Secondary Intramedullary Nailing Research Articles

Radiological and Functional Outcomes and Associated Factors After Secondary Intramedullary Nailing Among Patients With Open Fractures of the Lower Limb.

Background Open fractures of the lower limb are serious injuries caused by high-energy trauma that can lead to long-term disability. Initial treatment includes wound debridement, fracture reduction, and external fixation to stabilize bone fragments. Secondary nailing, a surgical technique to provide additional stability, has been shown to promote early mobilization and improve fracture alignment. However, there is a lack of consensus on the optimal timing and technique for secondary nailing. This study aims to evaluate the functional and radiological outcomes of patients who undergo secondary nailing for open fractures of the lower limb. Methods The study was a hospital-based prospective study of 53 patients who underwent secondary nailing for open fractures of the lower limbs. Patients aged 18 years or older, with Gustilo-Anderson classification grades 1, 2, or 3 A and B, who underwent wound debridement and external fixator application, followed by conversion to secondary intramedullary nail fixation between January 2019 and December 2021 were included in the study. The primary outcome measures were functional and radiological outcomes at follow-ups, assessed using the Lower Extremity Functional Scale (LEFS) and Radiographic Union Scale for Tibia fractures (RUST) score. Data were collected prospectively and analyzed using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY). Descriptive statistics were used to summarize patient demographics and injury characteristics, and the Student's t-test and analysis of variance (ANOVA) were used to compare continuous variables between groups. The study had a final analysis of 39 patients. Results The study reports the baseline characteristics, radiological, and functional outcomes of 39 patients who underwent secondary nailing for open fractures of the lower limb. The majority of the fractures occurred in the tibia (71.8%), with most classified as grade 3 (A and B) (69.2%). At the end of the six-month period after secondary nailing, 74.4% of the fractures had a union. Radiological and functional outcomes showed significant improvement after undergoing secondary nailing. Gender and age group did not have a significant association with the radiological outcome, while the time interval between external fixation and secondary nailing was significantly associated with the radiological outcome at six weeks and threemonths. Conclusion According to a study, secondary nailing is effective in managing lower limb open fractures with good radiological and functional outcomes. The time interval between external fixation and secondary nailing affects radiological outcomes, with longer delays leading to lower RUST scores. Orthopaedic surgeons should consider this factor when planning surgical management. Larger sample sizes and more extended follow-up periods are needed to confirm findings and evaluate the effect of other variables on the outcome.

Secondary intramedullary nailing for open tibial shaft fractures. Comparison of a one-stage versus two-stage surgical procedure

IntroductionThe objective of this study was to compare the rates of radiological and clinical complications after sequential treatment of a tibial shaft fracture by external fixation followed by secondary nailing with an early-stage conversion (C1S) versus a two-stage late conversion (C2S). The hypothesis of this work was that treatment with C1S does not increase the risk of surgical site infections compared to C2S, and allows faster healing with a lower malunion rate. Material and methodsWe carried out a retrospective and comparative study based on the files of the traumatology department of the Édouard Herriot University Hospital in Lyon. We reviewed the records of patients who presented with a Gustilo grade 1, 2 or 3a open tibial fracture treated with external fixation with conversion by intramedullary nailing within 6 months from January 2010 to December 2020. We assessed the occurrence of Surgical Site Infections (SSI), consolidation time, time until resumption of weight bearing and the malunion rate. ResultsOf the 55 patients included, a C1S procedure was performed in 25 cases (45.5%) versus 30 cases (54.5%) for C2S. No significant difference was found concerning the occurrence of SSI after intramedullary nailing between the two groups (p=0.81). A significant difference was observed in terms of bone healing (p=0.036) and the malunion rate (0.0013) in favor of nailing in one stage. DiscussionThe strategy of converting an open leg fracture early, in one stage (C1S), after initial external fixator placement allows for faster healing and weight bearing, while ensuring a lower malunion rate compared to that of a late two-stage conversion. In the absence of a scar at the time of intramedullary nailing, C1S does not increase the risk of surgical site infections. While the choice of a late and sequential two-stage operation is likely related to the surgeon's apprehension around conversion of an open leg fracture by intramedullary nailing, this study could promote the use of C1S in a greater number of situations. Level of evidenceIV.

