Primary Intramedullary Nailing Research Articles

Outcomes of Early Intramedullary Nail Fixation for Open Tibial Shaft Fracture

Background: Open tibial shaft fractures necessitate immediate treatment. Because of the potential of infection, treatment of open tibial shaft fractures is debatable. It is suggested that intravenous antibiotics and fracture debridement be administered within 6 to 24 hours. Few studies have looked at outcomes when surgical therapy is given more than 24 hours after the fracture occurs. Aim of the study: The purpose of this study is to identify the risk factors for nonunion and infection after early intramedullary nailing in an open tibial shaft fracture. Methods: This study was conducted in TMSS Medical College, Bogura, Bangladesh. A retrospective study looked at open tibial shaft fractures treated with primary intramedullary nailing, from January 2021 to January 2022. The study included 42 patients who were admitted to the study institution. All collected data was entered into a Microsoft Excel Work Sheet and analyzed in SPSS 11.5 using descriptive statistics. Results: Forty-two patients (42 fractures) were included: 7 Gustilo type I, 18 type II, 12 type III-A, and 5 type III-B. Infection occurred in eight patients (19%). At the latest follow-up, one patient showed signs of non-union. Infection risk did not linked with Gustilo (p = 0.53) or AO type (p = 0.66). The time between trauma and wound debridement was substantially greater in infected patients (p = 0.049). Forty fractures (95.2%) healed in a mean of 6.9 6.1 months (range, 2-40). Non-union was associated with AO type (p = 0.05) but not with Gustilo type (p = 0.07). Conclusion: The only factor impacting infection risk was the length of time between treatments. Non-union status was tied to AO comminution grade. Primary intramedullary nailing appeared to be reliable if treated early and with thorough debridement. The benefits are early restoration of weight-bearing and a reduced patient load.

Acute minimally invasive bone grafting of long bone fractures to reduce the incidence of fracture non-union

Diaphyseal fractures of the femur and tibia are a frequent consequence of trauma and are most often managed with intramedullary nailing. Although outcomes from these fractures are generally perceived as good, it is estimated that 7 to 14% of people with tibial and femoral shaft fractures progress to non-union and an even greater proportion suffer delayed union, which causes substantial health and economic burdens both for patients and health services. Compared to those whose fractures unite within the normal timeframe, patients suffering delayed union or non-union suffer more pain, worse functional outcomes, greater psychological disability and longer amounts of time off work. In response to non-union, invasive and costly secondary procedures such as exchange nailing, supplementary fixation and/or bone grafting are commonly required. We hypothesise that performing acute autologous bone grafting at the time of the primary intramedullary nailing procedure would reduce the incidence of fracture delayed union and non-union for tibial and femoral shaft fractures. The autologous cancellous bone retrieved during reaming with intramedullary nailing is usually discarded. We propose a minimally invasive surgical technique to transplant the retrieved intramedullary reamings to the fracture site during the primary fracture fixation. Autologous cancellous bone grafting is the gold standard for management of fracture non-union, and works by providing osteoprogenitor cells, an osteoconductive scaffold, and growth factors to the fracture site, where they are crucial for fracture healing. Proprietary biological products have also been developed that aim to replicate the results from bone grafting. Although autologous cancellous bone grafting is a proven and robust technique for the treatment of atrophic fracture non-union, it has not been widely studied in the acute management of femoral and tibial shaft fractures. The proposed hypothesis is amenable to testing in randomized clinical trials. If found to be effective in reducing rates of delayed union and non-union with minimal adverse events, this method could be adopted on a large scale, potentially transforming acute management of long bone fractures, and improving patient outcomes from these injuries.

Functional outcome of management of open fractures both bones of leg with primary intramedullary interlocking nailing

Functional outcome of management of open fractures both bones of leg with primary intramedullary interlocking nailing

Intramedullary nailing of concurrent ipsilateral fractures of the tibia and femur: primary synchronous nailing versus staged osteosynthesis with temporizing external fixation.

