Treatment Of Tibial Shaft Fractures Research Articles

Individual risk factors for deep infection and compromised fracture healing after intramedullary nailing of tibial shaft fractures: A single centre experience of 480 patients

IntroductionDespite modern advances in the treatment of tibial shaft fractures, complications including nonunion, malunion, and infection remain relatively frequent. A better understanding of these injuries and its complications could lead to prevention rather than treatment strategies. A retrospective study was performed to identify risk factors for deep infection and compromised fracture healing after intramedullary nailing (IMN) of tibial shaft fractures. Materials and methodsBetween January 2000 and January 2012, 480 consecutive patients with 486 tibial shaft fractures were enrolled in the study. Statistical analysis was performed to determine predictors of deep infection and compromised fracture healing. Compromised fracture healing was subdivided in delayed union and nonunion. The following independent variables were selected for analysis: age, sex, smoking, obesity, diabetes, American Society of Anaesthesiologists (ASA) classification, polytrauma, fracture type, open fractures, Gustilo type, primary external fixation (EF), time to nailing (TTN) and reaming. As primary statistical evaluation we performed a univariate analysis, followed by a multiple logistic regression model. ResultsUnivariate regression analysis revealed similar risk factors for delayed union and nonunion, including fracture type, open fractures and Gustilo type. Factors affecting the occurrence of deep infection in this model were primary EF, a prolonged TTN, open fractures and Gustilo type. Multiple logistic regression analysis revealed polytrauma as the single risk factor for nonunion. With respect to delayed union, no risk factors could be identified. In the same statistical model, deep infection was correlated with primary EF. ConclusionsThe purpose of this study was to evaluate risk factors of poor outcome after IMN of tibial shaft fractures. The univariate regression analysis showed that the nature of complications after tibial shaft nailing could be multifactorial. This was not confirmed in a multiple logistic regression model, which only revealed polytrauma and primary EF as risk factors for nonunion and deep infection, respectively. Future strategies should focus on prevention in high-risk populations such as polytrauma patients treated with EF.

Measuring illness beliefs in patients with lower extremity injuries: Reliability and validity of the Dutch version of the Somatic Pre-Occupation and Coping questionnaire (SPOC-NL)

IntroductionPositive coping strategies, illness perceptions and recovery expectations are associated with better clinical outcomes and earlier return to work after injuries. The Somatic Pre-Occupation and Coping (SPOC) questionnaire captures illness beliefs and coping towards recovery of physical function and return to work after surgical treatment of tibial shaft fractures. The aim of this study was to translate and culturally adapt the SPOC into Dutch (SPOC-NL) and evaluate its reliability and validity in patients with lower extremity injuries. MaterialsThe SPOC-NL contains four subscales: Somatic complaints, Coping, Energy, and Optimism. Patients treated for lower extremity injuries (N=106) completed the SPOC-NL, Short Form-36 and Short Musculoskeletal Function Assessment (SMFA-NL) questionnaire, and reported their current work status and self-perceived work ability. To assess test–retest reliability, 56 patients completed the SPOC-NL for a second time two weeks after the first administration of the SPOC-NL. We calculated Cronbach's Alpha, intraclass correlation coefficients (ICCs) and G coefficients to measure internal consistency and overall reliability, and used the Bland and Altman method to assess bias between test and retest SPOC-NL scores. To determine construct validity, we explored 16 a priori hypotheses regarding correlations between SPOC-NL scores and subscale scores and SF-36, SMFA-NL, work status and work ability. ResultsInternal consistency was good to excellent, with Cronbach's Alpha values ranging between 0.79 and 0.94 and G coefficients ranging between 0.77 and 0.95. Test–retest reliability was also good, since high ICCs (0.72–0.91) and G coefficients (0.82–0.94) were found. Construct validity of the SPOC-NL was good, as 75% of the predefined hypotheses were confirmed. Compared to participants who were on sick leave or receiving disability benefits, participants with a paid job had significantly higher scores on the total score and the subscales Somatic complaints and Energy of the SPOC-NL. Participants with high work ability also had significantly higher scores on the total score and all subscales than participants with low work ability. Discussion and conclusionsThe SPOC-NL is a reliable and valid measure for the assessment of illness beliefs and coping towards recovery and it is strongly related to work status and self-perceived ability to work in patients with lower extremity injuries.