Factors Determining the Functional and Radiological Outcome after Secondary Nailing in Open Fractures of Lower Extremity- A Prospective Cohort Study

Introduction: Open long bone fractures of lower limb are cumbersome to treat. Because of the increased chances of infection, wound debridement and external fixation is the primary procedure followed by a secondary intramedullary nailing when the wound improves. Pin tract infection, loss of fixation, non union is the most frequently encountered complications of external fixation. These complications have discouraged surgeons all over the world in accepting external fixation as a definitive method of fracture treatment. Secondary intramedullary interlocking nailing provides intramedullary input of cancellous tissue at the fracture site due to reaming and nailing. Aim: To evaluate the factors determining the outcome after secondary nailing in open fractures of lower extremity. Materials and Methods: The prospective cohort study was conducted from October 2017 to April 2020 at Pondicherry Institute of Medical Sciences, Pondicherry, India, 33 patients who had open long bone fractures of lower limb and underwent secondary nailing following external fixation, were evaluated. The patients were followed up for a period of six months. Factors such as age, bone involved, grade of injury, timing of debridement, time interval between external fixation and secondary nailing were analysed to see whether they affect the outcome of secondary nailing of open fractures of long bones. All patients underwent an initial thorough wound debridement and external fixation application. A secondary nailing was done once wound had settled down. Age, gender, bone involved, grade of injury, timing of debridement and timing of secondary nailing were noted for all the patients and patients were followed up at six weeks, three months and six months. Final functional outcome (end of six months) was calculated using Lower Extremity Functional Scale (LEFS) and radiological union (end of six months) was calculated using Radiological Union Scale in Tibial fractures score (RUST). Results: There were no statistically significant differences in RUST/LEFS score at the end of six months, with respect to age (p-value=0.825/0.847), gender (p-value=0.235/0.348), bone involvement (p-value=0.726/0.757), grade of injury (p-value=0.107/0.546) and timing of debridement (p-value=0.117/0.374). The mean RUST scores at six weeks, three months and six months were 4.39, 6.57 and 9.28, respectively. The mean LEFS scores at six weeks, three months and six months were 20.96, 34.92, 49.5, respectively. The radiological union rate in this study was 60.61% at the final follow-up. But patients who underwent secondary nailing with 10 days of primary debridement and external fixation had a statistically significant (p-value) better outcome in terms of RUST (p-value at 3 months=0.045)/LEFS (p-value at 6 months=0.030). Conclusion: The interval between external fixation and secondary nailing was found to be a significant determinant of radiological outcome at three months (p-value at 3 months=0.045) and better functional outcome at six months (p-value at 6 months=0.030) with patients undergoing secondary nailing within 10 days of external fixation having a good final outcome. However, the radiological outcome between the two groups was comparable at six months follow-up.

Study of functional outcome of management by external fixation followed by definitive internal fixation in compound tibial fractures

Aim: To study the functional outcome of compound tibial fractures managed by external fixation followed by definitive internal fixation. Methodology: This prospective study was done from November 2016 to November 2018, for a period of 24 months, in Department of Orthopaedics & Traumatology, Osmania General Hospital, Hyderabad. Patient with compound tibial fractures meeting all the inclusion criteria were treated by external fixation followed by definitive internal fixation, later followed up regularly to check for functional outcome of the fracture in terms of fracture union both clinically and radiologically, improvement in leg motion, ability to walk. Results: In our series, Male predominated with the ratio of 9:1. In our series, RTA was the predominant cause of injury. In RTA, 2-wheeler Vs. 4- wheeler was the most common (10 cases). In our series, 23% of the patients had Associated Injuries. Most of the fractures were in middle half of the tibia. average time to admission after injury was 9 hours (Minimum of 1½ hours to 45 hours). In cases referred from outside Hyderabad average time to admission after injury was 15½ hours. In our series, average time from admission to surgery (External fixation) was 6½ hours (minimum of 1 hour to 14 hours). Union was observed in 11 of the 13 patients. The mean time to union was 27 weeks (range 20 weeks to 40 weeks). The timing of secondary intramedullary nailing in our study shows that Grade II open fractures were undergone nailing with average of 11.8 days with the range of 6 -20 days. Grade III A fractures have undergone nailing with average of 30 days with the range of 14 – 48 days. For grade III B fractures nailing was done with the average of 32.5 days ranging from 28– 45 days. The final outcome mainly depends on the age of the patient, time of admission since injury, type of injury. Good result is favoured by the debridement technique, appropriate selection of timing for external fixation and intramedullary nailing. Conclusion: Early intervention and aggressive soft tissue management in open tibial fractures result in decreased number of procedures, minimal hospital stay and early return to their daily routine.

