When Will I Return To Normal After Tibial Nailing

Int Orthop. 2008 February; 32(i): 69–74.

Language: English | French

Intramedullary fixation of tibial shaft fractures: a comparison of the unlocked and interlocked nail

Yih-Shiunn Lee

Department of Orthopedic Surgery, Taipei City Hospital, Heping Branch, No. 33, Section 2, Chung-Hwa Rd, Taipei, Taiwan

Ting-Ying Lo

Department of Orthopedic Surgery, Taipei Urban center Hospital, Heping Branch, No. 33, Department 2, Chung-Hwa Rd, Taipei, Taiwan

Hui-Ling Huang

Department of Orthopedic Surgery, Taipei City Hospital, Heping Co-operative, No. 33, Section 2, Chung-Hwa Rd, Taipei, Taiwan

Received 2006 Jul ix; Revised 2006 Jul 12; Accustomed 2006 Aug 28.

Abstract

The study is a prospective evaluation and comparison. 80-2 patients with tibial shaft fractures were treated with intramedullary fixation past either an unlocked nail (ULN) or an interlocked blast (ILN). All patients were followed up for 12 months with a functional score evaluation. The patients were divided into ii groups, based on the method of treatment. The ULN group included 42 patients with an average age of 43.1 years. The ILN group included forty patients with an boilerplate age of twoscore.0 years. Both groups were like in the injury mechanism, fracture location, open fracture type and associated medical atmospheric condition (all P > 0.05). The operative time was shorter and the wound size smaller in the ULN grouping when compared to the ILN group (P < 0.001). The marriage charge per unit, healing time and malunion charge per unit were not significantly unlike between the two groups (P > 0.05). Although the functional score showed no divergence between the groups (P = 0.3), the ILN group had a greater power to return to their work 6 months after surgery (P = 0.03). In decision, unlocked nailing for tibial shaft fractures is a uncomplicated and effective method especially in the treatment of centre-third fractures. Interlocked nailing gives stable fixation without cast immobilisation, which resulted in a greater power for the patients to return to their previous work 6 months afterwards surgery.

Résumé

Etude prospective et comparative de 82 patients avec une fracture de la diaphyse tibiale traitée par clou centro-médullaire non vérrouillé (ULN) ou vérrouillé (ILN). Tous les patients étaient suivis 12 mois, avec une évaluation fonctionnelle. Le groupe ULN comprenait 40 patients d'âge moyen 43.1 ans. Le groupe ILN comprenait 40 patients d'âge moyen twoscore ans. Les deux groupes étaient similaires pour le mécanisme, la localisation de la fracture, le blazon d'ouverture, et les weather médicales générales. (tous les P > 0.05). Le temps opératoire est plus court et la taille de l'incision plus petite dans le groupe ULN (P < 0.001). Le taux de consolidation et le temps de consolidation ne sont pas différents entre les deux groupes (P > 0.05). Bien que le score fonctionnel ne montre pas de différence entre les deux groupes, le groupe ILN à une plus grande facilité à la reprise du travail half dozen mois après la chirurgie (P = 0.03). En conclusion l'enclouage non vérrouillé est une bonne méthode surtout dans les fractures du tiers moyen de la diaphyse tibiale. Fifty'enclouage vérrouillé procure une fixation stable sans immobilisation platrée donnant une plus grande capacité de reprise des activités antérieures 6 mois après la chirurgie.

Introduction

Although nonoperative handling for stable closed tibial fractures may requite good results [12, 13], unstable closed and grade I and Two open fractures of the tibial shaft are at present treated with intramedullary nails, with or without locking [1–5, 8, 17]. Although interlocked nailing can achieve stable fixation and a high wedlock rate [1, 2, 5], it is more hard to apply and is time consuming. In that location is an increased risk of intraoperative complications [i, 2]. In contrast, the technique of unlocked nailing is simple. However, cast immobilisation is required due to its substantially poor command of rotation [4]. Considering it is unclear which is the best method to treat a tibial shaft fracture, nosotros were inspired to prospectively compare the clinical event of patients treated with unlocked and interlocked nailing.