Effect of minimally invasive percutaneous plates versus interlocking intramedullary nailing in tibial shaft treatment for fractures in adults: A meta-analysis

OBJECTIVE:The aim of this article was to determine the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults.METHOD:Literature searches of the Cochrane Library, PubMed, EMBASE, the Chinese Biomedical Literature database, the CNKI database, Wanfang Data, and the Weipu Journal database were performed up to August 2013. Only randomized and quasi-randomized controlled clinical trials comparing the use of percutaneous plates and interlocking intramedullary nails for tibial shaft fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards.RESULTS:Eleven trials were included. Compared with interlocking intramedullary nailing, minimally invasive percutaneous plates shortened fracture healing time and resulted in lower rates of postoperative delayed union and pain. There was no significant difference between the two methods with regard to the rates of excellent and good Johner-Wruh scoring, the rate of reoperation, and other complications.CONCLUSIONS:Overall, insufficient evidence exists regarding the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults. Low-quality evidence suggests that minimally invasive percutaneous plates could shorten fracture healing time, decrease the rate of postoperative delayed union, and decrease pain levels compared with interlocking intramedullary nailing. There is no significant difference between the two groups in terms of functional recovery scores, reoperation, and other complications. Further research that includes high-quality randomized controlled, multicenter trials is required to compare the effects of minimally invasive percutaneous plates versus interlocking intramedullary nailing in the treatment of tibial shaft fractures in adults.

Ilizarov external fixation or locked intramedullary nailing in diaphyseal tibial fractures: a randomized, prospective study of 58 consecutive patients

The aim of this study was to compare the Ilizarov circular fixator (IL) and locked intramedullary nailing (IM). Patients with isolated tibia shaft fractures were randomly allocated to either the IL (n = 31) or IM (n = 27) method. Conventional radiographs, postoperative pain assessment, self-appraisal scores and complications were evaluated. At the clinical 1-year follow-up, the patients were also evaluated by an independent observer. The minority of patients had open fractures, two and nine patients in the IM and IL groups, respectively. Eight patients in the IM group and four in the IL group sustained major complications (p = 0.107). In the IM group, two patients developed compartment syndrome, one deep infection, one hardware failure, one delayed union, one pseudarthrosis and two had a malunion. In the IL group, two patients developed pseudarthrosis and two had a malunion. Superficial pin-site infections were observed in 16 patients in the IL group. The fractures had healed radiographically at 12 weeks in both groups. At the 1-year follow-up, there were differences in pain (VAS) and satisfaction (VAS) scores in favor of IL treatment (VAS, p = 0.03 and p = 0.02, respectively). There were no differences between the groups with regard to range of motion (ROM) in the knee and ankle joints. The registration of local tenderness and pain revealed that there were 19 patients with anterior knee pain in the IM group and one in the IL group at the 1-year follow-up (p < 0.001). The IL is a safe and reliable alternative to IM for the treatment of tibial shaft fractures, with a low complication rate and good clinical outcome. Both treatments were well tolerated, but at the 1-year follow-up the patients in the IM group had more pain and were less satisfied. Finally, there was a high frequency of anterior knee pain in the IM group.

Reamed versus unreamed nail in the treatment of tibia shaft fractures.