The optimal timing to definitive osteosynthesis in the polytraumatized patient remains an unanswered question. Early total care, damage control orthopaedics, and early appropriate care have been described to manage the fractures in these patients, but there is a paucity of literature specific to ipsilateral tibial and femoral fractures. We sought the perioperative outcomes of primary simultaneous intramedullary nailing (IMN) versus temporizing external fixation (EF) of both fractures. A chart review of all patients who sustained fractures of the ipsilateral femur and tibia that were definitively treated with (IMN) from January 2010 to December 2020 was performed. Patients who underwent initial EF and those that were primarily treated with IMNs were examined. IMNs and EF were the initial treatment in 23 and 16 patients, respectively. The mean (range) injury severity score (ISS) was 23.3 (33) in the EF group vs. 18.5 (34) in the IMN group, (p = 0.0686). The EF group had a higher total transfused units of packed red blood cells 7.4 vs. 2.8, the mean initial operative time was 236 vs. 282.6 (min), (p = 0.7399), a longer mean total operative time 601.78 vs. 236 (min), and longer mean length of stay 15.6 vs. 11 (days), (p < 0.5). Rates of complications were not significantly different between groups. Primary IMN is as safe as provisional EF in the adequately resuscitated patient with ipsilateral femoral and tibial fractures. This implies the fixation of both fractures into a single surgery without increasing perioperative complications, and decreasing total hospital stay in patients with sufficient preoperative resuscitation.

Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings.

Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes. We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier. There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6h. Mean duration of antibiotics therapy was 4.3days, and the mean duration of hospital stay was 4.1days. All patients were followed up to union. Mean time to radiographic union was 6.1months for the tibia and 5.7months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection. The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.

Prise en charge actualisée des pseudarthroses diaphysaires aseptiques du tibia : revue systématique

IntroductionTibia fractures are the most common long bone injuries encountered in the trauma population. The majority are treated successfully but non-union remains a common complication. A systematic review of current evidence regarding the management for aseptic diaphyseal tibial non-unions was undertaken. MethodsA systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), was conducted. ResultsA total of 632 publications were screened for inclusion. Full text review of 91 studies resulted in 26 publications being retained for final review. The majority of patients included in the studies either underwent exchange nailing (n=315) or primary intramedullary nailing (n=174) with respective union rates of 88% and 95% being achieved. The highest union rate (97%) was achieved with the use of fine wire external fixation. The major adjuvant treatment modalities were fibula osteotomies (n=372; 41%), fixation dynamization (n=208; 23%) and bone grafting (n=183; 20%). ConclusionThe lack of standardization in reporting of outcomes and the diversity of management strategies employed precludes definitive conclusions or recommendations. Further research is required to ascertain the ideal treatment strategy in the management of aseptic tibial diaphyseal non-unions. Level of evidenceIV.

Primary intra medullary inter locking nailing for open tibia fractures a prospective analysis of functional and radiological outcome

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tibia is the most commonly fractured long bone in the body encountered in today’s practice. The use of non-operative treatment of tibial fractures is associated with a high prevalence of malunion, joint stiffness and poor functional outcome. This study was conducted to analyze the functional and radiological outcome of patients treated for open fractures of tibia with primary intramedullary interlocking nailing within 24 hours of injury.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; From October 2013 to May 2015, a prospective and descriptive study was done where 30 consecutive patients with open tibial fractures was treated with primary intramedullary interlocking nailing within 24 hours of injury, at Pondicherry institute of medical sciences, Pondicherry. Functional outcome was assessed using Karlstrom and Olerud scores and radiological outcome was assessed by radiographic union scale of tibial fractures (RUST) scores at 6 weeks, 3rd, 6th, 9th and 12th month post-operatively. Intra-operative and post-operative complications were noted and documented. The results were analyzed using SPSS software.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The most common age group who presented was between 18-30 years and the average age was 36.7 years. 36.67% had grade I injury, 40% had grade II injury, meanwhile, grade IIIA injuries constituted 20% and grade IIIB injuries constituted 3.33%. The average functional score was 33.33 which showed overall good result. The average RUST score was found to be 11.33 denoting union.&lt;/p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt;Hence, we observed that intramedullary interlocking nailing is a good procedure in terms of functional and radiological outcome if done within 24 hours of injury.&lt;p class="Body"&gt; &lt;/p&gt;

Contemporary management of aseptic diaphyseal tibia non-unions – A systematic review