Secondary intramedullary nailing following external fixation for open tibial shaft fractures

Objective To explore the clinical efficacy of secondary unreamed intramedullary nailing following primary external fixation for open tibial shaft fractures. Methods From March 2011 to June 2014, we treated 28 open tibial shaft fractures. They were 17 men and 11 women, aged from 21 to 62 years(average, 38. 2 years). After thorough debridement, the tibia was stabilized temporarily with external fixation. The wounds were handled with primary closure or secondary repair with skin grafts or tissue flaps. After the wounds healed, the external fixation was replaced by unreamed intramedullary nailing. Fracture union and complications were documented. The clinical efficacy was evaluated at the final follow-ups according to the Johner-Wruhs scoring system. Results All the 28 patients were followed up for 12 to 18 months(average, 13. 5 months). Bony union was achieved in all after 4 to 15 months(average, 4. 9 months). Delayed union was observed in 4 cases which were healed after dynamic fixation. There was no deep infection, nail breakage, malunion or limb shortening in any one. Mild knee pain was reported by 5 cases after surgery. According to the Johner-Wruhs criteria, 18 cases were excellent, 7 good, and 3 moderate, giving an excellent to good rate of 89. 3%. Conclusion Primary external fixation and secondary unreamed intramedullary nailing can result in good fracture union with satisfactory biomechanical stability and favorable early rehabilitation in the treatment of open tibial shaft fractures. Key words: Tibial fractures; Fracture fixation, intramedullary; External fixator

Limb salvage in a partially amputated distal femur with extensive segmental bone loss using the nailing after lengthening technique: a case report.

Segmental long bone defects resulting from high-energy trauma with severe soft tissue loss are difficult problems to manage. Amputation was for a long time the primary mainstay of treatment. This is the report on a 15-year-old male patient who sustained a third-degree open, traumatic fracture with partial amputation of the left distal femur and extensive bone loss of 26 cm. Successful limb salvage was performed after vascular repair, shortening of the bone defect, primary placement of an antibiotic cement spacer and simple external fixation. This was followed by bifocal lengthening modifying the simple frame until limb equality was achieved and secondary intramedullary nailing 11 months after injury.

A62 External fixation and secondary intramedullary nailing of open fractures of the tibial shaft after damage control in multiple trauma patients

A62 External fixation and secondary intramedullary nailing of open fractures of the tibial shaft after damage control in multiple trauma patients

The Effect of timing of conversion from external fixation to secondary intramedullary nailing in experimental tibial fractures

Diaphyseal tibial fractures with initial temporary external fixation (EF) are usually converted to intramedullary nailing (IMN) within 2 weeks, and no consensus on the optimal conversion time point exists. Current clinical practice is mainly based on estimation of the risk of postoperative infection. This is the first investigation of the effect of timing of such conversion on fracture healing. Forty male rats received a standardized tibial shaft osteotomy and EF. The animals were then randomly assigned to conversion to IMN at either 7 (group A, N = 10), 14 (group B, N = 10), or 30 (group C, N = 10) days after initial fixation. Group D (N = 10) served as a control group without conversion. Evaluation at 60 days included X-ray, DXA, and mechanical testing. Group A had significantly increased bone mineral content and callus area compared to the control group. Groups B and C showed significantly inferior mechanical bending strength and rigidity compared to both group A and the control group (D). The timing of the conversion procedure has a significant effect on fracture healing. Early conversion procedure did not improve healing compared to control, but was advantageous compared to late conversion (at 2 or 4 weeks) with higher mineralization and superior biomechanical properties.

