Unreamed Intramedullary Nailing Research Articles

SHORT TERM FUNCTIONAL OUTCOME OF CLOSED REDUCTION AND FIXATION OF TIBIA SHAFT FRACTURES USING UNREAMED ENDERS NAIL IN ADULT POPULATION - A PROSPECTIVE STUDY

Most of the tibial shaft fractures are the result of high energy trauma. There are various non surgical and surgical methods for managing tibial shaft fractures ranging from conservative casting, tubular external fixator, ring external fixator, open reduction and plating, reamed intramedullary interlocking nailing and unreamed intramedullary nailing. Aim of the study was to evaluate the functional outcomes of closed reduction with unreamed enders nailing as a definitive treatment option for closed tibial shaft fractures in adult population. In the study we included 150 adult patients who had sustained closed tibial fractures and underwent closed reduction and fixation with unreamed enders nailing within 12 hours of the injury. Eye of the nail, present at the distal end of the nails was locked. Total surgical time was averaged to 27.6 minutes. Evaluation was done by the time of clinical union, time of radiological union and VAS score. Ten patients had a delayed union. Two patients developed infection which was managed with oral antibiotics. In the conclusion, we found out that unreamed enders nailing procedure preserves the periosteum and its blood supply due to minimal exposure and improves the healing of fracture and decreases the incidence of infection. This method reduces the operative time, has a relatively less learning curve, reduces fluoroscopic exposure, reduces blood loss, reduces infection rate, doesnt expose the joint thus maintaining its congruity, reduces the cost of implant, reduces patient hospital stay, reduces the antibiotic usage and the implant removal at a later stage can be done as a day care procedure.

The Effect of Reamed and Unreamed Intramedullary Nail Fixation on the Prognosis of Femoral Shaft Fracture

The Effect of Reamed and Unreamed Intramedullary Nail Fixation on the Prognosis of Femoral Shaft Fracture

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial.

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda. Randomized clinical trial. Regional referral hospital in Uganda. Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019. Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24). The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications. Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection. In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reamed versus unreamed intramedullary nailing for the treatment of femoral shaft fractures among adults: A meta-analysis of randomized controlled trials

BackgroundThe purpose of this meta-analysis is to compare the merits and drawbacks between reamed intramedullary nailing (RIN) and unreamed intramedullary nailing (URIN) among adults. MethodsWe comprehensively searched PubMed, MEDLINE database through the PubMed search engine, Google Scholar, Cochrane Library, Embase, VIPI (Database for Chinese Technical Periodicals), and CNKI (China National Knowledge Infrastructure) from inception to March 2020. Outcomes of interest included nonunion rates, implant failure rates, secondary procedure rates, blood loss, acute respiratory distress syndrome (ARDS) rates, and pulmonary complications rates. ResultsEight randomized controlled trials were included. The result of nonunion rates shows that the nonunion rate is significantly lower in the RIN group (RR = 0.20, 95% CI = 0.09–0.48, Z = 3.63, P = 0.0003). There were no significant differences for the risk of implant failure rates (RR = 0.55, 95% CI = 0.18–1.69, Z = 1.04, P = 0.30). The secondary procedure rates were significantly lower in the RIN group (RR = 0.28, 95% CI = 0.12–0.66, Z = 2.91, P = 0.004). The result shows that the blood loss of URIN group is significantly lower (RR = 145.52, 95% CI = 39.68–251.36, Z = 2.69, P = 0.007). The result shows that there was no significant difference in the ARDS rates (RR = 1.53, 95% CI = 0.37–6.29, Z = 0.59, P = 0.55) and the pulmonary complications rates between RIN group and URIN group (RR = 1.59, 95% CI = 0.61–4.17, Z = 0.94, P = 0.35). ConclusionsReamed intramedullary nailing would lead to lower nonunion rate, secondary procedure rate and more blood loss. Unreamed intramedullary nailing is related to a higher nonunion rate, secondary procedure rate and less blood loss. No significant difference is found in implant failure rate, ARDS rate and pulmonary complication rate between the two groups.

