Unreamed interlocking nailing in open fractures of tibia

Journal of Orthopaedic Surgery, Dec 2004 by Joshi, D, Ahmed, A, Krishna, L, Lal, Y

ABSTRACT

Purpose. To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the unreamed intramedullary nailing.

Methods. Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at Safdarjung Hospital, New Delhi, India. Records of 56 patients (4 women and 52 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures in all patients. All fractures were classified according to Gustilo and Anderson system for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted with assistance by an image intensifier. All nails were statically locked with one screw each proximally and distally.

Results. The patients were followed up for a mean period of 20 months (range, 18-24 months) and were evaluated according to the modified Ketenjian's criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Two of 4 type-IIIA and all 4 type-IIIB fractures had chronic osteomyelitis. Of 56 patients, 6 had early infection, 6 had delayed union, 6 had infected non-union, 2 had nail breakage, 8 had screw breakage, and 10 had anterior knee pain.

Conclusion. Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in those type-III fractures with delayed presentation was not recommended, because of high incidence of complications.

Key words: bone nails; fracture fixation, intramedullary; fractures, open; tibial fractures

INTRODUCTION

With increasing number of vehicles on the roads in India, complex trauma cases caused by traffic accidents have increased progressively. Tibia is one of the most common bones to sustain open injury because of its superficial nature. Early debridement and unreamed interlocking nailing have emerged as important modalities for the management of open fractures of tibia (Figure). Because many cases in India were presented late to the emergency department with improper initial management, our results of the management of open fractures are likely to be different from those reported in the western literature. We studied the clinical outcomes of unreamed intramedullary interlocking nailing in 56 cases of solely compound fractures of tibia at Safdarjung Hospital in India.

METHODS

Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails. Four patients were lost to follow-up. 56 patients (4 women and 52 men) were followed up for a mean period of 20 months (range, 18-24 months). Only injuries associated with the tibial shaft were included. Fractures associated with head injury, chest injury, major nerve-vessel injury, upper position of proximal tibial shaft fractures, type-IV Winquist comminuted fractures, and fractures within 5 cm of distal articular surface of tibia were excluded.

Traffic accidents were the cause of fractures in all patients. The patients' median age was 30 years (range, 16-72 years). The morphology of all fractures was classified according to the classification of Gustilo and Anderson1 for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures (Table 1). 36 fractures were at mid-shaft level and 20 fractures were at the positions of either the upper one third or the lower one third of the tibia. In all the cases, we began administering injectable third-generation cephalosporins and aminoglycosides in the emergency room and kept using them after surgery for 2 weeks and 5 days, respectively. In cases of gross contamination, metronidazole was added. Wounds were copiously irrigated with normal saline (10-20 1). After thorough debridement under anaesthesia, an unreamed interlocking nail (size 8 in 52 cases and size 9 in 4 cases) was inserted under image intensifier guidance. All the nails were statically locked with one screw each proximally and distally.

The mean operating time was one hour (range, 45-90 minutes). Mean interval from injury to operation was 24 hours (range, 8-48 hours). 50 of the 56 cases (89%) presented to emergency department within 24 hours of injury; however, 98% of them were operated after 24 hours of injury because of delay in setup. Only 6 cases presented after 24 hours (2 cases of type IIIA and 4 cases of type IIIB). Wounds were re-examined after 24 hours and further debridements were planned accordingly. Primary wound closure was performed in 4 cases only. Muscle flaps and fasciocutaneous flaps were used to cover the exposed bone on postoperative day 7. Patients were followed up regularly and were evaluated functionally according to modified Ketenjian's criteria.2 X-rays were taken at regular intervals, and weightbearing were allowed based on radiological evidence of callus formation. Of 56 cases, 40 (71.4%) cases required only one debridement, 10 (17.9%) required 2 debridements (8 in type II and 2 in type IIIA), and 6 (10.7%) required 3 debridements (2 in type IIIA and 4 in type IIIB). The mode of soft tissue coverage is shown in Table 2.