Open Fracture Tibia Treated by Unreamed Interlocking Nail. Long Experience in El-Bakry General Hospital

Mohamed A. Abdelaal, Saied Kareem

Consultant of Orthopedic Surgery, El-Bakry General Hospital, Ministry of Health, Cairo, Egypt.
Lecturer of Orthopedic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt.

DOI: 10.4236/ojo.2014.43011                

Abstract

Background: Internal splintage of open tibial fractures had gained acceptance as a preferred method of early stabilization of such injuries. Patients and Methods: Fifty-five patients had been operated upon. They were followed from July 2008 to March 2013 (56 months) with an average time of 39 months. The final results had been evaluated through a scheme including 7 parameters: pain, union, malunion, infection, range motions of nearby joints, implant and technical failure and activity and returning to the same work. Results: According to previous parameters, union was achieved in 52 cases (94.5%) at an average time of 20 weeks (16 - 52 weeks) with 5.5% incidence of nonunion. Excellent and good ranges of knee and ankle motions were achieved at final follow-up visit in 49 cases (89.09%). The incidence of complication was acceptable mainly malunion 7.3%, deep infection 12.7%, implant and technical failure 9.1% full activity and returning to the same work achieved in 89.1%. The overall net results of our series are as follows: excellent—19 cases (34.5%), good—27 cases (49.1%), fair—6 cases (10.9%) and poor—3 cases (5.5%). Conclusion: Utilizing unreamed interlocking nail for open tibial fractures is a good method of treatment particularly those of grade (II), and (IIIA).

Keywords

Fracture Tibia; Unreamed; Interlocking Nail

1. Introduction

Open tibial fractures are more frequent than any other long bone fractures. Because of high prevalence of complications associated with these fractures, the optimum method of treatment remains a subject of controversy [1] . The prognosis of these fractures is determined primarily by the amount of devitalized soft tissues caused by the injury and by the level and type of bacterial contamination. Also, the extent of soft tissue damage is determined by energy absorbed by the affected area at the time of injury. The goals of treating these fractures are: preventing infection, restoring soft tissue vitality, achieving bony union and instituting early joint motion and muscle rehabilitation. Various techniques had been utilized including: plaster cast immobilization [2] , functional cast brace utilized by Sarmiento [3] , external fixators either uniplanar or multiplanar fixators [4] [5] . Also, Circular fixators utilized for fractures of the periarticuler region, either proximal or distal, were proved to be effective to provide good stability [6] .

Internal fixation utilizing plates and screws provide rigid fixation for unstable fractures and so, reducing the problem of non-union [6] [7] . However, stripping of soft tissues to apply the plate had increased the rate of infection [8] .

Intramedullary fixation using Lottes and Ender nails [9] had been used successfully though they were not preferred in comminuted fractures as they might lead to shortening or redisplacement [10] [11] .

Interlocking nailing without reaming resulted in lower incidence of malunion, non-union and rate of infection and allowed early patient rehabilitation especially for unstable fractures [12] .

We aim in our study to present our experience on dealing with open tibial fractures treated by unreamed interlocking tibial nail. Also, assessing the effectiveness both clinically and radiologically utilized this procedure.

2. Patients and Methods

Fifty-Five patients with open tibial fractures were treated and followed from July 2008 to March 2013 (56 months). In our institute (El-Bakry General Hospital). There were 44 males (80%) and 11 females (20%). The age ranged between 25 to 65 years with mean age 33.2 years. Right side affected in 31 cases (56.4%) and left side in 24 cases (43.6%). The fractures were simple in 34 cases (61.8%) and comminuted in 21 cases (38.2%). The upper third affected in 11 cases (20%), middle third in 35 cases (63.6%) and lower third in 9 cases (16.4%). The causative trauma was motor car accident in 25cases (45.5%), fall from height in 19 cases (34.5%), direct trauma with heavy object in 9 cases (16.4%) and 2 cases (3.6%) caused by gunshot injury. Eight cases (14.5%) had associated muscle-skeletal injuries (5 with fracture femur; one case with stable pelvic fracture and two cases with colles. Regarding wound evaluation we utilized Gustilo-Anderson classification [13] . There were 17 cases Grade (II), 14 cases Grade (IIIA) and 7 cases Grade (IIIB) (Tables 1 and 2).