The aim of the prospective randomized study was to compare the results of the treatment of tibia shaft fractures (TSF) by reamed or unreamed intramedullar nail. There were 103 patients with 104 TSF enrolled in the study within the period from December 2005 to June 2010. Seven patients were excluded from the study. Factors of injury severity, course of surgery and hospitalization, and incidence of early and delayed complications were recorded. X-ray was performed every 4weeks until the fracture was healed. Functional results were evaluated at least 1year after the surgery. Closed fractures were classified according to Tscherne classification and the open ones according to Gustilo classification. Forty-eight patients with 49 TSF were treated by unreamed tibial nail. There were 15 women and 33 men in this group. Injury severity score (ISS) ranged from 4 to 25 (ø 6.63). There were 45 closed fractures (0 16; I 22; II 7) and four open fractures (I 2; II 1; IIIA 1). In the reamed nail group there were 48 TSF. ISS ranged from 4 to 18 (ø 6.13). There were 35 closed (0 17; I 13; II 5) and 13 open (I 5; II 5; IIIA 3) fractures in this group. The time of operation was on average 15min shorter in the unreamed nail group. X-ray healing was the same in both groups (18.12 versus 17.92weeks). We had four patients in the unreamed nail group and six patients in the reamed nail group with delayed healing (28-44weeks). We recorded no infection, loss of reduction or re-operation in both groups. Follow-up of functional results was 90%. There was no statistically significant difference in clinical and functional results between the groups. We suggest that both methods are comparable.

Sa4.12 Does the change in the mass of parapatellar muscle influence the patellofemoral kinematics in the sagittal plane following the surgical treatment of tibial shaft fractures?

Sa4.12 Does the change in the mass of parapatellar muscle influence the patellofemoral kinematics in the sagittal plane following the surgical treatment of tibial shaft fractures?

Advantage and limitations of a minimally-invasive approach and early weight bearing in the treatment of tibial shaft fractures with locking plates

Intramedullary nailing is a common method of treating tibial shaft fractures. However, precise control of reduction at the proximal and distal quarters is difficult to achieve. The purpose of this study was to assess the results of plating using locking screws and the feasibility of a minimally-invasive approach. All patients with tibial shaft fracture treated by means of locking plates from January 2004 to October 2006. Thirty-two fractures were treated in 32 patients with a mean age of 43.8 years. Internal fixation with a locking plate and screw construct, using a minimally-invasive or standard approach. Surgical approach, time to weight bearing, complications and their type, time to bone union, alignment in the frontal and sagittal planes on anteroposterior and lateral radiographs. The minimally-invasive approach was performed in 28 cases and immediate full weight bearing allowed in 25 cases. At a mean follow-up of 27 months, two patients had died and two patients were lost to follow-up. The mean time to bone union was 9.1 weeks. Four cases had a complicated course: one infection, one compartment syndrome, one hardware breakage and one pseudarthrosis. Six cases ended up with valgus malunion exceeding 5° in the frontal plane, already present at the time of surgery. Where a minimally-invasive approach can be performed, immediate pain-free weight bearing can be allowed without further displacement at follow-up. The observed rate of malunion underlines the need for adequate reduction and shows that the rationale for success does not solely depend on the plate anatomic design but also on the skills of the operating surgeon. Level I university regional hospital Cohort study.

Combining plates and nails in the treatment of ipsilateral unicondylar tibial plateau and shaft fractures

Objective To analyze the feasibility and effect of combining intramedullary nails and plates in the treatment of ipsilateral unicondylar tibial plateau fractures with non.contiguous tibial shaft fractures.Methods From May 2003 to November 2005,21 patients with ipsilateral unicondylar tibial plateau fracture and non-contiguous tibial shaft fracture were treated with combining intramedullary nails and plates,including 15 males and 6 females,with the mean age of 34 years (range,20-55 years).The tibial plateau fractures were classified according to Schatzker et al.; 4 cases were type Ⅰ,11 cases type Ⅱ,6 cases type Ⅲ and 1 case type Ⅵ.Middle third tibial shaft fractures were in 13 patients,and distal third tibial shaft fractures were in 8 patients.Once the reduction was obtained,we first fixed tibial plateau with plate and then tibial shaft with medullary nail in 19 cases; in 2 cases,we first fixed the tibial shaft with medullary nail and then tibial plateau with plate.Results 1All patients were followed up for 0.9 to 4 years (average,2.2 years).Bone union was obtained in all patients.The tibial plateau fractures united after an average of 12 weeks,and the tibial shaft fractures united after an average of 29 weeks.Delayed union of the tibial shaft fracture occurred in 3 patients,and the fracture healed finally by removing the proximal locking.Tibial plateau malunion occurred in one patient due to malreduction.According to HSS scores,excellent result was obtained in 17 patients (80.95％),good in 3 patients (14.29％),fair in 1 patient (4.76％).Conclusion With careful attention to some techniques,ipsilateral unicondylar tibial plateau fractures with non-contiguous tibial shaft fractures can be treated successfully by combining medullary nail and plate. Key words: Tibial fractures; Fracture fixation,internal; Fracture fixation,intramedullary