Conversion of External Fixation to Definitive Intramedullary Nailing in Experimental Tibial Fractures

ABSTRACTBackground and Purpose: Initial treatment with external fixation of tibial fractures is indicated in severely injuried multitrauma patients. A conversion procedure to secondary nailing is often performed later to enhance fracture repair. The aim of the study was to compare definitive treatment of experimental tibial fractures with external fixation to an early conversion to secondary intramedullary nailing with large and small diameter nails. Methods: Thirty male rats were subject to a standardized tibial shaft osteotomy initially stabilized with external fixation. On day 7, they were assigned to either the control group (group A, N = 10) or conversion to secondary nailing with a small (group B, N = 10) or large diameter nails (group C, N = 10). Evaluation at 60 days included radiography, dual energy radiographic absorptiometry (DXA), and mechanical bending testing. Results: All fractures healed radiographically with bridging of the fracture line and more or less visible periosteal callus formation. Group B demonstrated significantly increased mineralization and callus formation measured as DXA parameters, bone mineral content (BMC), and callus area (CA) compared to both the other two groups. This group also tended to have mechanically stronger bones with higher fracture energy compared to both the other two groups, but no significant difference in mechanical prioperties between the groups was found in our study. Interpretation: In conclusion, we found that conversion from external fixation of leg fractures in rats to intramedullary nailing did not improve bone healing significantly supporting external fixation as definitive fracture management.

Secondary Intramedullary Nailing After Primary External Fixation In The Treatment Of Tibial Fractures

Results of the treatment of 10 open tibial fractures are reported. Initial treatment involved application of external fixator, debridement of wound and parental antibiotic administration. Secondary procedure was carried out on an average of 8 weeks after the initial procedure. Secondary intramedullary interlocking nailing was done with Gross-Kempf tibial nail. All fractures united at an average of 14 months after secondary procedure. Pin tract infection was seen in four cases and was treated with appropriate antibiotics in three patients and removal of nail in one case. More than five degree deformity in the coronal plane was seen in two cases and 10 degrees of sagittal plane deformity in one case. The over all functional outcome was satisfactory in this series. The findings of the study suggest that primary external fixation followed by secondary intramedullary nailing is a viable option in open tibial fractures in adults.

Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures

Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures

Overdistraction of the Fracture Eases Reduction in Delayed Femoral Nailing: Results of Intraoperative Force Measurements

(Initial) primary external fixation of femoral shaft fractures followed by secondary intramedullary nailing is a concept of damage control orthopedics. We hypothesized that external fixation with overdistraction of the fracture might reduce reduction forces and shorten reduction time during the secondary nailing. An experimental study on seven patients with eight fractures of the femoral shaft was conducted. Intraoperative reduction forces were determined in all patients using a load cell. The amount of distraction was measured on the latest radiographs before nailing. The reduction time was recorded as an indirect indicator of the intricacy of reposition. Reduction forces and reduction times were compared between those fractures fixed with shortening (Group A) and those fixed in distraction (Group B). Three femurs showed some shortening and five femurs showed some distraction within the fracture. The maximum measured distraction force along the shaft axis was 396 N. On average the maximal force was 336 N (+/- 51.9 N) in Group A and 200 N (+/- 43.1 N) in Group B. This difference is statistically significant (p = 0.007). The average reduction time was 28.3 minutes (+/- 21.8 minutes) in Group A and 5.8 minutes (+/- 4.0 minutes) in Group B. This difference shows a trend toward significance (p = 0.056). Fracture shortening leads to higher restraining forces and consequently prolonged reduction time in delayed nailing. Overdistraction should be performed as soon as possible under careful soft-tissue monitoring.

Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures

Risk factors for deep infection in secondary intramedullary nailing (IMN) after external fixation (EF) for open tibial fractures were investigated by multivariate analysis following univariate analyses. Forty-two open tibial fractures were treated with secondary IMN after EF. The open tibial fractures were classified according to the criteria proposed by Gustilo et al.: type II, 11; type IIIA, 8; type IIIB, 22 and type IIIC, 1. Locked IMNs with limited reaming were performed in 27 patients, and locked IMNs without reaming in 15 patients. The following factors contributing to deep infection were selected for analysis: age, gender, Gustilo type (II or III), fracture grade by AO type (A or B+C), fracture site, existence of multiple trauma (Injury Severity Score, ISS<18 or ISS> or = 18), existence of floating knee injury, debridement time (< or = 6 h or > 6 h), reamed (R) versus unreamed (UR) nailing, duration of external fixation (< or = 3 weeks or >3 weeks), interval between removal of EF and IMN (< or = 2 weeks or >2 weeks), skin closure time (< or = 1 week or >1 week), existence of superficial infection (+ or -) and existence of pin tract infection (+ or -). The relationship between deep infection and the above factors was evaluated by univariate analyses. Seven (16.7%) of the 42 open tibia fractures developed deep infections. All deep infections occurred in Gustilo type III (22.6%, 7/31). Only the skin closure time was a significant factor affecting the occurrence of deep infection on the present analysis (p = 0.006). The present evaluation showed that early skin closure within 1 week is the most important factor in preventing deep infections when treating open tibial fractures with secondary IMN after EF.

