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

Is immediate weight bearing safe for subtrochanteric femur fractures in elderly patients treated by cephalomedullary nailing? A multicentric study in one hundred eighty-two patients

PURPOSE

Biomechanical superiority of intramedullary nails over extramedullary implants has been proved for subtrochanteric fractures. Nevertheless, postoperative management of these patients has not changed, with high rates of protected weight-bearing after intramedullary nailing. The purpose of this study is to determine the mechanical complications of immediate postoperative full weigh-bearing for subtrochanteric femur fractures in elderly patients treated with a cephalomedullary nail.

METHODS

We performed a retrospective case series study from patients treated with a cephalomedullary nail for subtrochanteric fractures (AO/OTA 31A.3 and 32A-32C) over a nine-year period. Patients in the immediate full weight-bearing (IFWB) group received orders for immediate full weight bear as tolerated on postoperative 48 h. Patients in the non- or limited- weight-bearing (NLWB) group received orders not to full weight bear in the immediate postoperative.

RESULTS

There were five (2.7%) cases of implant failure including four cutouts and one nail breakage that needed a reoperation. Of them, one (2.2%) followed the NLWB protocol and four (2.9%) followed the IFWB protocol. Mean length of stay was 7.9 days (median 8, range 3-21) in the NLWB group and 10.7 days (median 8, range 2-60) in the IWBAT group. The NLWB group observed a 2.8-day shorter postoperative length of stay when compared to the IFWB, but the median remained equal.

CONCLUSION

This study suggests that geriatric patients with subtrochanteric fractures treated by intramedullary nailing and in which a good fracture reduction was achieved, may be able to tolerate immediate postoperative full weight-bearing, not increasing reoperation rates due to implant failure.

Three predictive scores compared in a retrospective multicenter study of nonunion tibial shaft fracture

BACKGROUND

Delayed union, malunion, and nonunion are serious complications in the healing of fractures. Predicting the risk of nonunion before or after surgery is challenging.

AIM

To compare the most prevalent predictive scores of nonunion used in clinical practice to determine the most accurate score for predicting nonunion.

METHODS

We collected data from patients with tibial shaft fractures undergoing surgery from January 2016 to December 2020 in three different trauma hospitals. In this retrospective multicenter study, we considered only fractures treated with intramedullary nailing. We calculated the tibia FRACTure prediction healING days (FRACTING) score, Nonunion Risk Determination score, and Leeds-Genoa Nonunion Index (LEG-NUI) score at the time of definitive fixation.

RESULTS

Of the 130 patients enrolled, 89 (68.4%) healed within 9 months and were classified as union. The remaining patients (n = 41, 31.5%) healed after more than 9 months or underwent other surgical procedures and were classified as nonunion. After calculation of the three scores, LEG-NUI and FRACTING were the most accurate at predicting healing.

CONCLUSION

LEG-NUI and FRACTING showed the best performances by accurately predicting union and nonunion.

Kneeling tolerance following intramedullary nailing or plate fixation of uncomplicated distal tibia fractures

INTRODUCTION

Distal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee function in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following distal tibia fracture to assist in the preoperative consent process.

HYPOTHESIS

There is no difference in kneeling tolerance following either tibial nailing or plate fixation of distal tibia fractures.

MATERIAL AND METHODS

Retrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome measure was the Kneeling Test (KT). Secondary outcome measures were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. There were 28 patients recruited (18 IMN and 10 ORIF) with a mean age of 44years. Mean overall follow-up was 13.3months (range 8-25, SD 3.6). All fractures had completely healed without postoperative complication.

RESULTS

The IMN affected limb had a significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs. 94.9 respectively, p<0.005) Additionally, the IMN group performed significantly worse when compared to the ORIF group (mean KT 70.4 vs. 92.5 respectively, p<0.005). No significant differences (p>0.05) in kneeling function existed for the ORIF group when comparing affected to non-affected limbs. Secondary outcome analysis showed significantly worse overall WOMAC and FJS in the IMN group compared to the ORIF group (mean WOMAC 19.3 vs. 6.9 respectively, p=0.040; mean FJS 38.3 vs. 75.9 respectively, p=0.005).