Patients and methods

Between May 2002 and May 2005, 126 consecutive patients with tibial shaft fractures were operatively treated in our orthopaedic department. Inclusion criteria for this report were: (1) acute and unilateral fractures; (ii) middle-3rd fractures or distal-3rd tibial fractures with at least v cm of distance from the fracture site to the ankle plafond; (iii) intramedullary fixation with either an unlocked or an interlocked nail; (iv) patients with the power to walk without any assistance before injury. Exclusion criteria for this study were: (1) proximal-third fractures; (ii) nonunion and pathological fractures; (3) astringent open up fractures (Gustilo course III); (4) fractures involving the ankle articulation such as pilon fractures; (5) requiring intensive care or requiring other departments for handling. The 92 patients who met the inclusion criteria were randomly distributed to five senior surgeons co-ordinate to their assigned shifts. These patients were treated either with an unlocked nail (ULN) or an interlocked boom (ILN) in turn. X patients could not be followed up regularly due to death (one instance), co-morbid psychological disorders (two cases) or relocation (seven cases), and they were excluded. Fourscore-two patients with an boilerplate age of 41.half dozen years were followed up for 12 months afterwards belch from the infirmary and were included in this written report. In that location were 17 open fractures including 13 Gustilo blazon I and four type II. An open fracture was treated by irrigation, thorough debridement and appropriate intravenous antibiotics. Later on fixing the fractures, the wound was left open or was approximated loosely to encompass nigh of the exposed os, according to the condition of soft tissue.

The 82 patients were divided into two groups, based on the method of handling. The ULN group included 42 patients with an boilerplate age of 43.1 years. Thirty-five patients (83.iii%) suffered from vehicular trauma. There were x open up fractures including eight type I and 2 blazon II. The ILN group included twoscore patients with an boilerplate age of 40.0 years. Thirty-three patients (82.5%) suffered from vehicular trauma. There were seven open fractures including five type I and two type II (Tabular array1).

Table i

Preoperative demographics and associated medical conditions in the two groups

	Unlocked	Interlocked	P
Vehicular trauma (*N)	35	33	one.0
Loftier-energy fall (*N)	ii	4	0.43
Sports injury or minor trauma (*North)	3	1	0.62
Other injury (*N)	2	2	1.0
Middle-third fracture (*N)	thirty	32	0.45
Distal-3rd fracture (*N)	12	8	0.45
Open type I	8	5	0.55
Open type Ii	2	2	ane.0
Gender (F/M)	18/24	21/nineteen	0.51
Mean age (years)	43.1	forty.0	0.38
Hypertension (*N)	two	1	one.0
Diabetes (*N)	i	ii	0.61
Renal diseases (*N)	1	0	1.0
Respiratory (*N)	1	1	1.0
Heavy smoker (*North)	three	three	1.0