IntroductionTibia fractures are the most common long bone injuries encountered in the trauma population. The majority are treated successfully but non-union remains a common complication. A systematic review of current evidence regarding the management for aseptic diaphyseal tibial non-unions was undertaken. MethodsA systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), was conducted. ResultsA total of 632 publications were screened for inclusion. Full text review of 91 studies resulted in 26 publications being retained for final review. The majority of patients included in the studies either underwent exchange nailing (n=315) or primary intramedullary nailing (n=174) with respective union rates of 88% and 95% being achieved. The highest union rate (97%) was achieved with the use of fine wire external fixation. The major adjuvant treatment modalities were fibula osteotomies (n=372; 41%), fixation dynamization (n=208; 23%) and bone grafting (n=183; 20%). ConclusionThe lack of standardization in reporting of outcomes and the diversity of management strategies employed precludes definitive conclusions or recommendations. Further research is required to ascertain the ideal treatment strategy in the management of aseptic tibial diaphyseal non-unions. Level of evidenceIV.

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

BackgroundIntramedullary 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. HypothesisActive smoking and an initial open wound are independent risk factors for complications. Materials and methodsWe 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. ResultsWe 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. DiscussionActive 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 evidenceIV; single-centre retrospective cohort study.

Primary intramedullary nailing in compound Type 1 and 2 femur shaft fractures and their effect on functional outcome

Background: Femur shaft fractures are the most common long bone fractures encountered in orthopedic practice. Open fractures of the femur shaft are due to high-energy trauma; these patients are usually associated with other system injuries and vascular involvement. The initial management of open fractures includes antibiotics, debridement, and stabilization. If the initial debridement is believed to be adequate, definitive fixation of the femoral shaft can be performed usually with reamed intramedullary nailing. The present study was conducted to evaluate the functional outcome in open Type 1 and 2 femur shaft fractures managed with primary intramedullary nailing and the complications related to it. Materials and Methods: Twenty-two patients, having Grade 1 and 2 compound femur shaft fractures were admitted and included in the study from January 2016 to February 2019 after obtaining valid consent. All the patients were investigated with X-rays, and fractures were classified according to Gustilo–Anderson classification. All the patients were treated primarily with intramedullary nailing, and the functional outcome was assessed by using Harris Hip Score and Oxford Knee Score. Results: Thirteen (59.09%) patients had Type 1 open femur shaft fractures and nine (40.90%) patients had Type 2 fractures. Fracture union was observed in six patients (27.27%) at 3 months and in 16 (72.72%) at 3–6 months. Complications observed were superficial wound infections in two patients, deep infections in two patients, and nonunion in one patient. Thirteen (59.09%) patients got excellent outcome, four (18.18%) patients got good outcome, three (13.63%) patients got fair outcome, and two (09.09%) patients got poor outcome. Conclusion: Primary intramedullary nailing is an effective method of managing Type 1 and 2 open femur shaft fractures if thorough early and timely debridement can be done. It is associated with less complications, helps in early mobilisation and also avoids secondary procedures.

Outcomes of Primary Tibiotalocalcaneal Nailing for Complicated Diabetic Ankle Fractures

