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Jones CA, Seilern und Aspang J, Holmes JS, Zamanzadeh RS, Phen HM, Baker JL, Hernandez-Irizarry RC, Moore TJ. Incidence and Risk Factors of Heterotopic Ossification in the Knee After Reamed Tibial Nailing. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202402000-00002. [PMID: 38324456 PMCID: PMC10846776 DOI: 10.5435/jaaosglobal-d-23-00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/26/2023] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Heterotopic ossification (HO) in the knee after tibial intramedullary nailing (IMN) has yet to be thoroughly investigated. Our aim was to assess frequency and associated factors for HO in the knee after tibial IMN. METHODS This is a retrospective review at a single level 1 urban trauma center of 213 patients who underwent reamed tibial IMN. Plain radiographs were reviewed postoperatively and on final follow-up (≥6 weeks). Chart review was performed for surgical approach (suprapatellar versus infrapatellar), demographics, injury characteristics, and clinical follow-up. The primary outcome was frequency of HO. RESULTS HO on final follow-up (mean: 41.43 weeks) was recorded in 15% cases. Postsurgical retroinfrapatellar reaming debris (odds ratio [OR], 4.73), Injury Severity Score (OR, 1.05), intensive care unit admission (OR, 2.89), chest injury (OR, 3.4), and ipsilateral retrograde femoral IMN (OR, 5.08) showed a notable association with HO development. No association was observed in HO formation between surgical approach, knee pain, or range-of-motion deficits. DISCUSSION Radiographic evidence of HO in the knee after reamed tibial IMN is not uncommon and is associated with retained reaming debris, Injury Severity Score, chest injury, intensive care unit admission, and ipsilateral retrograde femoral nailing. No differences were noted in HO formation between approaches. HO was not associated with knee pain or range-of-motion deficits.
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Affiliation(s)
- Corey A. Jones
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | | | - Jeffrey S. Holmes
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | - Ryan S. Zamanzadeh
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | - Huai M. Phen
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | - J.'Lynn L. Baker
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | | | - Thomas J. Moore
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
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Albareda J, Ibarz E, Mateo J, Suñer S, Lozano C, Gómez J, Redondo B, Torres A, Herrera A, Gracia L. Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study. Injury 2021; 52 Suppl 4:S61-S70. [PMID: 33707035 DOI: 10.1016/j.injury.2021.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful. MATERIAL AND METHODS This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation. RESULTS The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%. CONCLUSIONS The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.
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Affiliation(s)
- J Albareda
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - E Ibarz
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - J Mateo
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital. Zaragoza, Spain
| | - S Suñer
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - C Lozano
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - J Gómez
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital.
| | - B Redondo
- Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Torres
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Herrera
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - L Gracia
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
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Bhan K, Tyagi A, Kainth T, Gupta A, Umar M. Reamed Exchange Nailing in Nonunion of Tibial Shaft Fractures: A Review of the Current Evidence. Cureus 2020; 12:e9267. [PMID: 32821613 PMCID: PMC7431313 DOI: 10.7759/cureus.9267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
One of the most dreaded complications of fracture management is a nonunion. Nonunions are usually difficult to manage and can be a source of significant mental, physical, and financial distress to the patient. The incidence of nonunion is dependent on multiple factors including degree of comminution, open versus closed, concomitant infection, and vascular status, and therefore the management of such nonunions continues to be an often debated topic. Currently, there is no clear consensus on the role of reamed exchange nailing for tibial shaft nonunions. While reamed exchange nailing for aseptic tibial shaft nonunions has shown promising results, with very high union rates, many surgeons prefer newer novel techniques such as plating along with osteoperiosteal decortication or the use of more conventional compressive plating with bone grafts. The aim of this article is to critically review and understand the available evidence base on reamed exchange nailing in nonunion of tibial shaft fractures and to explore the other options available and their indications.
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Affiliation(s)
- Kavyansh Bhan
- Trauma and Orthopaedics, Whipps Cross University Hospital, London, GBR
| | - Anshika Tyagi
- Orthopaedic Surgery, Maulana Azad Medical College, New Delhi, IND
| | - Tejasvi Kainth
- Language Access and Internal Medicine, Winnipeg Regional Health Authority, Winnipeg, CAN
| | - Apurv Gupta
- Surgery, Maulana Azad Medical College, New Delhi, IND
| | - Muhammad Umar
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
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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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Van Steyn P, Romash M. An Innovative Approach to the Repair of Distal Tibia Nonunion Using a Retrograde Buried Tibio-Talar-Calcaneal Nail: A Case Report. J Foot Ankle Surg 2016; 56:117-120. [PMID: 27612414 DOI: 10.1053/j.jfas.2016.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Indexed: 02/03/2023]
Abstract
We report a case using retrograde tibial nailing as treatment of nonunion of a distal tibial osteotomy, which was performed as part of a complex reconstruction of distal tibial malunion with ankle arthritis. Although retrograde nailing has classically been used for tibial-talar-calcaneal arthrodesis, this method spares the subtalar joint. Preservation of some hindfoot motion by subtalar mobility allows for a decrease in the loss of function typically seen with tibial-talar-calcaneal arthrodesis.