DISCUSSION

The use of intramedullary nailing for the treatment of distal tibia fracture results in a mean reduction of 20% in kneeling tolerance in comparison to ORIF. The resulting kneeling tolerance is comparable to that of patients post-total knee arthroplasty. The present findings should assist in the consent process for patients with high kneeling demands in sportive, professional or cultural pastimes.

LEVEL OF EVIDENCE

IV; retrospective cohort study with quantitative outcome measurement.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients

BACKGROUND

Intramedullary nailing is the standard of care for tibial shaft fractures. The risk factors for infectious and/or mechanical complications, notably non-union, remain incompletely understood. The objective of this study was to evaluate risk factors for complications, notably non-union.

HYPOTHESIS

Active smoking and an initial open wound are independent risk factors for complications.

MATERIALS AND METHODS

We retrospectively included consecutive patients managed for open or closed tibial shaft fractures by primary intramedullary nailing between 2013 and 2018. We collected data on preoperative factors related to the patient and to the mechanism of injury (age, sex, smoking history, energy of the trauma, open wound), on intraoperative factors (residual interfragmentary gap), and on postoperative factors (early or delayed weight-bearing). We evaluated the associations between these factors and the occurrence of complications, notably non-union, by performing a univariate analysis followed by a multivariate analysis.

RESULTS

We included 184 patients [mean age, 38.5±17.6 (range, 15-91), 72.2% of males]. One or more complications developed in 28 (15.2%) patients and non-union occurred in 15 (8.1%) patients. There were three significant risk factors for complications: active smoking (OR, 7.93; 95%CI, 2.76-22.7), a residual interfragmentary gap >5mm (OR, 4.92; 95%CI, 1.72-14.02), and an initial open wound (OR,5.16; 95%CI, 1.62-16.43) (p<0.05). The same three factors were significant risk factors for non-union. Energy of the trauma, age, sex, and early or delayed weight bearing were not significantly associated with an excess risk of complications.

DISCUSSION

Active smoking, a residual interfragmentary gap >5mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing to treat a tibial shaft fracture. Preventive strategies and specific information could be implemented for these patients.

LEVEL OF EVIDENCE

IV; single-centre retrospective cohort study.

Does immediate weight-bearing following intramedullary tibial nailing affect union rates? The results from a single UK trauma unit

Introduction

Extra-articular diaphyseal tibial fractures are a common injury and are often treated with intramedullary nailing (IMN). Weight-bearing (WB) of simple tibial fractures treated with an IMN immediately as pain allows is now standard practice. Our aim was to assess the impact of varied WB on fracture union following IMN of diaphyseal tibia fractures.

Methods

We conducted a retrospective cohort study of tibial fractures treated with IMN in our department between 2012-2017. WB status was recorded in the post-operative note and subsequently reviewed in the patients’ follow-up appointments. Patients were divided in three groups; Group I: immediate full-WB, Group II: non-WB for 6 weeks and Group III: 2 weeks non-WB, 4 weeks increasing partial-WB and full-WB at 6 weeks. Radiographic union score for tibial fractures (RUST) of ≥10 at a painless fracture site was considered as evidence of fracture union.

Results

92 patients with comparable pre-operative demographics [mean age 40 y (16-88)] were included. The median union time in weeks for each group was: Group I 17.3, Group II 21.7 and Group III 19.5 (F 1.09, p 0.34). Survival analysis and log rank test did not show any difference in union times between the three groups (x2 1.1, p 0.57). 12 delayed unions were identified across all groups. Multiple logistic regression identified three factors that could increase the rate of delayed union – non-WB, smoking and IMN size 11/12 mm - however the results were not statistically significant.

Conclusion

Immediate post-operative WB does not adversely affect union time in statically locked IMNs. In fact, although our data show no statistically significant difference in fracture healing between the three groups, full WB seems to decrease overall time to union. In conclusion, we could suggest that full WB after IMN in patients with AO 42-A/B type fractures is safe practice.