Intramedullary nail versus bridge plate in open tibial fractures - randomized clinical trial

IntroductionOpen tibial shaft fractures present a challenge to the orthopedic surgeon, because they are common, have a high rate of complications and still have a controversial treatment. As a result of the high incidence of these fractures, the need of a definitive treatment and the unavailability of the intramedullary nail or a well-trained team, we developed this study to compare the effectiveness of the bridge-plating (BP) with the unreamed intramedullary nail (UIMN) in the treatment of open tibial shaft fractures. Materials and methodsEighty patients were included in a prospective, consecutive and random way and then randomized in two groups of treatment: unreamed intramedullary nail and bridge-plating.The primary outcomes were the reoperation rate and the Johner-Wruhs functional criteria. Secondary outcomes were complication rates, partial and total weight bearing time and bone consolidation time. We verified the existence of normality in the quantitative variables for the outcomes using the Kolmogorov-Smirnov test. The Chi-Square test was utilized to compare the methods according to the relative frequencies and the comparison between the methods regarding the average of the quantitative variables was done through the T-Student test. ResultsBoth the reoperation rates and the functional criteria of Johner-Wruhs showed no difference between the two groups. The exposure time and the total surgical time were longer in the UIMN group, however the consolidation time, partial weight bearing time and total weight bearing time did not show significant difference. A significant difference was found between the groups in the implant failure rate, in favor of UIMN, the angular malalignment was another secundary outcome that showed a non significant difference in favor of UIMN. ConclusionsWe concluded that both methods were effective for the treatment of open tibia shaft fractures, however, the implant failure rate was higher in the bridge plate group.

Surgical management of compound fracture tibia using an unreamed interlocking intramedullary nail

Background and Objectives: Tibial fractures are one of the most common long bone fractures with increasing number of motor vehicle accidents. Complications like compartment syndrome, neurovascular injuries, malunion are common. Reaming before insertion of nail disrupts the medullary blood supply. Infection rate with reaming is high because the foreign bodies, dust, etc are pushed deeper into the tissues with reaming. Thus considering all these factors, the unreamed intramedullary nail can be used for the management of compound fractures of tibia. Materials and methods: The present study was conducted at the Department of Orthopedics, Adichunchangiri Institute of Medical Sciences, B G Nagara, Mandya district after obtaining ethical clearance. This study was conducted on 20 patients involving both male and female. Study was conducted for a period of 18 months from December 2018 to June 2020. Cases were followed up with 4 visits.Results: Compound fractures of the tibia treated by unreamed interlocking intra medullary nail gave excellent results measured by surgical outcome and patient satisfaction. This technique boasts lower rates of complications in comparison with other treatment modalities. Interpretation & Conclusion: Unreamed interlocking nailing is a lucrative option in management of compound and segmental tibial fractures. It promotes early union. Also it has low risk of infection. Early mobilisation can be advocated. It helps early return to activities.

Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis.

To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures. MEDLINE, EMBASE, CENTRAL, and OpenGrey. Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type. Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis. A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)]. In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43-1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37-1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58-1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage. Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study

IntroductionIntramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful. Material and methodsThis study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation. ResultsThe behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%. ConclusionsThe results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.

Clinical Study of Functional Outcome of External Fixator Device as a Primary Definitve Treatment of Open Tibia Fracture

Background: Open fractures of leg are quite common in Road traffic accidents. The ideal protocol for openfractures of leg is initial thorough debridement, soft tissue coverage and intramedullary nailing or externalfixator application. External fixator may be later converted to internal fixation with reamed or unreamedintramedullary nail or left as a definitive treatment.Methodology: This prospective study was conducted at Rohilkhand Medical College And Hospital fromJanuary 2019 to January 2020 on patients presenting with open tibial fracture. Tubular External Fixator wasused. Total 30 patients were enrolled in this study.Results: In our study 30 patients were included in which 20 were male and 10 were females with meanage 32.2 years including children and elderly age group there was no age bar. Mean operative time was 60minutes. Average time for union was 24 weeks.Conclusion: External fixation as a primary definitive treatment for open tibial fracture is a cost effectiveprocedure in developing country with minimal morbidity and mortality.

Prognostic factors for predicting health-related quality of life after intramedullary nailing of tibial fractures: a randomized controlled trial.

AimsUsing tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.MethodsThe Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL.ResultsFor patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing.ConclusionWe identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL.Cite this article: Bone Jt Open 2021;2(1):22–32.