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Affiliation(s)
- Peter Van Steyn
- Medical Student, Eastern Virginia Medical School, Norfolk, VA.
| | - Michael Romash
- Orthopaedic Surgeon, Sports Medicine of Chesapeake, Chesapeake, VA
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Li AB, Zhang WJ, Guo WJ, Wang XH, Jin HM, Zhao YM. Reamed versus unreamed intramedullary nailing for the treatment of femoral fractures: A meta-analysis of prospective randomized controlled trials. Medicine (Baltimore) 2016; 95:e4248. [PMID: 27442651 PMCID: PMC5265768 DOI: 10.1097/md.0000000000004248] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Intramedullary nailing is commonly used for treating femoral shaft fractures, one of the most common long bone fractures in adults. The reamed intramedullary nail is considered the standard implant for femoral fractures. This meta-analysis was performed to verify the superiority of reamed intramedullary nailing over unreamed intramedullary nailing in fractures of the femoral shaft in adults. Subgroup analysis of implant failure and secondary procedure was also performed. METHODS Electronic literature databases were used to identify relevant publications and included MEDLINE (Ovid interface), EMBASE (Ovid interface), and the Cochrane Central Register of Controlled Trials (CENTRAL; Wiley Online Library). The versions available on January 30, 2016, were utilized. Only human studies, which were designed as randomized controlled clinical trials, were included. Two authors independently evaluated the quality of original research publications and extracted data from the studies that met the criteria. RESULTS Around 8 randomized controlled trials involving 1078 patients were included. Reamed intramedullary nailing was associated with shorter time to consolidation of the fracture (SMD = -0.62, 95% CI = -0.89 to -0.35, P < 0.00001), lower secondary procedure rate (OR = 0.25, 95% CI 0.10-0.62, P = 0.003), lower nonunion rate (OR = 0.14, 95% CI = 0.05-0.40, P < 0.01), and lower delayed-union rate (OR = 0.19, 95% CI = 0.07-0.49, P < 0.01) compared to unreamed intramedullary nailing. The 2 groups showed no significant differences in risk of implant failure (OR = 0.50, 95% CI 0.14-1.74, P = 0.27), mortality risk (OR = 0.94, 95% CI 0.19-4.68, P = 0.94), risk of acute respiratory distress syndrome (ARDS; OR = 1.55, 95% CI 0.36-6.57, P = 0.55), or blood loss (SMD = 0.57, 95% CI = -0.22 to 1.36, P = 0.15). CONCLUSION Reamed intramedullary nailing is correlated with shorter time to union and lower rates of delayed-union, nonunion, and reoperation. Reamed intramedullary nailing did not increase blood loss or the rates of ARDS, implant failure, and mortality compared to unreamed intramedullary nailing. Therefore, the treatment of femoral fractures using reamed intramedullary nailing is recommended.