*N = number of patients

In the ULN grouping, the operations were performed under spinal amazement. The patients were placed in a supine position with the injured extremity in acute flexion at the knee articulation. Closed reduction of the fracture was performed nether an image intensifier. A standard medial parapatellar approach was used, and the starting point was opened by using an awl. A tibial Kuntscher nail (I.Q.L) between 8 and 12 mm in diameter was inserted through the patellar tendon without reaming. The nail was carefully hammered in. If the nail became stuck, information technology was removed and a smaller 1 was inserted. Fluoroscopy was used to verify the nail length and post-reduced fracture site. If marked fracture angulation was noted under fluoroscopy, gentle closed reduction was done before casting. An to a higher place-knee joint bandage was used for 4 weeks. The patients then started progressive weight bearing in a below-knee bandage with costless motion of the knee for some other 4 weeks. All patients were told to avoid work with heavy loads or aggressive practice using the involved extremity during the post-obit 3 months. In the ILN group, a standard medial parapatellar approach was practical, and the starting signal was opened by using an awl. Afterward placing the guide wire primal to the distal subchondral plate, the intramedullary culvert was reamed till appropriate fit of the reamer in the culvert was achieved. During reaming, the alignment of the fractures was maintained and checked repeatedly with the image intensifier. After the culvert was well-prepared, a Russel-Taylor tibial interlocking nail (Smith and Nephew Richards Inc., Memphis, TN) of the appropriate size was selected with a diameter of i mm narrower than that of the final reamer. After insertion of the nail into the distal tibia, at to the lowest degree ane distal screw provided sufficient rigid stability. An to a higher place-knee joint splint was practical for i calendar week. A brusk leg splint for soft tissue healing was given to all of the patients for another ii weeks. Upon discharge from the infirmary, the patients were allowed to toe-impact weight bear until the wound had healed. Subsequently iv weeks, patients were permitted to increase their weight begetting.

Plain films in the firsthand postoperative period were reviewed for the capability of fracture reduction for all 82 patients. Varus-valgus alignment was determined by measuring the bending between the lines fatigued perpendicular to and bisecting the tibial plateau and proximal medullary canal with a line bisecting the distal medullary canal and tibial plafond on anteroposterior radiographs. Anteroposterior alignment was determined by measuring the angle betwixt a line parallel to the proximal fragment and a line parallel the distal fragment on lateral radiographs. We divers first-class reduction as <2 mm of fracture gap and approximately 5° of angulatory deformity in whatever aeroplane (valgus/varus or anterior/ posterior). Expert reduction was regarded every bit 2 to 5 mm of fracture gap and approximately five° of angulatory deformity in any plane. Poor reduction was given for >5 mm of fracture gap or >five° of angulatory deformity in any airplane. Adequate reduction included excellent and expert reductions. Bony union was defined as evidence of bridging callus across the fracture sites or the obliteration of the fracture lines based on X-ray findings. Malunion was defined as fractured healing >5° of angulatory deformity in any aeroplane, or internal rotation of x° or more than, external rotation of more than 15° or shortening of two cm or more. Nonunion was defined as no show of healing after half dozen months.

Twelve months postoperatively, we evaluated the functional consequence using the functional score of Karlstrom and Olerud [nine]. In this arrangement, the clinical data are evaluated, including pain, damage of walking, climbing stairs, or previous sports activity, work limitation, skin condition, deformity, muscle atrophy, length discrepancy, loss of genu movement, loss ankle move and loss of pronation/supination. At that place are 3 grades (1, two and iii points) in each item, and the maximum score is 36 points.

In both groups, the chi-square test or Fisher's exact examination was used for assay of the gender versus type, associated medical condition, reduction rate, union charge per unit, malunion rate, complication rate, charge per unit of return to previous work and charge per unit of return to the aforementioned able-bodied activities. A Student'due south t-test was used for comparison of the age, operating time, wound size, infirmary stay and functional score. Operating time was measured from the beginning of surgery to skin closure. The statistic software SPSS 10.0 was used to analyse the information: P values beneath 0.05 were considered significant.

Results

Both groups were like in the injury mechanism, fracture location, open fracture type, mean age, gender and associated medical condition (all P values were approximately 0.38) (Table1). The operative time was significantly less in the ULN group when compared to the ILN group (P < 0.001). The wound size was also significantly smaller in the ULN grouping when compared to the ILN group (P < 0.001). There was no significant departure (P=0.28) in hospital stay between the ULN group (boilerplate: 5.9 days, range: 3-ten days) and the ILN group (average: 5.ane days, range: 3–ix days). In the ULN group, all but one fractures healed in 6 months (Fig.ane). The mean healing fourth dimension was 16.ii±4.half dozen weeks. In the ILN group, healing occurred in all but ii cases (%) in 6 months with a mean of 18±iii.3 weeks. The nonunion was treated past exchange nailing and autologous os grafting. The union rate and healing fourth dimension were not significantly unlike between the ii groups (P=0.61, 0.33, respectively) (Tabletwo).