No difference in the long term final functional outcome after nailing or cast bracing of high energy displaced tibial shaft fractures

BackgroundCast bracing (CB) has been a well established method of treating tibial shaft fractures. Majority of the recent literature on treatment of tibial shaft fractures have upheld intramedullary nailing (IMN) as the treatment of choice. Most of these studies are from the west, in public funded health set ups and in hospitals with very low rates of infection. This has lead to bewilderment in the minds of surgeons wishing to opt for conservative treatment in countries with scarcity of health resources. We therefore undertook this study to compare the two modalities in the scenario of the developing world.Material and methodsSixty-eight consecutive patients were treated alternately with CB and IMN for high energy, displaced, closed and Gustilo Grade 1 open fractures of the tibial shaft, between 1995 and 2001.ResultsAn average follow up at 4.3 years revealed no statistical difference in the final functional outcome as per Johner and Wruhs' criteria with modification to Indian lifestyle. IMN group had a) slightly shorter time to fracture union (mean 21.3 weeks versus 23.1 weeks for CB, p > 0.05), (b) lesser time off work (mean 17.6 weeks versus 25.6 weeks for CB, p <0.01), (c) fewer outpatient visits (mean 6.2 versus 9.7 for CB, p < 0.05), (d) less limb length discrepancy (mean 4.3 mm versus 6.6 mm for CB, p < 0.05). The difference in residual antero-posterior angulation (mean 3.2 degrees for IMN versus 4.9 degrees for CB, p = 0.14) and varus-valgus angulation (mean 3.7 degrees for IMN versus 5.1 degrees for CB, p = 0.7) were not statistically significant. However CB group had no deep infections as compared to two in the IMN group. The average cost of hospital treatment of CB group was less than half incurred by the IMN group (average USD 831 versus USD 2071 for nailed group, p < 0.05).ConclusionTreating tibial shaft fracture either with IMN or CB provided equally gratifying results with no statistical difference in final functional outcome. The economic cost to the patient in Indian conditions is significantly less with CB and therefore stands as an equally reliable treatment option, especially in countries with fewer resources.

Tibia Fractures

The purpose of this study is to provide a summary of the absolute and the relative surgical indications for both closed and operative treatment of tibial shaft fractures. A literature review of the pertinent literature was undertaken, and a limited number of the most significant papers are cited. Recommendations are provided for fractures that are most likely to need surgical intervention and relative indications for fractures that may benefit from surgical stabilization. Successful closed treatment can be achieved either by casting and conventional 3-point molding or by utilizing the Sarmiento technique of casting. Either technique depends on soft tissues to maintain bony alignment. The reported results are significantly improved after surgical stabilization after open tibial shaft fractures and tibial shaft fractures associated with ipsilateral femoral fractures. Relative indications for surgical stabilization include comminuted fractures, displaced fractures with an intact fibula, and displaced fractures in adolescents. Compartment syndrome remains the most significant early complication encountered when treating tibial shaft fractures in children and adolescents by either closed or surgical methods and should be considered in the face of pain out of proportion to the injury or increasing narcotic requirements. Tibial fractures are one of the more common injuries treated by orthopedic surgeons. Although most can be treated by closed techniques, certain fractures benefit significantly from surgical stabilization.

Critical analysis of tibial fracture healing following unreamed nailing.

Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing. One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing. Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p=0.005), fracture site gap (p=0.01), degree of comminution (p=0.0003), associated soft tissue injuries (p=0.02) and the time to dynamisation (p=0.0001). High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.