Resuscitation of the patient, thorough irrigation utilizing 3 - 7 liters saline solution. All contaminated, devitalized soft tissues and bone fragments were excised and gunshots extracted. Broad spectrum antibiotic was given (3rd generation cephalosporin, 1 gm. IV/12 hours).

Nailing was done at time of debridement in 32 cases, less than 12 hours in12 cases, delayed for 72 hours due to other medical problems in 6 cases and delayed between 7 - 15 days with average 6 days in 5 cases Table 3.

Table 1. Distribution of patients.

Table 2. Classification of fractures.

Table 3. Timing of nailing.

Surgical Technique

Length and width of nail was provisionally determined preoperatively. The nail of proper width and length was assembled to the Distal Locking Target Device to adjust distal locking screws position. Through longitudinal paramedian incision about 4 cm parallel to patellar tendon, the entry point of nail detected and opened using a curved Awl. Guide-wire passed through medullary canal down to level of the fracture site and under direct vision (in cases of Grade (II) and Grade (III) fractures) while utilizing image intensifier (in cases of Grade (I) fractures). The guide wire was directed toward the distal fragment and its position checked again radiographicaly for further confirmation. The chosen nail attached to insertion jig and driven over the guide wire through the medullary canal. Distal locking Target Device assembled to the jig and distal locking screws inserted first then the proximal ones.

The closure of the wound was done by primary closure in 32 cases; it was done by secondary closure with a lateral skin release in 15 cases; and it was done by secondary closure with a split thickness skin grafting in 5 cases and with secondary closure with muscle pedicle rotation flaps with split thickness skin grafting in 3 cases. There was a marginal flap necrosis in one case, but all of them were managed by debridement and re-suturing.

Wounds dressed every other day and weight bearing was encouraged for those who had no other associated injuries prohibiting walking (5 cases) and as soon as patient tolerability to pain permitted.

Dynamization by removal of either proximal or distal locking screws done for 38 cases (69.1%), fibular osteotomy in addition to dynamization done in two cases (3.6%), autogenous bone grafting done for 4 cases (7.3%), bone marrow injection for 3 cases (5.5%) and in two cases (3.6%) both dynamization and bone grafting had been done (Figures 1 and 2).

3. Results

The patients of this series were followed for 18 - 56 months with average 39 months. They were evaluated both clinically and radiologically. Evaluation based on a scheme including 7 items:

1) Pain; 2) Union and Non-union; 3) Malunion; 4) Infection; 5) Range of nearby joints motions; 6) Implant and technical failure; 7) Full activity and return to same work.

According to this scheme, results were classified into 4 categories: Excellent, Good, Fair and poor. The criteria of each item are explained in Table 4.

Patient rated (excellent) if all his parameters were rated excellent but if one parameter rated (good), his rate would decrease to good instead. The overall results of our series are as follows:

Excellent:           19 case (34.5%).

Good:                  27 cases (49.1%).

Fair:                    6 cases (10.9%).

Poor:                   3 cases (5.5%).

3.1. Pain

Nineteen cases (34.5%) had no pain (Excellent), 28 cases (50.9%) had pain with strenuous activity (Good), 6 cases (10.9%) had pain elicited with normal activities (Fair) and in 2 cases (3.7%) pain developed even at rest (Table 5).

3.2. Union

Union evaluated clinically by capability of patient to bear weight fully on affected side without pain, absence of

(a)(b)(c)(d)(e)

Figure 1. (a) Open fracture B.B. Rt. Leg Grade (II). (b) X-ray showing short oblique diaphyseal fracture. (c) Intramedullary fixation with Interlocking Tibial Nail. (d) four months post-operative showing complete union of fracture. (e) Full knee flexion with proper squatting of the patient.

Table 4. Full activity & return to same work.

Conflicts of Interest

The authors declare no conflicts of interest.

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