149501 PMCID: PMC4145248 DOI: 10.1186/s13018-014-0074-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 07/27/2014] [Indexed: 11/10/2022] Open
Abstract
Background Open fractures of the tibial diaphysis are usually caused by high-energy trauma and associated with severe bone and soft tissue injury. Reamed and unreamed intramedullary nailing are often used for treatment of tibial injury. The purpose of this study was to investigate the clinical efficacy of reamed versus unreamed intramedullary nailing for open tibial fractures (OTF). Methods A meta-analysis was conducted according to the guidelines of the Cochrane Collaboration using databases containing the Cochrane Library, PubMed, EMbase, Chinese Biomedical Database, Chinese VIP information, and WanFang Database. Randomized and semi-randomized controlled clinical trials of both reamed and unreamed intramedullary nailing for OTF treatment were analyzed using Reviewer Manager (RevMan5.0) software. Results A total of 695 references were initially identified from the selected databases. However, only four studies were assessed, matching all the eligibility criteria conducted by two independent reviewers. The result showed that there was no statistical difference in healing rate, secondary surgery rate, implant failure rate, osteofascial compartment syndrome, and infection during the postoperative period between reamed and unreamed nails in OTF. Conclusions Findings of this study suggest that there was no statistical difference between reamed and unreamed intramedullary nailing in clinical treatment of OTF. However, the result of this meta-analysis should be cautiously accepted due to some limitations, and further studies are still needed.
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Affiliation(s)
| | - Hongxing Zou
- Department of Orthopaedics, The 94th Hospital of PLA, Nanchang 330002, Jiangxi, China.
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Xia L, Zhou J, Zhang Y, Mei G, Jin D. A meta-analysis of reamed versus unreamed intramedullary nailing for the treatment of closed tibial fractures. Orthopedics 2014; 37:e332-8. [PMID: 24762836 DOI: 10.3928/01477447-20140401-52] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 10/09/2013] [Indexed: 02/03/2023]
Abstract
Controversy exists regarding the clinical outcomes of reamed vs unreamed intramedullary nailing in the treatment of closed tibial fractures. This study assessed the effects of reamed vs unreamed intramedullary nailing for closed tibial fractures. The authors searched PubMed, EMBASE, BIOSIS, and the Cochrane Controlled Trials Register for randomized and quasi-randomized controlled clinical trials from January 1980 to June 2012 comparing reamed with unreamed intramedullary nailing for closed tibial fracture in adults. Primary outcomes were nonunion, delayed union, malunion, secondary procedure, failure of implants, compartment syndrome, infection, and knee pain. Eight randomized and 1 quasi-randomized clinical trials (1229 fractures) were included. No statistically significant differences were found between reamed and unreamed nailing groups in delayed union (P=.20), malunion (P=.28), infection (P=.36), compartment syndrome (P=.36), and knee pain (P=.93). The unreamed group had a higher rate of fracture nonunion than the reamed group (P=.02). The subgroup analysis of implant failures (broken screws vs broken nails) indicated that reamed nailing significantly reduced the risk of screw breakage (P<.001); however, there was no significant difference between reamed and unreamed intramedullary nailing in nail breakage (P=.94). The subgroup analysis of a secondary procedure showed that the reamed intramedullary nailing resulted in significantly lower risks of implant exchange (P=.01) and dynamization (P=.04); however, there was no significant difference in bone grafting rate (P=.73). Evidence comparing reamed with unreamed intramedullary nailing for closed tibial fractures indicates that reamed intramedullary nailing may lead to significantly lower risks of nonunion, screw failure, implant exchange, and dynamization without increasing operative complications.