Prospective comparative study of functional outcome of treatment of tibial shaft fracture in adult by cast versus intramedullary nailing

All patients with an isolated closed unilateral fracture of the tibial diaphysis admitted in our institution between November 2009 and October 2010 were evaluated for inclusion in the present study. Inclusion criteria were displaced closed fractures. The fractures of type A and B, according to the AO-classification system, were considered suitable for the study.16 The following exclusion criteria were used: 1) Patients who had other major injuries which could influence the final functional result, 2) patients with cardiopulmonary, rheumatological, neurological, or metabolic disease, 3) patients with previous injuries which influenced their general function, 4) patients with fractures within 5 cm distal to the tibial tuberosity or 7 cm proximal to the ankle joint, 5) open fractures, and 6) those with open growth plates. Thirty-four patients (26 men) having a mean age of 38 years fulfilled the criteria and entered the study. The patients gave their informed written consent before inclusion in the study, which was approved by the hospital’s ethics committee. Patients who agreed to participate in the study were randomized using the technique of stratified randomization by minimization.17 This method ensures that the treatment groups are similar as regard to the percentage of patient factors that are considered of major prognostic importance. The aim is to balance the marginal treatment totals for each level of each patient factor. Using a computer minimization program, each patient was allocated according to high-energy, soft-tissue injury (closed), age (under or over 50 years), smoking (yes or no), alcoholism (yes or no), and occupation (sedentary, mobile, heavy, unemployed). Fractures caused by traffic accident or a fall from a height of at least 3 meters were classified as highenergy trauma.18 Patients in each stratum were randomly allocated for treatment by unreamed intramedullary nailing or plaster cast. Seventeen patients were randomized to have an intramedullary nail (group I), and 17 patients were randomized to have a plaster cast (group II). All fractures were unilateral. Nineteen involved the right leg and 4 patients were injured by falling accidents. Traffic accidents caused the injuries in 26 patients, 11 of them were pedestrians, 2 were automobile drivers, and 13 were motorcycle drivers. Two patients were injured in sporting accidents and 2 others were injured at work. The severity of the closed injuries was classified according to (Table 1).19 Eight fractures were caused by low-energy trauma, while 26 fractures were caused by high-energy trauma (Table 1). The type of fracture was classified according to the AO system (Table 2). Seven fractures involved the proximal third of the tibia, 21 the middle third, and 6 the distal third. Twentynine patients had an associated fibula fracture, 8 at the same level as the tibia fracture, and 21 at a different one (Table 2). The median time of delay to operation was 5 days for group I and no days for group II. Gender, smoking habits, age, type of trauma, severity of soft-tissue damage, and degrees of comminution of the fractures were similar in the 2 groups. Closed tibial nailing was performed with the patient lying supine. A calcaneal pin was used if traction was required. We used a longitudinal medial parapatellar incision and approach to the Prospective comparative study of functional outcome of treatment of tibial shaft fracture in adult by cast versus intramedullary nailing

Recommendations for avoiding knee pain after intramedullary nailing of tibial shaft fractures.

BackgroundThe objective of this study is to analyze the proximal tibiofibular joint in patients with knee pain after treatment of tibial shaft fractures with locked intramedullary nail.FindingsThe proximal tibiofibular joint was analyzed in 30 patients, who reported knee pain after tibial nailing, and standard radiograph and computed tomography were performed to examine the proximal third of the tibia. Twenty patients (68.9%) presented the proximal screw crossing the proximal tibiofibular joint and 13 (44.8%) had already removed the nail and/or screw. Four patients (13.7%) reported complaint of knee pain. However, the screw did not reach the proximal tibiofibular joint. Five patients (17.2%) complained of knee pain although the screw toward the joint did not affect the proximal tibiofibular joint.ConclusionWhen using nails with oblique proximal lock, surgeons should be careful not to cause injury in the proximal tibiofibular joint, what may be one of the causes of knee pain. Thus, the authors suggest postoperative evaluation performing computed tomography when there is complaint of pain.