Category:Trauma, Ankle, Ankle ArthritisIntroduction/Purpose:Ankle fractures in complicated diabetic patients (i.e. presence of neuropathy, nephropathy, or peripheral vascular disease) have significantly increased rates of complications with markedly worse functional outcomes. Current management advocates for operative intervention due to high rates of fracture reduction loss and Charcot arthropathy in those treated nonoperatively. Tibiotalocalcaneal (TTC) nails have been reported in the literature as a salvage option when initial ankle stabilization has failed. We hypothesize that the minimally invasive, robust construct that primary TTC fixation with an intramedullary nail offers will result in high rates of limb salvage, acceptable rates of complications, and nominal loss of function.Thus, the purpose of this study was to evaluate the outcomes of primary TTC intramedullary nailing for definitive treatment of neuropathic ankle fractures.Methods:This was an IRB approved retrospective study of 27 complicated diabetic patients who underwent TTC nailing of their ankle fracture as a primary treatment without formal joint preparation. The study was undertaken at an urban Level 1 trauma center. Complicated diabetes was defined as having one or more of the following formal diagnoses: neuropathy (20 patients), nephropathy (4), PVD (3). Mean clinical follow up was 888 days (range 21-2843 days). Patients were screened for associated risk factors such as open fracture, neuropathy, nicotine and alcohol abuse, obesity and elevated Hba1c. Data was also collected on surgical complications such as superficial and deep infection, wound dehiscence, amputation, revision fixation, hardware failure, malunion, nonunion. Outcomes were measured in length of hospital stay, loss of ambulatory level, and time to death.Results:The mean age was 66 (32-92) years with an average BMI of 38 (21-68). Six of 27 fractures were open and 20 of 27 patients were neuropathic. Mean hemoglobin A1C was 7.4 (5.5-13). Average hospital stay was 6 days (0-22). The average patient was fully weight bearing at 6 weeks (1-17). Two patients underwent removal of hardware, due to pain and proximal screw failure respectively. One patient required formal arthrodesis. There were no malunions, symptomatic nonunions, or instances of Charcot arthropathy. Two patients underwent repeat debridement for infection, resulting in antibiotic nail placement and above knee amputation respectively. A total of eight patients had died by final follow up (mean 1048 days) from index procedure. Overall, mean ambulatory status was maintained.Conclusion:Primary tibiotalocalcaneal nailing is a viable alternative to previously described methods of fixation of complicated diabetic ankle fractures. With high limb salvage rates, early weight bearing, maintained ambulatory status and low rates of return to the operating room, our technique can be considered an applicable approach to increase overall survivability of threatened limbs and lives with acceptably low complications.

Primary interlocking nailing for open fractures of tibial shaft: a clinical study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The excellent method for treating fractures of the tibial shaft was the closed intramedullary nailing technique. But because of limited references related to the results, incidence of infection, non-union of open injury. Hence, it was decided to analyse open tibial fractures treatment by primary interlocking nailing.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 50 Patients with open fractures of the tibial shaft which were treated with primary interlocking nail were studied in the period of 14 months.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In present study 18 (36%) type I, 22 (44%) type II and 10 (20%) type IIIA Gustilo open fractures were treated. The average duration of time between injury and nailing was 3.5 hours (range was 1.5 hours to 4 hours). After reaming, 40 (80%) fractures were fixed, without reaming, 10 (20%) of fractures were fixed. The average time to union was 27 weeks for type I fractures, 30 weeks for type II fractures and 33 weeks for type IIIA fractures. There was 1 non-union. There were 4 deep infections.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The best mode of therapy was primary interlocking intramedullary nailing for open fractures.&lt;/p&gt;

Intramedullary nailing for adult open tibial shaft fracture. An 85-case series

IntroductionTreatment of open tibial shaft fracture is controversial due to the risk of infection. We assessed results in a continuous series of open tibial shaft fractures treated by primary intramedullary nailing. HypothesisFactors can be determined for non-union and onset of infection following primary intramedullary nailing in open tibial shaft fracture. Patients and methodA retrospective study assessed open tibial shaft fractures treated by primary intramedullary nailing between January 2007 and December 2013. Fractures were classified on the AO and Gustilo classifications. Infection rates and time to union were compared. ResultsEighty-five patients (85 fractures) were included: 13 Gustilo type I, 43 type II, 19 type III-A and 10 type III-B. Eight patients had infection (9%). Healing and union were obtained after nail exchange and reaming in 5 cases, and after bone transport in 2. One patient showed non-union at last follow-up. Infection risk did not correlate with Gustilo (p=0.55) or AO type (p=0.69). The interval between trauma and wound debridement was significantly longer in infected patients (p=0.048). Eighty-three fractures (97.6%) healed, at a mean 6.9±6.1 months (range, 2–40). Non-union was associated with AO type (p=0.04), and showed a non-significant association with Gustilo type (p=0.06). DiscussionTime to treatment was the only factor influencing risk of infection. Non-union was related to AO comminution grade. Primary intramedullary nailing seemed reliable if treatment was early, with rigorous debridement. The advantages then are early resumption of weight-bearing and low patient burden. Level of evidenceV, retrospective study.

Infections in primary intramedullary nailing of open tibial fractures: a review article.