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Deleanu B, Prejbeanu R, Poenaru D, Vermesan D, Haragus H. Reamed versus unreamed intramedullary locked nailing in tibial fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 24:1597-601. [PMID: 24384861 DOI: 10.1007/s00590-013-1401-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 12/22/2013] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Bogdan Deleanu
- I-st Discipline of Orthopedics and Trauma, Emergency Clinical County Hospital, University of Medicine and Pharmacy 'Victor Babes' Timisoara, 10 Iosif Bulbuca Blvd, Orthopedics and Trauma Building, 300736, Timisoara, Romania
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Li CX, Zhao HJ, Zhao WQ, Xu YQ. System evaluation on reamed and non-reamed intramedullary nailing in the treatment of closed tibial fracture. Acta Cir Bras 2013; 28:744-50. [PMID: 24114305 DOI: 10.1590/s0102-86502013001000010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/12/2013] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To systematically evaluate the clinical efficacy of reamed and nonreamed intramedullary nailing in treatment of closed tibial fractures with Cochrane systematic review methods. METHODS According to the Cochrane systematic review methods, literatures were retrieved from Cochrane library, PubMed, EMbase and other database. Randomized controlled trials (RCTs) and quasi-randomized controlled clinical trials about reamed and nonreamed intramedullary nailing in the treatment of closed tibial fractures were collected and RevMan 5.0 was chosen for meta-analysis. RESULTS A total of seven studies were included in this meta-analysis. Reamed intramedullary nailing was better than nonreamed intramedullary nailing in nonunion rate [P = 0.02, RR = 0.46, 95% CI: (0.24, 0.91)] and implant failure rate [P <0.0001, RR = 0.36, 95% CI: (0.22, 0.57)]. No statistically significant difference was observed in malunion rate, compartment syndrome rate, postoperative infection [P = 0.18, RR = 0.50, 95% CI: (0.18, 1.383); P = 0 43, RR = 0.77, 95% CI: (0.40, 1.48); P = 0.27, RR = 0.38, 95% CI: (0.01, 7.87)]. CONCLUSION Compared with the nonreamed intramedullary nailing, reamed intramedullary nailing can lead to better outcome in the treatment of closed tibial fractures.
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Abstract
INTRODUCTION Unreamed intramedullary nailing (UIMN) is an effective treatment procedure for the majority of tibial fractures, with locking constituting the technical support for the buttressing and neutralisation principles underlying intramedullary nailing. It has been claimed that the added versatility obtained from the use of more bolts in distal locking is very important. Several studies have been made concerning the optimum number of locking bolts in distal tibial fractures; however, to the best of our knowledge, no study has dealt with the question of whether two or three bolts should be used in diaphyseal fractures. MATERIAL AND METHODS In this paper, we evaluate the results of treating 86 diaphyseal tibial fractures (type 42 according to the AO classification) with Expert Tibial UIMN (Synthes™, West Chester, PA, USA) and distal blocking with either two or three bolts. Mean patient age was 35 years (21-51). RESULTS We found that the consolidation time is shorter, less radiation time is needed and the material cost is lower when two bolts are used. No other differences were found regarding mean operative time, wound healing, pain at fracture site, joint function, angular deviation or rotation. CONCLUSIONS For type 42 AO tibial fractures treated with Expert Tibial UIMN, distal blocking should be performed with only two bolts.
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Abstract
Background Relatively few studies have addressed plate osteosynthesis for open proximal tibial fractures by now. The purpose of this study was to assess the results of minimally invasive plate osteosynthesis (MIPO) for open fractures of the proximal tibia. Methods Thirty-four patients with an open proximal tibial fracture were treated by MIPO. Thirty of these, who followed for over 1 year, constituted the subject of this retrospective study. According to the AO Foundation and Orthopaedic Trauma Association (AO-OTA) classification, there were 3 patients of type 41-C, 6 of type 42-A, 8 of type 42-B, and 13 of type 42-C. In terms of the Gustilo and Anderson's open fracture grading system, 11 patients were of grade I, 6 were of grade II, and 13 were of grade III (III-A, 6; III-B, 6; III-C, 1). After thorough debridement and wound cleansing, when necessary, a soft tissue flap was placed. Primary MIPO (simultaneous plate fixation with soft tissue procedures) was performed in 18 patients, and staged MIPO (temporary external fixation followed by soft tissue procedures and subsequent conversion to plate fixation after soft tissue healing) was performed in 12 patients. Results were assessed according to the achievement and time to union, complications (including infections), and function of the knee joint using Knee Society scores. Statistical analysis was performed to identify factors influencing results. Results Primary union was achieved by 24 of the 30 study subjects. Early bone grafting was performed in 6 cases with a massive initial bone defect expected to result in non-union. No patient had malalignment greater than 10°. The mean Knee Society score was 88.7 at final follow-up visits, 23 patients achieved an excellent result, and 7 a good result. There were 3 superficial and 5 deep infections, but none required early implant removal. Functional results were similar for primary and staged MIPO (p = 0.113). Fracture pattern (p = 0.089) and open fracture grade (p = 0.079) were not found to influence the results. Conclusions If soft tissue coverage is adequately performed, MIPO could be regarded as an acceptable method for the treatment of open proximal tibial fracture.
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Affiliation(s)
- Joon-Woo Kim
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, Korea
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