Intramedullary Nailing Following External Fixation in Femoral and Tibial Shaft Fractures

Intramedullary nailing is the standard of care for the definitive management of lower extremity long bone fractures. Occasionally, temporary external fixation is used in fractures with severe open wounds or vascular injury before definitive intramedullary nailing. Secondary intramedullary nailing following external fixation is somewhat controversial, especially with respect to the duration of external fixation that is allowable before the risk of infection following later nailing becomes too great. Several recent studies have provided further insight into this issue. The primary objective is to evaluate infection and nonunion rates in patients treated with temporary external fixation and secondary intramedullary nailing for lower extremity long bone fractures. The secondary objective is to evaluate whether the duration of external fixation and the interval time (defined as the time from external fixator removal to intramedullary nailing) influence the risk of infection after intramedullary nailing.

Treatment of Open Tibial Fractures with External Fixation and Secondary Intramedullary Nailing by Polytraumatized Patients

Treatment of Open Tibial Fractures with External Fixation and Secondary Intramedullary Nailing by Polytraumatized Patients

Secondary intramedullary nailing after distraction osteogenesis

Secondary intramedullary nailing after distraction osteogenesis

Secondary intramedullary nailing after distraction osteogenesis: 30 patients followed for 2-12 years.

There is no consensus about replacement of an external fixator by reamed intramedullary nailing in fracture cases. We evaluated the outcome in 30 patients (33 segments) of secondary intramedullary nailing during the consolidation phase after callus distraction using an external device. The main reasons for nailing were docking site nonunion (17 patients), angular deformity or fracture of the lengthened area (8 patients) or intolerance of the external device (5 patients), in 11 patients combined with a delayed distracted callus maturation. The average follow-up time was 4 (2-12) years. Intramedullary infection after nailing occurred in 1 case, and slight loss in callus length in 5 cases. Failure of union at the docking site with nail breakage occurred in 1 case. In the other patients, consolidation in the lengthened callus area and also union at the docking site were achieved on average 6 months after nailing. We believe that intramedullary nailing during the consolidation phase after bone lengthening or bone transport is a treatment option for delayed callus maturation or docking site nonunion, reducing prolonged use of the external fixator.

Secondary Intramedullary Nailing for the Treatment of Complications after Bone Lengthening

Secondary Intramedullary Nailing for the Treatment of Complications after Bone Lengthening

Treatment of Severe Open Fractures of Tibial Shaft: Comparison Between Ilizarov External Fixation and Secondary Intramedullary Nailing

Treatment of Severe Open Fractures of Tibial Shaft: Comparison Between Ilizarov External Fixation and Secondary Intramedullary Nailing

Spread of infection, in an animal model, after intramedullary nailing of an infected external fixator pin track

Implant sepsis, due to previous external fixator pin track infection, is the most common complication of secondary intramedullary (IM) nailing of the tibia. We have developed an animal model, which allows different treatment methods to be studied. Using an established ovine model of a pin track infection, Staphylococcus aureus was used to infect the external fixator pins, two weeks prior to reamed IM nailing. In the control group, the animals were killed at a mean of 10.5 days following nailing, when widespread infection was evident, with septic arthritis, abscess formation, and infection of the entire length of the tibia in all six animals. In the treatment group, before IM nailing, the pin sites were débrided, and both local and systemic antibiotics were administered. All surgical wounds healed without evidence of infection, 4 of the 6 animals survived for 28 days, and bacteria were only isolated from 1 of the 6 implants. Treatment was successful at reducing, but not eliminating, infection after secondary nailing.