Clinical and radiological evaluation of fracture union in pathologic fractures after closed intramedullary nailing and adjuvant radiotherapy: A retrospective study

Introduction/Objective. Pathologic fractures are devastating complications in metastatic bone disease. Treatment of these condition varies, and includes systemic therapies and surgical interventions. Lack of evidence still exists for standardized care. The aim of this study is to analyze radiological healing response and clinical outcomes after intramedullary nailing (IMN) and adjuvant radiotherapy in complete pathologic fractures of femur or humerus Methods. A total of 19 patients who presented with pathological fracture were retrospectively reviewed. Data regarding demographic characteristics, clinical outcomes and radiologic images were obtained from hospital records. All patients in this cohort were treated with closed, unreamed IMN and adjuvant radiation treatment. Results. Pain relief and full range of motion was obtained in all patients. The mean postoperative Musculoskeletal Tumor Society scores at last follow-up were 69% (range 50?85). All patients demonstrated complete radiographic healing between 2 and 6 months. Only one patient required reoperation for refracture at the tip of the nail which was revised with a longer nail. Conclusion. Our study demonstrated that pathologic fractures managed with closed unreamed IMN and adjuvant multifractional 20 Gy dose radiotherapy yielded good clinical outcomes with complete radiologic response regardless of patient?s life expectancy, adjuvant treatments and overall condition. Closed unreamed IMN was also associated with decreased surgical time in these high-risk patients.

Metabolic Shock in Elderly Pertrochanteric or Intertrochanteric Surgery. Comparison of Three Surgical Methods. Is there a Much Safer?

IntroductionTrochanteric fractures are a major trauma in the elderly population and represent a significant part of public health spending. Various fixation devices are used as treatment for these fractures. This study aimed to evaluate three surgical methods in the treatment of pertrochanteric femoral fractures.Materials and methodsFrom January 1, 2013, to December 31, 2014, 86 patients were divided into 3 groups. Fifteen patients were treated with osteosynthesis by reamed intramedullary nailing (RIMN), 15 patients were treated with unreamed intramedullary nailing (UIMN), and 13 patients were treated with dynamic hip screw (DHS) plate osteosynthesis. All patients were >75 years of age. They were evaluated with a clinical radiological follow-up and laboratory examination (LDH, CPK, IL-1-B, IL-8, TNF-α, alpha-1-acid glycoprotein, D-dimer, fibrinogen, ESR, CRP, and procalcitonin).ResultsIL-8, TNF-α, fibrinogen, D-dimer and alpha-1-acid glycoprotein levels were higher in the DHS group compared with the other two groups at 1 month after surgery (P<0.05). LDH, IL-1β, and IL-6 levels were higher in the DHS group compared with the other two groups at 3 months after surgery (P<0.05). From 3 to 6 months after surgery, the TNF-α level was high in the DHS and RIMN groups (P<0.05). Infection markers did not demonstrate a difference among the 3 groups. Twelve patients died during the 12-month follow-up. Regardless of the method used, morbidity and mortality are linked to enticement and comorbidities rather than surgery within 48 hours after the trauma.ConclusionsFrom our study, we can affirm that the values of cytokines and interleukins observed remain high during the 12-month follow up, regardless of whatever fixation devices or surgery type was performed within 48 hours of injury. Inflammatory markers are higher in patients in the DHS group. This can probably be explained by the fact that DHS technique is performed by open surgery, and this can create a higher inflammation of soft tissue. Mortality is reduced in the first 30 days after surgery if patients are mobilized early. Therefore, mortality in our study population of patients aged >75 years is linked more to the chronic inflammatory state and comorbidities, rather than fixation device or surgical type used.However, future studies are needed to answer further questions that go beyond the scope of our study.

Smoking, Obesity, and Disability Benefits or Litigation Are Not Associated with Clinically Important Reductions in Physical Functioning After Intramedullary Nailing of Tibial Shaft Fractures: A Retrospective Cohort Study.