An external file that holds a picture, illustration, etc. Object name is 264_2006_271_Fig1_HTML.jpg

A 45-year-old female person patient with right distal-third tibial fracture was treated with unlocked nailing. a Preoperative lateral view showed a displaced and spiral tibial fracture. b Radiograph at the immediate postoperative menstruum showed excellent fracture reduction. c Radiograph at 16 weeks postoperatively showed fracture healing

Table ii

Operative information, hospital stay, wedlock rate and healing time in the ii groups

	*ULN (mean ± SD)	+ILN (mean ± SD)	P
Wound size (cm)	4.iii ± 1.2	8.ane ± 2.2	<0.001
OP fourth dimension (min)	24 ± viii	78 ± 24	<0.001
Hospital stay (days)	5.nine ± ane.4	5.1 ± 1.ii	0.28
Union rate	41/42	38/40	0.61
Hateful healing time (weeks)	xvi.2 ± 4.6	18 ± 3.three	0.33

Evaluation of the immediately postoperative roentgenograms for capability of reduction revealed first-class results in 42.9% (xviii cases) of the ULN group and 70% (28 cases) of the ILN group. Practiced reduction was achieved by 50% (21 cases) of the ULN grouping and 27.5% (xi cases) of the ILN group. Poor reduction was shown in 7.i% (iii cases) of the ULN group and 2.five% (i case) of the ILN grouping. The adequate reduction rates between the ULN group (92.9%) and the ILN grouping (97.5%) showed no significant difference (P = 0.62).

With regard to malalignment, four individuals in the ULN group (ix.5%) had malunion including two fractures with 6° and 10° anterior malalignment, one with 10° posterior angulation, and the remaining one had 7° valgus deformity. Clinically, there was no case of meaning tibial shortening. In particular, iii of the four malunions involved distal-third fractures and the remaining one occured in a eye-third fracture. In the ILN group B, there was ane malunion (two.5%) with 8° posterior angulation. The malunion rates between the ULN group (nine.5%) and the ILN group (2.5%) showed no pregnant difference (P = 0.36). However, in the ULN group, distal-third fractures showed a trend towards increased malunion rate when compared to middle-third fractures, although this was not significant (3/12 versus one/30, P = 0.06).

The ULN group had four early complications (9.5%) that were related to nail migration. Ii of them had early removal of the involved nails as fracture healing progressed. The remaining two required exchange to a larger nail. The ILN grouping had four early on complications (10%) including a superficial infection, one deep infection, and two with broken locking screws. The superficial infection occurred in a closed fracture of a diabetic patient with poor command of blood sugar. She was diagnosed clinically at the first follow-upwards visit virtually 8 days after surgery. After 7 days handling with oral antibiotics, the wound healed uneventfully. The deep infection occurred in an open type 2 fracture. Although an organism-specific antibody was given parentally in this patient, persistent drainage from a wound over the fracture site was noted. After thorough debridement, removal of the nail and advisable intravenous antibiotics, the infection was controlled. There were no signs of chronic osteomyelitis at the concluding follow-upward. 2 patients had broken distal locking screws before fracture healing (Fig.ii). Secondary surgery was carried out for broken screws and dynamisation. Totally, the early complication rate of the ULN group (ix.5%) showed no significant difference compared with the ILN group (x%) (P=1.0).