Treatment of acute tibial shaft fractures with an expandable nailing system: A systematic review of the literature

Locked Intramedullary Nailing is an established method of treatment for tibial shaft fractures. Locking of tibial nails is however not without its drawbacks. Locking is time consuming, and is associated with a noteworthy complication rate. The Fixion IM nailing system is an expandable nail designed to eliminate some of these drawbacks. We have performed a systematic review of the literature to determine the safety and efficacy of this system. Publications examining the use of the Fixion system were identified from the MEDLINE and the Cochrane databases. Forty-one citations were generated by the MEDLINE search. Of these, two quasi-randomised trials and eight case series satisfied our selection criteria and were reviewed. Overall the average réopération rate for the Fixion nail was 10.2%. Shortening occurred in 3%of cases and fracture propagation was reported in 2% of cases. The Fixion cohort united at an average of 12.2 weeks and the average operative time was 54 minutes. The Fixion system eliminated complications and reoperations associated with the use of locking screws. Further studies in the form of randomised controlled trials are needed to evaluate the Fixion system against conventional locked nails.

The use of gentamicin-coated nails in the tibia: preliminary results of a prospective study.

BackgroundThe use of antibiotic-coated implants may reduce the rate of infection and facilitate fracture healing after surgical treatment of tibial shaft fractures. A new biodegradable gentamicin-loaded coating of an implant (UTN PROtect®) was CE-certified in August 2005. In this prospective, non-randomized case series, we investigated the clinical, laboratory and radiological outcomes of 21 patients who underwent surgical treatment in closed or open tibial fractures, as well as revisions with the UTN PROtect® gentamicin-coated intramedullary nail.MethodsOf 21 patients (13 men, 8 women), 19 completed the 6-month follow-up. The study population included patients with complex tibial fractures and late revision cases. Clinical outcomes comprised adverse events, including infections and the SF-36 physical score. Laboratory outcomes, including C-reactive protein and leukocyte count as inflammatory markers, haemoglobin and serum gentamicin, were measured at baseline and up to 6 months post operatively. Radiographic assessments of fracture healing and weight-bearing capacity were determined at 5 weeks, 3 and 6 months after surgery.ResultsNo implant-related infections occurred; one patient had superficial wound healing problems. Mean C-reactive protein levels remained below 5 mg/L throughout the study, with a peak at 4–7 days after surgery (4.4 mg/L; range 0.5–16.1 mg/L). Leukocyte counts and haemoglobin levels did not vary over time during the study. The mean SF-36 physical score at 6 months was 42.6 (range 19.4–56.7). Radiographic union defined as three or four bridged cortices was achieved in 11 patients (58%) after 6 months. The remaining eight patients showed partial fracture healing with one or two bridged cortices. Additionally, 13 patients (68%) demonstrated full weight-bearing capacity after 6 months.ConclusionsThe use of the UTN PROtect® intramedullary nail was associated with good clinical, laboratory and radiological outcomes after 6 months. These preliminary results support the use of gentamicin-coated implants as a new potential treatment option for the prevention of infection in trauma patients and in revision cases.Level of EvidenceLevel II.

Removal of a bent tibial intramedullary nail: a rare case report and review of the literature

Intramedullary interlocking nailing is a gold standard for treatment of tibial shaft fractures. Bending of a nail secondary to trauma is a rare complication, which may be encountered in healed or unhealed tibial shaft fractures. Removal of such bent nail is always a challenge. We reported this case to discuss various techniques for removal of bent nails and to share our experience in removing a bent tibial intramedullary nail in a 30-year-old man, who was admitted in our department with re-fracture of the right tibial shaft due to a roadside accident two years after the initial surgical treatment. The intramedullary nail, bent by 30 degrees and visible on anterioposterior as well as on lateral radiographs, was firstly weakened by partially cutting the convex wall, then straightened by applying external force, and finally removed by using the standard nail removal method.

