Abstract
PurposeThe aim of this study was to evaluate a standardized treatment protocol regarding the rate of secondary bone union, complications, and functional outcome.MethodsThis 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.ResultsOsseous 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.DiscussionReamed 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.
Highlights
The gold standard for the treatment of tibial shaft fractures is intramedullary nailing
Healing rates of more than 90 % have been described for alternative methods such as expandable intramedullary implants or plating [12, 13]. In this clinical trial we evaluated our therapeutic concept of closed revision and reamed exchange nailing for the treatment of aseptic tibial shaft nonunion including removal of the intramedullary nail, limited reaming of the intramedullary canal, and insertion of an intramedullary nail that is larger in diameter than the removed nail, canal filling in size, and offers optimal stability for uneventful bone healing [14]
Between 2003 and 2012, a prospective cohort study was performed in a Level I Trauma Centre, and 188 patients were included who had been treated with intramedullary nailing of a tibial shaft fracture and had developed aseptic tibial shaft nonunion
Summary
The gold standard for the treatment of tibial shaft fractures is intramedullary nailing. The technique of closed reduction and intramedullary stabilization follows the principle of biological osteosynthesis and is considered a dynamic stabilization technique resulting in secondary bone healing. Despite progress in surgical techniques and modern implants, impaired bone healing remains a challenging problem, at the tibia where there is limited soft tissue coverage and a high rate of open injuries. The incidence of tibial shaft nonunion or delayed union reported in the literature reaches up to 16.7 % following intramedullary nailing of tibia shaft fractures [1,2,3]. Whereas it is impossible to control injury-dependent risk factors for the development of a tibial shaft nonunion such as an open fracture and severe soft tissue injury [4], treatmentrelated factors can be addressed. Several factors originating from poor nailing technique such as fracture gap, axis deviation, and the application of small diameter nails and interlocking bolts result in instability of the osteosynthesis
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