Forty percent of long bone fractures involve the tibia. These fractures are associated with prolonged recovery and may adversely affect patients' long-term physical functioning; however, there is limited evidence to inform what factors influence functional recovery in this patient population. In a secondary analysis of a previous randomized trial, we asked: What fracture-related, demographic, social, or rehabilitative factors were associated with physical function 1 year after reamed intramedullary nailing of open or closed tibial shaft fractures? This is a secondary (retrospective) analysis of a prior randomized trial (Trial to Re-evaluate Ultrasound in the Treatment of Tibial Fractures; TRUST trial). In the TRUST trial, 501 patients with unilateral open or closed tibial shaft fractures were randomized to self-administer daily low-intensity pulsed ultrasound or use a sham device, of which 15% (73 of 501) were not followed for 1 year due to early study termination as a result of futility (no difference between active and sham interventions). Of the remaining patients, 70% (299 of 428) provided full data. All fractures were fixed using reamed (298 of 299) or unreamed (1 of 299) intramedullary nailing. Thus, we excluded the sole fracture fixed using unreamed intramedullary nailing. The co-primary study outcomes of the TRUST trial were time to radiographic healing and SF-36 physical component summary (SF-36 PCS) scores at 1-year. SF-36 PCS scores range from 0 to 100, with higher scores being better, and the minimum clinically important difference (MCID) is 5 points. In this secondary analysis, based on clinical and biological rationale, we selected factors that may be associated with physical functioning as measured by SF-36 PCS scores. All selected factors were inserted simultaneously into a multivariate linear regression analysis. After adjusting for potentially confounding factors, such as age, gender, and injury severity, we found that no factor showed an association that exceeded the MCID for physical functioning 1 year after intramedullary nailing for tibial shaft fractures. The independent variables associated with lower physical functioning were current smoking status (mean difference -3.0 [95% confidence interval -5 to -0.5]; p = 0.02), BMI > 30 kg/m2 (mean difference -3.0 [95% CI -5.0 to -0.3]; p = 0.03), and receipt of disability benefits or involvement in litigation, or plans to be (mean difference -3.0 [95% CI -5.0 to -1]; p = 0.007). Patients who were employed (mean difference 4.6 [95% CI 2.0 to 7]; p < 0.001) and those who were advised by their surgeon to partially or fully bear weight postoperatively (mean difference 2.0 [95% CI 0.1 to 4.0]; p = 0.04) were associated with higher physical functioning. Age, gender, fracture severity, and receipt of early physical therapy were not associated with physical functioning at 1-year following surgical fixation. Among patients with tibial fractures, none of the factors we analyzed, including smoking status, receipt of disability benefits or involvement in litigation, or BMI, showed an association with physical functioning that exceeded the MCID. Level III, therapeutic study.

Systematic Review and Analysis of the Quality of Randomized Controlled Trials Comparing Reamed and Unreamed Intramedullary Nailing of Tibial Fractures.

To evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems. PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail." Filters were applied for the years 1991-2019, full articles, human subjects, and English language. Inclusion criteria were (1) prospective and randomized trials, (2) studies reported >80% follow-up, and (3) articles amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) skeletally immature patients or (2) incomplete data sets. Articles were assessed with the Coleman Methodology Score, the Consolidated Standards of Reporting Trials systems, and Cowan's Categorical Rating by 2 independent observers. Scores for individual articles were averaged for the 2 observers. The total and subcategory scores for all included articles were also averaged with SD from both observers. Categories from the 2 grading systems with deficient reporting were measured as a percentage based on grading from both observers. Data were analyzed using kappa statistic and correlation coefficient to assess agreement and reliability. All included articles supported the use of reamed tibial intramedullary nails, but the overall quality of the literature fell in the middle of both the modified Coleman Score and Consolidated Standards of Reporting Trials grading scheme ranges despite being Oxford Level 1. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Infection Rate of Reamed versus Unreamed Intramedullary Nailing in Open Tibia Fractures