Open fractures are insidious and life-threatening injuries. They frequently involve the leg. Our aim is to evaluate the efficacy of primary intramedullary nailing as a definitive treatment of open tibial fractures, compared to other fixation tools in terms of deep infections, healing fracture time and bony repair. We reviewed the available literature concerning treatment and management of open tibial fractures. Primary intramedullary nailing is similar to delayed intramedullary nailing after external fixation in terms of union, malunion and nonunion rate. Furthermore, primary intramedullary nailing is superior compared to all other fixation tools, in terms of development of deep infections, provided that a good debridement of soft tissue, lavage of the fracture site and adequate antibiotic prophylaxis should be performed before nailing. Primary intramedullary nailing should be considered for the definitive treatment of open tibial fractures, providing many advantages in terms of rehabilitation, time of hospitalization and costs.

PRIMARY UNREAMED NAILING IN GRADE I, II AND IIIA OPEN FRACTURES OF THE TIBIA SHAFT: A PROSPECTIVE STUDY OF THE OUTCOMES IN 80 PATIENTS

Introduction. To evaluate the incidences of union, nonunion and infection in the treatment of open tibial shaft fractures of Gustilo–Anderson types I, and IIIA treated with primary unreamed solid intramedullary locked nail (UTN). Materials and Methods. It is a prospective study of 80 open tibial shaft fractures. According to the AO classification, 36 patients (44%) were of type A, 29 (36%) were of type B and 15 (18%) were of type C. According to the Gustilo–Anderson classification, 31 patients (38.7%) were of grade I, 24 (30%) were of grade II and 25 (31%) were of grade IIIA. For the definitive stabilization of the fracture was used a UTN. Results. Bone healing was achieved in 98.4% of the cases, with a mean time of 24.2 weeks, ranging from 14 weeks to 110 weeks. Union without infection was seen in 70 patients (87%) and nonunion was seen in five patients (6%). Deep infection was seen in three patients (3.7%) and malunion was seen in two patients (2.5%). Conclusion. The treatment of open tibial shaft fractures with unreamed solid intramedullary locked nail allows high rates of bone healing and low rates of nonunion and deep infection, and if the presence of infection is excluded, then the results of unreamed nailing and reamed nailing are the same.

Primary Intra-Medullary Nailing of Open Tibia Fractures Caused by Low-Velocity Gunshots: Does Operative Debridement Increase Infection Rates?

Although gunshot-induced extremity fractures are typically not considered open fractures, there is controversy regarding wound management in the setting of operative fixation to limit infection complications. Previous studies have evaluated the need for a formal irrigation and debridement (I&D) prior to intra-medullary nailing (IMN) of gunshot-induced femur fractures but none have specifically evaluated tibias. By comparing primary IMN for tibial shaft fractures caused by low-velocity firearms additionally treated with a formal operative I&D (group 1) with those without an I&D (group 2), we sought to identify whether there are: differences in treatment group infection rates; particular fracture patterns more prone to infection; and patient characteristics more prone to infections. Retrospective cohort study at a single level I trauma center of gunshot-induced tibial shaft fractures managed primarily with IMN in 39 patients from October 1, 2008 to October 30, 2016. The following were studied: demographics, follow-up, fracture characteristics, injury management, and patient outcome. Fractures were categorized based on the Orthopaedic Trauma Association (OTA) classification system for diaphyseal tibia/fibula fractures. All patients had intravenous antibiotic agents at presentation and received three days of post-operative intravenous antibiotic agents per institutional protocol. In group 1, 6 of 23 patients (26.1%) developed superficial infections and 4 of 23 patients (17.4%) developed deep infections. In group 2, none of 16 patients (0%) developed superficial infections and 1 patient (6.25%) developed a deep infection, making the total cohort infection rate 28.2% (11/39). Superficial infections were associated with a formal I&D whereas deep infections were not. Tobacco smokers and type 42-A fractures had higher infection rates when treated with a formal I&D. A formal debridement, followed by primary IMN in tibia fractures caused by low-velocity firearms is associated with an increased risk of superficial infection that is well managed with antibiotic agents, but the incorporation of a debridement does not affect rate of deep infection. A formal I&D during IMN fixation should be avoided in patients that are smokers and have type 42-A tibia fractures as these are factors associated with increased infection rates.