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Affiliation(s)
| | | | | | | | | | - You-Ming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Correspondence: You-Ming Zhao, Department of Orthopaedics, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (e-mail: )
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Rössig C, Angrisani N, Helmecke P, Besdo S, Seitz JM, Welke B, Fedchenko N, Kock H, Reifenrath J. In vivo evaluation of a magnesium-based degradable intramedullary nailing system in a sheep model. Acta Biomater 2015; 25:369-83. [PMID: 26188326 DOI: 10.1016/j.actbio.2015.07.025] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/01/2015] [Accepted: 07/14/2015] [Indexed: 01/10/2023]
Abstract
The biocompatibility and the degradation behavior of the LAE442 magnesium-based intramedullary interlocked nailing system (IM-NS) was assessed in vivo in a comparative study (stainless austenitic steel 1.4441LA) for the first time. IM-NS was implanted into the right tibia (24-week investigation period; nails/screws diameter: 9 mm/3.5 mm, length: 130 mm/15-40 mm) of 10 adult sheep (LAE442, stainless steel, n=5 each group). Clinical and radiographic examinations, in vivo computed tomography (CT), ex vivo micro-computed tomography (μCT), mechanical and histological examinations and element analyses of alloying elements in inner organs were performed. The mechanical examinations (four-point bending) revealed a significant decrease of LAE442 implant stiffness, force at 0.2% offset yield point and maximum force. Periosteal (new bone formation) and endosteal (bone decline) located bone alterations occurred in both groups (LAE442 alloy more pronounced). Moderate gas formation was observed within the LAE442 alloy group. The CT-measured implant volume decreased slightly (not significant). Histologically a predominantly direct bone-to-implant interface existed within the LAE442 alloy group. Formation of a fibrous tissue capsule around the nail occurred in the steel group. Minor inflammatory infiltration was observed in the LAE442 alloy group. Significantly increased quantities of rare earth elements were detected in the LAE442 alloy group. μCT examination showed the beginning of corrosion in dependence of the surrounding tissue. After 24 weeks the local biocompatibility of LAE442 can be considered as suitable for a degradable implant material. STATEMENT OF SIGNIFICANCE An application oriented interlocked intramedullary nailing system in a comparative study (degradable magnesium-based LAE442 alloy vs. steel alloy) was examined in a sheep model for the first time. We focused in particular on the examination of implant degradation by means of (μ-)CT, mechanical properties (four-point bending), clinical compatibility, local bone reactions (X-ray and histology) and possible systemic toxicity (histology and element analyses of inner organs). A significant decrease of magnesium (LAE442 alloy) implant stiffness and maximum force occurred. Moderate not clinically relevant gas accumulation was determined. A predominantly direct bone-to-implant contact existed within the magnesium (LAE442 alloy) group compared to an indirect contact in the steel group. Rare earth element accumulation could be observed in inner organs but H&E staining was inconspicuous.
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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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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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Schemitsch EH, Bhandari M, Guyatt G, Sanders DW, Swiontkowski M, Tornetta P, Walter SD, Zdero R, Goslings JC, Teague D, Jeray K, McKee MD. Prognostic factors for predicting outcomes after intramedullary nailing of the tibia. J Bone Joint Surg Am 2012; 94:1786-93. [PMID: 23032589 PMCID: PMC3448300 DOI: 10.2106/jbjs.j.01418] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prediction of negative postoperative outcomes after long-bone fracture treatment may help to optimize patient care. We recently completed the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT), a large, multicenter trial of reamed and unreamed intramedullary nailing of tibial shaft fractures in 1226 patients. Using the SPRINT data, we conducted an investigation of baseline and surgical factors to determine any associations with an increased risk of adverse events within one year of intramedullary nailing. METHODS Using multivariable logistic regression analysis, we investigated fifteen baseline and surgical factors for any associations with an increased risk of negative outcomes. RESULTS There was an increased risk of negative events in patients with a high-energy mechanism of injury (odds ratio [OR] = 1.57; 95% confidence interval [CI], 1.05 to 2.35), a stainless steel compared with a titanium nail (OR = 1.52; 95% CI, 1.10 to 2.13), a fracture gap (OR = 2.40; 95% CI, 1.47 to 3.94), and full weight-bearing status after surgery (OR = 1.63; 95% CI, 1.00 to 2.64). There was no increased risk with the use of nonsteroidal anti-inflammatory agents, late or early time to surgery, or smoking status. Open fractures had a higher risk of events among patients treated with reamed nailing (OR = 3.26; 95% CI, 2.01 to 5.28) but not in patients treated with unreamed nailing (OR = 1.50; 95% CI, 0.92 to 2.47). Patients with open fractures who had wound management either without any additional procedures or with delayed primary closure had a decreased risk of events compared with patients who required subsequent, more complex reconstruction (OR = 0.18 [95% CI, 0.09 to 0.35] and 0.29 [95% CI, 0.14 to 0.62], respectively). CONCLUSIONS We identified several baseline fracture and surgical characteristics that may increase the risk of adverse events in patients with tibial shaft fractures. Surgeons should consider the predictors identified in our analysis to inform patients treated for tibial shaft fractures. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emil H Schemitsch
- Division of Orthopaedics, Department of Surgery, University of Toronto, St. Michael's Hospital, Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada.