Background: Intramedullary nailing (IM nailing) is the standard of care for the treatment of most diaphyseal lower extremity fractures. A few studies have assessed and compared the infection rate following reamed and unreamed IM nailing in open long bone fractures. In the present study, we attempted to compare the infection rate between two procedures in open fractures of tibia.&#x0D; Methods: In this prospective study, we included consecutive patients suffering from open fractures of tibia (Gustilo subtypes II or IIIA) who required IM nailing. Patients younger than 16 years old, other Gustilo types (I, IIIB, and IIIC), fractures reaching to the tibial plateau articular surface, and simultaneous fractures of other bones in the extremity were excluded. All patients were followed up for one year to assess the postoperative infection rate.&#x0D; Results: Of 59 patients, 37 underwent reamed IM nailing and 22 underwent unreamed IM nailing. In reamed group, 4 cases (10.8%) experienced an infection requiring reoperation and antibiotic therapy, while in the unreamed group, it was 5 cases (22.7%). The difference between the groups was not statistically significant.&#x0D; Conclusion: Reamed and unreamed IM nailing procedures for fractures of tibia have similar outcome regarding long-term postoperative infections that require reoperation and antibiotic therapy.

Intramedullary Nail Fixation for the Treatment of Pathologic Humeral Shaft Fractures.

The goal of this study was to report the clinical outcomes of pathologic humeral shaft fractures treated with reamed or unreamed intramedullary nail fixation in an era of longer patient survival. A retrospective review was conducted of all patients who underwent intramedullary nail fixation performed by a single surgeon for pathologic humeral shaft fractures at a Level I trauma center from 2009 to 2017. Of the 25 patients who were identified, 9 were excluded. Groups were categorized according to whether they underwent reamed or unreamed fixation, and they were evaluated for evidence of union, complications, and reoperation. Of the patients, 11 underwent an unreamed procedure and 5 underwent a reamed procedure. Mean length of follow-up was 51.5 weeks. Of the patients who participated, 12 (75%) showed evidence of union and 2 patients (12.5%) showed evidence of nonunion, with no statistical difference between the groups. Five patients (31.3%) had complications. One nonunion occurred in the reamed group and did not require reoperation. In the unreamed group, complications consisted of 1 delayed union, 1 nonunion treated with revision intramedullary nail fixation, and 2 cases of disease progression that required reoperation. Intramedullary nail fixation of pathologic humeral shaft fractures achieves rates of union parallel to those seen with fixation in a healthy population. The length of follow-up in the current study was longer than the life expectancy reported by previous authors, which can be attributed to improvements in the treatment of cancer. The current authors argue that unreamed fixation is the optimal technique because it yields similar outcomes to a reamed approach and is faster and potentially safer. [Orthopedics. 2020;43(5):e389-e398.].

Predicting tibia shaft nonunions at initial fixation: An external validation of the Nonunion Risk Determination (NURD) score in the SPRINT trial data

BackgroundPredictive models are common in orthopedic research; however, most models are not validated in an external population. The Nonunion Risk Determination (NURD) score was developed using a single-center cohort of 382 patients to reliably predict tibia shaft nonunions at the time of initial intramedullary nail fixation. The purpose of this study was to externally validate the NURD score using data from the SPRINT Trial. MethodsThe SPRINT trial was a multicenter study comparing reamed versus unreamed intramedullary nails in tibial shaft fracture patients. We assessed the prognostic performance of the NURD score in the SPRINT trial data with comparisons of the c-statistics, calibration plots, and a comparison of predicted probabilities at cut-points defined in the study to derive the NURD score. In addition, we compared the odds ratios of the NURD score components between the derivation (NURD) and external validation (SPRINT) data. ResultsThe NURD score demonstrated significantly worse discrimination in the SPRINT data than was observed in the original data (c-statistic: 0.61 vs. 0.85, p<0.01). The NURD score was well-calibrated in the derivation and SPRINT data. The SPRINT data had less heterogeneity, as determined by the standard deviation of the linear predictors (NURD: 1.4 vs. SPRINT: 0.4). Once we adjusted for case-mix differences, the NURD score had similarly strong discrimination in the SPRINT data (c-statistic: 0.81 vs. 0.85, p = 0.17). DiscussionBased on our external validation, the NURD score lacks generalizability as it underperforms with respect to discrimination in the SPRINT trial data. However, after adjusting for case-mix differences, the performance of the NURD score is comparable between the two datasets, suggesting robust reproducibility.

Management of humeral impending or pathological fractures with intramedullary nailing: reaming versus non reaming technique-a retrospective comparative study.