An external file that holds a picture, illustration, etc. Object name is 264_2006_271_Fig2_HTML.jpg

A 38-twelvemonth-old male patient with left distal-third tibial fracture was treated with interlocked nailing. a Preoperative AP view showed a displaced tibial fracture. b Radiograph at postoperative 12 weeks showed broken locking screws

Twelve months postoperatively, all patients' functional scores were evaluated. The mean score of the ILN group (33.two points) was like to the ILN group (34.1 points) (P = 0.48). In the ULN grouping, 19 patients (45.2%) returned to their previous work in 6 months. Ane yr after surgery, thirty patients (71.4%) could do the same athletic activities. In the ILN grouping, 28 patients (70%) returned to their previous work inside 6 months. I yr after surgery, 33 patients (82.5%) could practise the same athletic activities. At that place was no difference in returning to able-bodied activity between the ULN and the ILN group (P = 0.3). However, the ILN group had greater ability to return to their work 6 months subsequently surgery (P = 0.03).

Discussion

Nonoperative treatment of tibial fractures increases the incidence of malunion and unacceptable shortening. Hopper et al. [7] concluded that nonoperative treatment gave more malunion and shortening. In the present written report, there was no case of significant tibial shortening after intramedullary nailing. Five of 82 intramedullary nailed fractures (6.1%) healed with malunion. The malunion rate was similar to or lower than that of previous studies. Furthermore, the malunion charge per unit between the ULN group (nine.five%) and the ILN group (2.5%) showed no significant difference. Several factors were related to our reasonable malalignment rate of unlocked nailing: (ane) adequate fracture reduction during boom insertion; (2) fluoroscopy was used to verify the blast length and post-reduced fracture site; (c) if marked fracture angulation was noted under fluoroscopy, gentle closed reduction was done before casting. Notwithstanding, distal-third fractures treated with unlocked nailing showed a tendency of increased malunion rate when compared to middle-third fractures (P = 0.06). We felt that unlocked intramedullary nailing in a larger metaphyseal canal might have limitations in maintaining the initial reduction.

Fan et al. [5] reported that interlocked nailing of displaced tibial fractures was an constructive method that could achieve satisfactory clinical outcomes. All of the 20 patients returned to their former employment with full weight bearing. In the nowadays report, the functional score showed no departure between the ULN and the ILN groups. However, the ILN group had a greater power to return to their previous work half-dozen months later surgery when compared to the ULN group. We concluded that the interlocked nailing gave very stable fixation without postoperative cast immobilisation. The patients treated with this method had a greater ability to return to work in a curt fourth dimension. However, this technique was more than difficult and time consuming. Theoretically, the technique of unlocked nailing is relatively simple, requiring a short operative time and a pocket-size surgical wound. In this study, the operative time was shorter and the wound size was smaller in the ULN group when compared to the ILN group. Although the technique of unlocked nailing was simple, this fixation method produced loftier rates of blast migration [four, ten, 16]. In our study, four patients treated with unlocked nailing had nail migration and ii of them required revision before fracture union. Still, two patients treated with interlocked nailing had broken distal locking screws and required secondary operations. We felt that the reoperation for unlocked nail migration was acceptable since interlocked nails also required secondary surgery for broken screws or dynamization.

A patient with an open tibial fracture has a significantly increased risk of infection after injury [14]. According to previous studies, open tibial fractures take been successfully treated with intramedullary nailing with low infection rates [half dozen, xi, xv]. Oh et al. [11] reported that 46 open up tibial fractures including 18 type I, eighteen type Ii and 10 blazon III were treated with unreamed nailing. The infection rate was six.five%. Shah et al. [15] reported that 36 open tibial fractures including 13 type I, 14 blazon II and 9 blazon 3 were treated with principal nailing. The deep infection rate was just 2.8%. In our study, the 17 open fractures including 13 blazon I and 4 type II were treated with primary nailing. Simply 1 deep infection (five.9%) occurred. Therefore, intramedullary nailing for open tibial fractures was a condom method with a low infection rate.

In conclusion, unlocked nailing for tibial shaft fractures is a uncomplicated and effective method particularly in the handling of eye-tertiary fractures. Interlocked nailing gives stable fixation without cast immobilisation, which results in a greater ability of patients to return to their previous work 6 months later on surgery.

References

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