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Fatigue performance of angle-stable tibial nail interlocking screws. INTERNATIONAL ORTHOPAEDICS 2012; 37:113-8. [PMID: 22875484 DOI: 10.1007/s00264-012-1633-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 07/17/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Tibial nail interlocking screw failure often occurs during delayed fracture consolidation or at early weight bearing of nailed unstable fractures, in general when high implant stress could not be reduced by other means. Is there a biomechanical improvement in long-term performance of angle stable locking screws compared to conventional locking screws for distal locking of intramedullary tibial nails? METHODS Surrogate bones of human tibiae were cut in the distal third and distal locking of the 10 mm intramedullary tibial nail was performed with either two angle stable locking screws or two conventional locking screws in the mediolateral plane. Six specimens per group were mechanically tested under quasi-static and cyclic axial loading with constantly increasing force. RESULTS Angle stable locking screw constructs exhibited significantly higher stiffness values (7,809 N/mm ± 647, mean ± SD) than conventional locking screw constructs (6,614 N/mm ± 859, p = 0.025). Angle stable locking screw constructs provided a longer fatigue life, expressed in a significantly higher number of cycles to failure (187,200 ± 18,100) compared to conventional locking screw constructs (128,700 ± 7,000, p = 0.004). CONCLUSION Fatigue performance of locking screws can be ameliorated by the use of angle stable locking screws, being especially important if the nail acts as load carrier and an improved stability during fracture healing is needed.
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Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev 2012; 1:CD008241. [PMID: 22258982 DOI: 10.1002/14651858.cd008241.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intramedullary nailing is commonly used for treating fractures of the tibial shaft. These fractures are one of the most common long bone fractures in adults. OBJECTIVES To assess the effects (benefits and harms) of different methods and types of intramedullary nailing for treating tibial shaft fractures in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and reference lists of articles to December 2009. The search was subsequently updated to September 2011 to assess the more recent literature. SELECTION CRITERIA Randomised and quasi-randomised controlled clinical studies evaluating different methods and types of intramedullary nailing for treating tibial shaft fractures in adults were included. Primary outcomes were health-related quality of life, patient-reported function and re-operation for treatment failure or complications. DATA COLLECTION AND ANALYSIS At least two review authors independently performed study selection, risk of bias assessment, and data collection and extraction. MAIN RESULTS Nine randomised and two quasi-randomised clinical trials, involving a total of 2093 participants with 2123 fractures, were included. The evidence was dominated by one large multicentre trial of 1319 participants. Both quasi-randomised trials were at high risk of selection bias. Otherwise, the trials were generally at low or unclear risk of bias. There were very few data on functional outcomes; and often incomplete data on re-operations. The trials evaluated five different comparisons of interventions: reamed versus unreamed intramedullary nailing (six trials); Ender nail versus interlocking nail (two trials); expandable nail versus interlocking nail (one trial); interlocking nail with one distal screw versus with two distal screws (one trial); and closed nailing via the transtendinous approach versus the paratendinous approach (one trial).No statistically significant differences were found between the reamed and unreamed nailing groups in 'major' re-operations (66/789 versus 72/756; risk ratio (RR) 0.88, 95% confidence interval (CI) 0.64 to 1.21; 5 trials), or in the secondary outcomes of nonunion, pain, deep infection, malunion and compartment syndrome. While inconclusive, the evidence from a subgroup analysis suggests that reamed nailing is more likely to reduce the incidence of major re-operations related to non-union in closed fractures than in open fractures. Implant failure, such as broken screws, occurred less often in the reamed nailing group (35/789 versus 79/756; RR 0.42, 95% CI 0.28 to 0.61).There was insufficient evidence established to determine the effects of interlocking nail with one distal screw versus with two distal screws, interlocking nail versus expandable nail and paratendinous approach versus transtendinous approach for treating tibial shaft fractures in adults.Ender nails when compared with an interlocking nail in two trials resulted in a higher re-operation rate (12/110 versus 3/128; RR 4.43, 95% CI 1.37 to 14.32) and more malunions. There were no statistically significant differences between the two devices in the other reported secondary outcomes of nonunion, deep infection, and implant failure.One trial found a lower re-operation rate for an expandable nail when compared with an interlocking nail (1/27 versus 9/26; RR 0.11, 95% CI 0.01 to 0.79). The differences between the two nails in the incidence of deep infection or neurological defects were not statistically significant.The trial comparing one distal screw versus two distal screws found no statistically significant difference in nonunion between the two groups. However, it found significantly more implant failures in the one distal screw group (13/22 versus 1/20; RR 11.82, 95% CI 1.70 to 82.38).One trial found no statistically significant differences in functional outcomes or anterior knee pain at three year follow-up between the transtendinous approach and the paratendinous approach for nail insertion. AUTHORS' CONCLUSIONS Overall, there is insufficient evidence to draw definitive conclusions on the best type of, or technique for, intramedullary nailing for tibial shaft fractures in adults. 'Moderate' quality evidence suggests that there is no clear difference in the rate of major re-operations and complications between reamed and unreamed intramedullary nailing. Reamed intramedullary nailing has, however, a lower incidence of implant failure than unreamed nailing. 'Low' quality evidence suggests that reamed nailing may reduce the incidence of major re-operations related to non-union in closed fractures rather than in open fractures. 'Low' quality evidence suggests that the Ender nail has poorer results in terms of re-operation and malunion than an interlocking nail.