To compare reamed intramedullary nailing (RIM) versus un-reamed intramedullary nailing (URIM) for the treatment of impending and pathological fractures of the humeral shaft in terms of 24-h postoperative pain, blood transfusion requirements, surgical time, surgical complications, medical complications, length of stay and consolidation rates. A retrospective comparative study between January 2013 and December 2018 was conducted. Student's t test, Mann-Whitney U and Chi-square tests were used to detect differences within the two study groups. Multiple linear regression was done to adjust for possible confounders. A total of 53 patients (33 RIM vs. 20 URIM) underwent humeral nailing. Fifteen (28%) were impending fractures (7 RIM vs. 8 URIM). Multiple myeloma (49%) and metastatic carcinoma (39.6%) were the most common etiologies. Pain score (5.13 ± 0.68 RIM vs. 6.78 ± 0.62 URIM; p = 0.082) and total dose of opioids (33.125 ± 27.6 RIM vs. 33.3 ± 22.28 URIM; p = 0.462) showed similar results. Blood transfusion was more prevalent within RIM group (34.48% RIM vs. 20% URIM; p = 0.044) with a clinical tendency of higher blood loss (207.86 ± 150.83RIM vs. 127.00 ± 179.98 URIM; p = 0.092). There was a consolidation rate of 71.05% (27/38) with no statistical difference (73.08% (19/26) RIM vs. 66.67% (8/12) URIM; p = 0.685). Our study suggests possible benefit of URIM in terms of less blood transfusions with no difference in consolidation rates. Even though without significance, a tendency to less blood loss, less events of systemic complication and lower length of stay was observed with URIM. Despite its limitations, this study can be used to design future prospective ventures that quantify patient-reported outcomes and provide more clear evidence.

Interlocking Tibial Nail in open Tibial Fracture

ABSTRACTPurpose : To assess the clinical outcome of intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the intramedullary nailing.METHODS: Between FEB 2018 and feb 2019, a total of 15 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at zagazig university hospital, (6 females and 9 males) were available for study All fractures were classified according to Gustilo and Anderson system for open fractures. There were 9 (60%) type-I, 5 (33.3%) type-II,1 (6.7%) type-IIIA, . After thorough debridement under anesthesia, an interlocking nail was inserted. All nails were statically locked with two screw each proximally and distally.RESULTS: The patients were followed up for a mean period of 12 months (range, 6-12 months) and union time were evaluated according to the R.U.S.T score Results were good to excellent Rust score was distributed as 11.26±0.96 with minimum 9 and maximum 12 which refers to full union . Of all 15 patient 8 cases (53.6%) were with no complication and Superficial wound infection was (13.3%) as Ankle stiffness 1 case (6.7%), Delayed union 1 case (6.7%) and anterior Knee pain were 3 patient with (20.1%).CONCLUSION: This study demonstrates that grade I, II and III A open tibial shaft fractures can be treated with primary debridement and locked unreamed intramedullary nailing with good short-term results, a better biomechanical stability and early rehabilitations and infection rates as compared to other methods.

Reamed Versus Unreamed Intramedullary Interlocking Nailing for Open Tibial Fractures – An Observational Study

Background and objectives: With increase in population, industrialization and traffic density there is high incidence of road traffic accidents. The incidence of high energy trauma are increasing in the same proportion. Tibial diaphyseal fractures are the commonest long bone fractures encountered by most orthopedic surgeons. One third of the length of tibial surface is subcutaneous, Open fractures are more common in tibia than in any other major long bone. This led us to design study of reamed versus unreamed intramedullary interlocking nailing for open tibial diaphyseal fractures. Materials and methods: 60 consecutive patients who had open fractures of tibial shaft were treated with wound debridement and interlocking intramedullary nailing with or without reaming during the period from October 2009 to September 2011. The patients have been followed up for 6-8 months during this study. Results: open tibial diaphyseal fractures surgically managed both reamed and unreamed gave good functional results. In our study according to Johner and Wruh’s criteria there is no significant difference in reamed and unreamed intramedullary interlocking nailing for open tibial diaphyseal fractures. Interpretation and Conclusion: Thorough and early wound debridement and early wound coverage along with intramedullary interlocking nailing for open tibial diaphyseal fractures is the key to minimize deep infection. No