Exchange Nailing for Hypertrophic Femoral Nonunion.

Exchange nailing has proven to be a reliable surgical technique for the management of aseptic femoral shaft nonunions. Similar to primary intramedullary nail fixation for femur fractures, exchange nailing for aseptic hypertrophic nonunions of the femur relies on successful navigation of the starting point and proper nail trajectory to minimize coronal and sagittal plane deformities. Compared with the supine position, the lateral decubitus position has the advantage of allowing gravity to displace the soft tissue around the piriformis start site to facilitate nail entry. In addition, the C-arm position and access to the affected limb from both sides by the surgeon and surgical assistant facilitate visualization of existing deformities and the ability to perform correction maneuvers. The purpose of this review is to highlight technical pearls associated with exchange nailing in a lateral decubitus position. Although other techniques are available, and should be used when indicated, exchange nailing provides patients with the opportunity to an early return to activity, improvement in pain and disability, and ultimate bony union.

A prospective study of functional outcome of primary intra-medullary nailing in type 3A and 3B open tibial diaphyseal fractures

Objectives: In a developing country such as ours, patients with Type III open Tibial fractures often reach the hospital late (after initial 6 hours) of sustaining high-velocity trauma. Primary internal fixation becomes a formidable challenge in such patients. Due to the paucity of articles exclusively dealing with this topic, we did a study to determine the functional outcome of primary intramedullary nailing in these patients. Materials and Methods: A prospective study was conducted with patients above 18yrs of age with Type 3A and 3B open Tibial Diaphyseal fractures presenting late after injury, initially treated with thorough wound debridement and lavage, followed by internal fixation with intra-medullary nailing. Patients were followed up at fixed intervals for a period of 1year. Results: 25 patients were enrolled in the study, 23 males and 2 females, time elapsed from injury to surgery ranged from 7hrs to as long as 5 days, average -2.66 days. 23 patients had a RUST score of 12 at 1yr follow-up. Functional outcome with Ketenjian and Shelton Criteria was excellent- good in 21 patients. 2 cases (8%) developed non-union, 3 cases (12%) developed post-op infection (Osteomyelitis). Conclusion: Thorough wound debridement and lavage, followed by primary intra-medullary nailing of Type 3A & 3B open Tibial diaphyseal fractures, have shown good results despite delay in presentation and surgery, in comparison to external fixation and secondary nailing.

Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation: The 'fix and shift' technique.

Background:Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult.Materials and Methods:Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with “fix and shift” technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators.Results:Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation.Conclusion:Management of Gustilo Anderson III B open tibial fractures with “fix and shift” technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, “fix and shift” could be recommended as one of the treatment modalities for open III B tibial fractures.

Are antibiotic nails effective in the treatment of infected tibial fractures?

BackgroundAntibiotic-impregnated cement nails are used to treat postoperative deep infections after primary intramedullary nail insertion for the treatment of tibial fractures. Few data exist regarding the efficacy of this treatment strategy. We hypothesized that such treatment with antibiotic nails results in a high rate of infection clearance at intermediate follow-up. MethodsWe conducted a retrospective review at our Level I trauma center. Patients who received intramedullary nails to stabilize tibial fractures (from 2000 to 2011) and subsequently required antibiotic nails to treat deep postoperative infection (n=55) were considered for study inclusion. Patients with less than 6 months of follow-up were excluded, leaving 41 patients in the study group (average age, 41 years; average follow-up, 20 months). ResultsThirty-one patients (76%) had no evidence of infection after treatment. The 10 patients for whom treatment failed were shown to have infection within the first 6 months. Two experienced persistent infection after antibiotic nail removal, necessitating massive débridement and ring fixator placement. Four patients underwent repeat antibiotic nail insertion after persistent infection. Three infections resulted in eventual above-knee amputations, and one chronic infection resulted in the need for multiple débridement and saucerization procedures. No complications associated with use of the antibiotic nails were observed. ConclusionThe use of antibiotic nails for treatment of tibial infections seems to be a reasonable option, clearing 76% of infections at the 6-month time frame. Further investigation is needed to compare this treatment algorithm with other strategies, such as antibiotic treatment without nail removal and massive débridement with ring fixator placement.