Tibial Shaft Fracture after Removal of an ACE Tibial Nail

Intramedullary interlocking nailing is the gold standard method for treatment of tibial shaft fractures. Thus, the growing use of the intramedullary nailing resulted in an increased number of tibial nails removal procedures in daily clinical practice. Despite adequate surgeon experience, the removal of tibial intramedullary nails is not without complications. One of the commonly used nails is the ACE (DePuy Orthopaedics, Inc., Warsaw, IN, USA). The purpose of this paper is to report such a complication following the removal procedure and review the pertinent literature. A 39-year-old female who had sustained a lower-third tibial fracture was treated with an intramedullary nail 5 years ago. Despite her unremarkable follow-up, for personal reasons, a removal procedure was planned. Two undisplaced fractures were observed in the postoperative radiological evaluation. The potential complications of the removal of intramedullary nailing of the tibia should be considered by both physician and patient.

The curative effects of intramedullary interlocking nailand small incision for the treatment of tibial shaft fracture

Objective To evaluate the clinical applied effects of tibial shaft fracture with intramedullary interlocking nail and small incision. Methods From November 2004 to October 2005,47 cases of tibial shaft fracture were treated with intramedullary interlocking nail, all the cases were adopted with small incision and intramedullary interlocking nail, and analysed the curative effects Results 47 cases were followed-up ranged 8 ～ 27 months. All cases resumed normal knee function 6 to 12 weeks after operation,without nonunion and malunion. Conclusion Treatment of tibial shaft fracture with intramedullary interlocking nail and small incision had the advantages of little trauma,good stability, high rate of fracture union and rapid functions recovery. It is worthy deserveed to be put into application and populatization in clinics. Key words: Small incision; Intramedullary interlocking nail; Tibial shaft fracture

Factors affecting the fracture healing in treatment of tibial shaft fractures with circular external fixator

This study aims to analyse the contribution of various risk factors for the delay of tibial shaft fractures treated by circular external fixator and predicting the high risk fractures for delayed union. 32 extraarticular tibial shaft fractures of 31 adult patients treated with circular external fixator were included. The patients were analysed according to age, energy of trauma, having an open fracture or not, AO classification, obliquity, use of supplementary fixation techniques in surgery, distance of fracture line to neighbouring rings, having a pin-track infection or not, reduction score, and smoking. There were eight delayed unions and two non-unions in our study. Consolidation time was significantly shorter ( p = 0.01) between the supplementary fixation group and the others. There was a significant difference in fracture healing time between pin-track-infected patients and the patients who did not have pin-track infection ( p = 0.037). In conclusion, our results indicate that non-union infection and not using supplementary fixation techniques are the major factors that delay the healing time. Supplementary fixation enhances the reduction rate and a low reduction score is related with the occurrence of a pin-track infection.

Diagnosis and treatment of the tibia shaft fracture accompanied with ipsilateral posterior malleolus fracture

Objective To discuss the cause and prevention of the tibial shaft fracture associated with ipsilateral posterior malleolus fracture. Methods From May 2001 to November 2004, 269 cases of tibial shaft fracture were treated in our department. Of them, 34 were complicated with ipsilateral posterior nialleolus fracture. They were 21 males and 13 females. Their ages ranged from 33 to 71 years old. There were 2 patients with tibial open fracture. Preoperatively conventional plain X-ray of the full-length tibia and ankle region was taken for all the patients. CT scanning was conducted for those who were suspected of the ipsilateral posterior malleolus fracture. Before tibial intramedulary nailing, the posterior malleolar fragments were fixed with an anterior lag-screw. Results The mean duration of follow-up was 11 months. The posterior malleolus fracture healed with excellent ankle function in 33 cases. The only one case whose posterior malleolus fracture had been overlookd until follow-up sufferd from ankle disfunction and pain. Conclusions The tibial shaft fracture is frequently complicated with and the ipsilateral posterior malleolus fracture in clinic which is re-sponsible for the ankle disfunction. Pre-operative CT scanning of the ankle and fixation of the fragments are key elements of the prevention. Key words: Tibial fracture; Ankle injuries ; Fracture fixation, intramedullary