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Affiliation(s)
- Xin Duan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Briel M, Sprague S, Heels-Ansdell D, Guyatt G, Bhandari M, Blackhouse G, Sanders D, Schemitsch E, Swiontkowski M, Tornetta P, Walter SD, Goeree R. Economic evaluation of reamed versus unreamed intramedullary nailing in patients with closed and open tibial fractures: results from the study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:450-457. [PMID: 21669369 DOI: 10.1016/j.jval.2010.10.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 08/13/2010] [Accepted: 10/08/2010] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Recently, results from the large, randomized study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT) trial suggested a benefit for reamed intramedullary nail insertion in patients with closed tibial shaft fractures largely based on cost-neutral autodynamizations and a potential advantage for unreamed intramedullary nailing in open fractures. We performed an economic evaluation to compare resource use and effectiveness of reamed and unreamed intramedullary nailing using a cost-utility analysis. METHODS We calculated quality-adjusted life years (QALYs) for each patient from a self-administered health utility index 3 questionnaire for the first 12 months following the intramedullary nailing. A convenience sample of 235 SPRINT patients provided data on costs associated with health care resource utilization. All costs are reported in Canadian dollars for the 2008 financial year. RESULTS We found incremental effects of -0.017 (95% confidence interval [CI] -0.021-0.058) and -0.002 (95% CI -0.060-0.062) QALYs for patients treated with reamed compared with unreamed intramedullary nails in closed and open fractures, respectively. The incremental costs for reamed compared with unreamed intramedullary nailing were $51 Canadian dollars (95% CI -$2298-$2400) in closed tibial fractures and $2546 Canadian dollars (95%CI -$1773-$6864) in open tibial fractures. Unreamed nailing dominated reamed nailing for both closed and open tibial fractures; however, the cost and the utility results had high variability. CONCLUSION Our economic analysis from a governmental perspective suggests small differences in both cost and effectiveness with large uncertainty between reamed and unreamed intramedullary nailing.
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Aro HT, Govender S, Patel AD, Hernigou P, Perera de Gregorio A, Popescu GI, Golden JD, Christensen J, Valentin A. Recombinant human bone morphogenetic protein-2: a randomized trial in open tibial fractures treated with reamed nail fixation. J Bone Joint Surg Am 2011; 93:801-8. [PMID: 21454742 DOI: 10.2106/jbjs.i.01763] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recombinant human bone morphogenetic protein-2 (rhBMP-2) improves healing of open tibial fractures treated with unreamed intramedullary nail fixation. We evaluated the use of rhBMP-2 in the treatment of acute open tibial fractures treated with reamed intramedullary nail fixation. METHODS Patients were randomly assigned (1:1) to receive the standard of care consisting of intramedullary nail fixation and routine soft-tissue management (the SOC group) or the standard of care plus an absorbable collagen sponge implant containing 1.5 mg/mL of rhBMP-2 (total, 12.0 mg) (the rhBMP-2/ACS group). Randomization was stratified by fracture severity. The absorbable collagen sponge was placed over the fracture at wound closure. The primary efficacy end point was the proportion of subjects with a healed fracture as demonstrated by radiographic and clinical assessment thirteen and twenty weeks after definitive wound closure. RESULTS Two hundred and seventy-seven patients were randomized and were the subjects of the intent-to-treat analysis. Thirteen percent of the fractures were Gustilo-Anderson Type IIIB. The proportions of patients with fracture-healing were 60% and 48% at week 13 (p = 0.0541) and 68% and 67% at week 20 in the rhBMP-2/ACS and SOC groups, respectively. Twelve percent of the subjects underwent secondary procedures in each group; more invasive procedures (e.g., exchange nailing) accounted for 30% of the procedures in the rhBMP-2/ACS group and 57% in the SOC group (p = 0.1271). Infection was seen in twenty-seven (19%) of the patients in the rhBMP-2/ACS group and fifteen (11%) in the SOC group (p = 0.0645; difference in infection risk = 0.09 [95% confidence interval, 0.0 to 0.17]). The adverse event incidence was otherwise similar between the treatment groups. CONCLUSIONS The healing of open tibial fractures treated with reamed intramedullary nail fixation was not significantly accelerated by the addition of an absorbable collagen sponge containing rhBMP-2.
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Affiliation(s)
- Hannu T Aro
- Turku University Hospital, Kiinamyllynkatu 10, 20520 Turku, Finland.
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Abstract
BACKGROUND Meta-analysis has become accepted as a methodically rigorous research tool, and as a result, many meta-analyses have been undertaken in orthopedic trauma, the implication being that their conclusions have improved surgeons' knowledge and facilitated improved clinical care. There have been criticisms of the methodology used in a number of meta-analyses; however, there has been no previous study of the clinical usefulness of their conclusions. METHODS A study of 60 orthopedic trauma meta-analyses published during or after 2000 was undertaken. We divided the conclusions of the meta-analyses into four types depending on their innovation and potential for improving clinical care. We also separated the meta-analyses according to whether they were undertaken by the Cochrane Collaboration or by independent surgeons. RESULTS Only 4 (6.7%) of the meta-analyses contained new, clinically useful, information, and 22 (36.7%) had no conclusions at all. A further 25 (41.7%) contained conclusions that were already in the standard orthopedic trauma literature. Approximately 70% of the Cochrane Collaborations had no conclusions. CONCLUSIONS We found considerable variability in the clinical usefulness of orthopedic trauma meta-analyses, and we question the clinical usefulness of this type of research.
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Cox G, Jones E, McGonagle D, Giannoudis PV. Reamer-irrigator-aspirator indications and clinical results: a systematic review. INTERNATIONAL ORTHOPAEDICS 2011; 35:951-6. [PMID: 21243358 DOI: 10.1007/s00264-010-1189-z] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 12/08/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND The 'reamer-irrigator-aspirator' (RIA) is an innovation developed to reduce fat embolism (FE) and thermal necrosis (TN) that can occur during reaming/nailing of long-bone fractures. Since its inception its indications have expanded to include the treatment of long-bone osteomyelitis and as a harvester of bone graft/mesenchymal stem cells (MSCs). METHODS This study involved a systematic review, via Pubmed® and Google Scholar®, of English language sources (nine non-clinical studies, seven clinical studies and seven case reports) using the keywords: 'reamer', 'irrigator', 'aspirator' (1st May 2010). Sources were reviewed with reference to the RIAs efficacy in (1) preventing FE/TN, (2) treating long-bone osteomyelitis, (3) harvesting bone graft/MSCs, and (4) operating safely. Experimental data supports the use of the RIA in preventing FE and TN, however, there is a paucity of clinical data. CONCLUSIONS The RIA is a reliable method in achieving high volumes of bone graft/MSCs, and high union rates are reported when using RIA bone-fragments to treat non-unions. Evidence suggests possible effectiveness in treating long-bone osteomyelitis. The RIA appears relatively safe, with a low rate of morbidity provided a meticulous technique is used. When complications occur they respond well to conventional techniques. The RIA demands further investigation especially with respect to the optimal application of MSCs for bone repair strategies.
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Affiliation(s)
- George Cox
- Department of Trauma and Orthopaedics, Academic Unit, Clarendon Wing, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, UK
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Abstract
In this review we focus on the local biologic and physiologic effects of intramedullary reaming of long bones. Among the topics discussed are the consequences for vascularity, as well as the pathophysiology of intramedullary pressure generation and temperature increase. Reaming techniques and their suggested effects on bone formation are outlined. Moreover, techniques for avoiding local and systemic complications are summarized.
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Affiliation(s)
- Roman Pfeifer
- Department of Orthopaedic and Trauma Surgery, University of Aachen Medical Center, 30 Pauwels Street, 52074 Aachen, Germany.
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Lam SW, Teraa M, Leenen LPH, van der Heijden GJMG. Systematic review shows lowered risk of nonunion after reamed nailing in patients with closed tibial shaft fractures. Injury 2010; 41:671-5. [PMID: 20226459 DOI: 10.1016/j.injury.2010.02.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 12/10/2009] [Accepted: 02/15/2010] [Indexed: 02/02/2023]
Abstract
Nonunion after intramedullary nailing (IMN) in patients with tibial shaft fractures occurs up to 16%. There is no agreement whether reaming prior to IMN insertion would reduce the nonunion rate. We aimed to compare the nonunion rate between reamed and unreamed IMN in patients with tibial shaft fractures. A systematic search was conducted in Pubmed, Embase, and the Cochrane Library. The selected publications were: (1) randomised controlled trials; (2) comparing the nonunion rate; (3) in patients with tibial shaft fractures; (4) treated with either reamed or unreamed IMN. Seven studies that satisfied the criteria were identified. They showed that reamed IMN led to reduction of nonunion rate compared to unreamed IMN in closed tibial shaft fractures (risk difference ranging 7.0-20%, number needed to treat ranging 5-14), while the difference between compared treatments for open tibial shaft fractures was not clinically relevant. The evidence showed a consistent trend of reduced nonunion rate in closed tibial shaft fracture treated with reamed compared to unreamed IMN.
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Affiliation(s)
- S W Lam
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.
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Abstract
Reaming and non-reaming of intramedullary nails in long bone fractures was a controversial and even emotional topic in recent decades. This article gives an historical overview of the development in this field and presents the background to the need for unreamed nailing. Furthermore, the current state of knowledge is illustrated by describing the results of a series of randomised controlled trials. Before the year 2000 nearly all German handbooks on orthopaedic and trauma surgery recommended unreamed intramedullary nailing as a more "biological" treatment that causes less harm to vascularity with equal or even better results. Unreamed nailing was in particular advocated for the treatment of open fractures. The tide turned as randomised controlled trials conducted since 2000 gave evidence that unreamed nailing leads to a higher rate of delayed or non-union, while the advantages to blood supply and infection rate could not be proven. According to evidence based medicine isolated femur and tibia fractures should be nailed in a reamed procedure. In a severe multiple injury setting it is safer to stabilize long bone fractures with external fixators, as adverse events are described for reamed and unreamed nailing.
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Abstract
The Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) was a randomized controlled trial to evaluate rates of reoperation and complications resulting from reamed versus unreamed intramedullary nailing for the treatment of tibial shaft fractures. The trial found a possible benefit for reamed intramedullary nailing in patients with closed tibial fractures, but no difference was found between the 2 approaches in patients with open fractures. This article is a review and critique of the methodology used in the SPRINT trial. Numerous aspects of the trial's design served to greatly reduce the potential bias, producing sound and reliable results. Overall, the SPRINT trial should provide recommendations for change in clinical practice and also set a benchmark for the conduct of randomized controlled trials in orthopedic surgery.
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Xue D, Zheng Q, Li H, Qian S, Zhang B, Pan Z. Reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures: a subgroup analysis of randomised trials. INTERNATIONAL ORTHOPAEDICS 2009; 34:1307-13. [PMID: 19841919 DOI: 10.1007/s00264-009-0895-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 09/06/2009] [Accepted: 10/04/2009] [Indexed: 10/20/2022]
Abstract
The choice between reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures is an ongoing controversy. We carried out a comprehensive search strategy. Six eligible randomised controlled trials were included. Three reviewers independently assessed methodological quality and extracted outcome data. Analyses were performed using Review Manager 5.0. The results showed lower risks of tibial fracture nonunion and implant failures with reamed nails compared to unreamed nails in closed tibial fractures [relative risk (RR): 0.41, 95% confidence interval (CI): 0.21-0.89, P = 0.008 for nonunion and RR: 0.35, 95% CI: 0.22-0.56, P < 0.0001 for implant failures], but no statistical differences in risk reduction of malunion, compartment syndrome, embolism and infection. Our results suggested no statistical differences in risk reduction of all the complications evaluated between reamed and unreamed nails in open tibial fractures. In conclusion, our study recommended reamed nails for the treatment of closed tibial fractures. But the choice for open tibial fractures remains uncertain.
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Affiliation(s)
- Deting Xue
- Department of Orthopaedics, Affiliated Hospital, Zhejiang University, Hangzhou, People's Republic of China
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Sigurdsen UEW, Reikeras O, Utvag SE. External fixation compared to intramedullary nailing of tibial fractures in the rat. Acta Orthop 2009; 80:375-9. [PMID: 19513888 PMCID: PMC2823217 DOI: 10.3109/17453670903035567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE It is not known whether there is a difference in bone healing after external fixation and after intramedullary nailing. We therefore compared fracture healing in rats after these two procedures. METHODS 40 male rats were subjected to a standardized tibial shaft osteotomy and were randomly assigned to 2 treatment groups: external fixation or intramedullary nailing. Evaluation of half of each treatment group at 30 days and the remaining half at 60 days included radiography, dual energy radiographic absorbtiometry, and mechanical testing. RESULTS Radiographically, both treatment groups showed sign of fracture healing with gradual bridging of the fracture line, while with intramedullary nailing the visible collar of callus was increased peripherally, indicative of periosteal healing. At 30 days, densitometric and mechanical properties were similar in the 2 groups. At 60 days, however, the intramedullary nailed bones had more strength, greater callus area, and higher bone mineral content in the callus segment compared to externally fixated fractures. INTERPRETATION Tibial shaft fractures in the rat treated with external fixation and intramedullary nailing show a similar healing pattern in the early phase of fracture healing, while at the time of healing intramedullary nailing provides improved densitometric properties and superior mechanical properties compared to external fixation. Clinical findings indicate that intramedullary nailing in human tibial fractures may be more advantageous for bone healing than external fixation, in a similar way.
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Affiliation(s)
| | - Olav Reikeras
- Department of Orthopedic Surgery, Rikshospitalet Medical CenterOsloNorway
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Bhandari M, Guyatt G, Tornetta P, Schemitsch EH, Swiontkowski M, Sanders D, Walter SD. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am 2008; 90:2567-78. [PMID: 19047701 PMCID: PMC2663330 DOI: 10.2106/jbjs.g.01694] [Citation(s) in RCA: 288] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There remains a compelling biological rationale for both reamed and unreamed intramedullary nailing for the treatment of tibial shaft fractures. Previous small trials have left the evidence for either approach inconclusive. We compared reamed and unreamed intramedullary nailing with regard to the rates of reoperations and complications in patients with tibial shaft fractures. METHODS We conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. Perioperative care was standardized, and reoperations for nonunion before six months were disallowed. The primary composite outcome measured at twelve months postoperatively included bone-grafting, implant exchange, and dynamization in patients with a fracture gap of <1 cm. Infection and fasciotomy were considered as part of the composite outcome, irrespective of the postoperative gap. RESULTS One thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized to unreamed nailing. Among all patients, fifty-seven (4.6%) required implant exchange or bone-grafting because of nonunion. Among all patients, 105 in the reamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event (relative risk, 0.90; 95% confidence interval, 0.71 to 1.15). In patients with closed fractures, forty-five (11%) of 416 in the reamed nailing group and sixty-eight (17%) of 410 in the unreamed nailing group experienced a primary event (relative risk, 0.67; 95% confidence interval, 0.47 to 0.96; p = 0.03). This difference was largely due to differences in dynamization. In patients with open fractures, sixty of 206 in the reamed nailing group and forty-six of 194 in the unreamed nailing group experienced a primary event (relative risk, 1.27; 95% confidence interval, 0.91 to 1.78; p = 0.16). CONCLUSIONS The present study demonstrates a possible benefit for reamed intramedullary nailing in patients with closed fractures. We found no difference between approaches in patients with open fractures. Delaying reoperation for nonunion for at least six months may substantially decrease the need for reoperation.
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Busse JW, Morton E, Lacchetti C, Guyatt GH, Bhandari M. Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons. Acta Orthop 2008; 79:689-94. [PMID: 18839377 DOI: 10.1080/17453670810016722] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Strategies to manage tibial fractures include nonoperative and operative approaches. Strategies to enhance healing include a variety of bone stimulators. It is not known what forms of management for tibial fractures predominate among Canadian orthopedic surgeons. We therefore asked a representative sample of orthopedic trauma surgeons about their management of tibial fracture patients. METHODS This was a cross-sectional survey of 450 Canadian orthopedic trauma surgeons. We inquired about demographic variables and current tibial shaft fracture management strategies. RESULTS 268 surgeons completed the survey, a response rate of 60%. Most respondents (80%) managed closed tibial shaft fracture operatively; 47% preferred reamed intramedullary nailing and 40% preferred unreamed. For open tibial shaft fractures, 59% of surgeons preferred reamed intramedullary nailing. Some surgeons (16%) reported use of bone stimulators for management of uncomplicated open and closed tibial shaft fractures, and almost half (45%) made use of this adjunctive modality for complicated tibial shaft fractures. Low-intensity pulsed ultrasound and electrical stimulation proved equally popular (21% each) and 80% of respondents felt that a reduction in healing time of 6 weeks or more, attributed to a bone stimulator, would be clinically important. INTERPRETATION Current practice regarding orthopedic management of tibial shaft fractures in Canada strongly favors operative treatment with intramedullary nailing, although respondents were divided in their preference for reamed and unreamed nailing. Use of bone stimulators is common as an adjunctive modality in this injury population. Large randomized trials are needed to provide better evidence to guide clinical decision making regarding the choice of reamed or unreamed nailing for tibial shaft fractures, and to inform surgeons about the actual effect of bone stimulators.
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Affiliation(s)
- Jason W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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The management of open tibial fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2008. [DOI: 10.1007/s00590-008-0328-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Arbuthnot JE, Perera A, Powers D. Primary rigid intramedullary nailing for fractures of the tibia: current concepts and technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2008. [DOI: 10.1007/s00590-008-0327-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bhandari M, Swiontkowksi MF. Re: Should the tibia be reamed when nailing? [Injury 36 (2005) 439-444]. Injury 2006; 37:574-5. [PMID: 16580674 DOI: 10.1016/j.injury.2006.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 01/16/2006] [Indexed: 02/02/2023]
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