ABSTRACT
Objective- The
purpose of this study is to compare the result of
intramedularyKuntscher’s nailing with that of external fixation
in the primary management of theOpen fracture of the tibial
shaft.
Design- Quasi-Experimental study.
Setting-A tertiary care hospital, Dharan, Nepal
Patients-Thirty Grade 3B tibia-fibula shaft fracture, age
30.9±12.7 years were
primarily Reduced and fixed by AO type uni or biplanar external
fixator (20 cases) and Kuntschers IM nail (10 cases).
Intra articular fracture, open epiphysis fractures and comminuted
fractures were excluded. Main outcome measure- 1.Time taken for
union, 2.Malunion, 3.Number of operations, 4.ROM, 5 Deep
infection, 6.Non union
Result-Time taken for union was more with IM nailing
(31.33±7.66 weeks) than External Fixator (26.15±5.62), p>0.05..
Odds of non-union 0.75 times with external Fixator as compared
to IM nailing but the 95% CI 0.27 – 2.06 making the association
Statistically insignificant at p = 0.891. Sample size was too
small for comparison of malunion and deep infection. Odds of
residual deformity were similar in the two groups but greater
numbers of surgeries were needed in the external fixator group.
Keywords: compound fracture tibia,
3B,External fixation, IM (K-nail) nailing
J.Orthopaedics 2004;1(3)e3
INTRODUCTION-
High velocity trauma is the cause of
maximum number of fatality in the younger age group worldwide.
The implication of losing a young active member of the
population is obvious in terms of personal, social and economic
losses to the family as well as the nation. In the field of
trauma surgery open fractures of the leg remain the injuries
with a higher complication rate. Bone and soft tissue injuries
need aggressive yet careful treatment to avoid further damage
that results in uncomplicated healing. Due to its location,
structural anatomy and sparse anterior soft tissue coverage the
tibia is particularly prone to exposure and ischaemia due to
injury. The optimum treatment for open fractures of the tibia
remains controversial 1. Treatment options include wound
debridement, reduction and immobilization with cast (Winnette
Orr), open reduction and plate fixation, external fixation and
intramedullary nailing. External fixation of open fracture with
severe soft tissues injury has been standardized during the
1980s 2. More recently closed undreamed nailing of open fracture
of tibia has become popular. Tibia nailing has been shown to be
a reasonable treatment option to external fixation in tibia 16
Shaft fractures with severe soft tissue
damage 3, 4. The process of external fixation has many
complications as pin tract infection, aseptic non-union,
re-fracture and may need bone grafting but has been said to have
the advantage of low infection rate. Intramedullary nailing
specially reamed nailing in open tibia fracture is said to have
a high rate of septic non-union. Kuntscher’s intramedullary
nailing has been used for fixation of a variety of fracture
including those of the tibia. Although this device does not have
the advantage of locking, it’s place in the armamentarium of
fixation of the tibia fracture is undisputed specially because
its allows vertical compression and is the most economic options
amongst all the intramedullary implants. The purpose of this
study is to compare the result of intramedullary Kuntscher’s
nailing with that of external fixation in the primary management
of the fracture of the tibial shaft.
PATIENTS AND
METHODS
Thirty cases of tibia-fibula shaft fracture
with soft tissue injury of Grade 3B between age of 16- 62 years
(30.9±12.7) treated at
BPKIHS, Dharan Nepal during march 2001 to march 2002 were
studied. The two modalities of primary fixation compared were AO
type uni or biplanar external fixator (20 cases) and Kuntschers
straight unlocked intramedullary nailing (10 cases). INCLUSION
CRITERIA –Patients in whom the fracture configuration was
amenable to fixation with intramedullary nailing by virtue of
having intact medullary cavity of sufficient length were
alternatively treated with k-nailing or external fixator.
EXCLUSION CRITERIA- Fracture extending into the articular
surfaces of either end of the tibia. Initial resuscitation,
splint age and primary care for the wound was provided in the
emergency room. Any bone fragments that were protruding out were
covered with sterile dressing. The patients were then taken to
the operating room and treated by pulsed lavage and debridement
of the wound and fixation of the fracture according to criteria
already mentioned. Every attempt was made to cover the exposed
part of tibia with soft tissue, however flap coverage was not
needed in any cases. The configuration of the external fixator
used was an either a delta frame or unilateral uni axial frame.
All patients were made to stand with support after 48 hours and
toe touching was permitted as per the stability of the fixation
diagnosed radio graphically. Partial weight bearing with support
was started within 2 weeks of fixation. Wounds were inspected at
the interval of 48-72 hours and repeat debridement was done
whenever required. Split thickness grafting was performed within
3 weeks of primary surgery. Clinical and radiological feature
assessed the progress of bony union at 6 weeks interval till
union was sound. Radiological criteria for union were same for
both the groups i.e. good evidence of bridging periosteal and
endosteal callus formation as seen by the obliteration of the
fracture line. The clinical assessment of the union was mainly
based on complete absence of pain and tenderness at the fracture
site. Satisfactory wound healing and good progress of
radiological union were taken as the criteria for removal of the
fixator and application of a patellar tendon-bearing cast. As
soon as the wound healed in the nailing group, a patellar
tendon-bearing cast was applied, gradual full weight bearing was
permitted, and support discarded. The cast continued till union
and was changed every 6 weeks with clinico-radiological
assessment. Active physiotherapy for regaining ankle and knee
mobility were instituted till the range of movement was
satisfactory. Complications were treated. The following 6
criteria were used to compare the 2 method of treatment
1. Time taken for union measured from day
of treatment to day full clinico-radiological Union assessed.
2. Malunion as defined as varus or valgus
alignment of 5or more, posterior Angulations 10°or
more. Shortening was considered as malunion if it was of >2 cm
as compared with the contra lateral leg.
3. Number of operations (all procedure that
necessitated general or spinal anesthesia and were directly
related to treatment of the tibial fracture were counted as
operations).
4.Final range of motion of the knee and
ankle as compared to the opposite side.
5 Presence of deep infection (exogenous
osreomyelitis)
6.Non-union
RESULTS:
External fixator was better on Union time,
deep infection rate and non-union rate. IM nailing was better on
malunion rate, chance of shortening and number of surgeries
needed.( Table 1 ) Multiple surgeries including repeat
debridement, split thickness skin grafting, bone grafting and
bone marrow injection were required in both groups. 1 patient in
the IM nailing group developed preoperative compartment syndrome
due to the original injury and required fasciotomy followed by
skin grafting. There was one valgus deformity at the distal
1/3rd of the leg in fixator group. One cases of IM nailing group
develop septic non – union, which is treated with Ilizarov
distraction osteogenesis method. The chance of non union in the
group were nearly 0.75 times with external fixator as compared
to IM nailing, however, since the sample size was small the
association did not reach statistical significance.(Table2)
DISCUSSION
Open fractures of tibia; commonly a
consequence of high velocity road traffic accident, affects
young males causing considerable morbidity. Time taken for union
was different in both the groups means 31.33±7.66(IM Nailing)
means 26.1538±5.625(external fixator) p>0.05 Odds of non union
were 0.75 times with external fixator as compared to IM nailing
but the 95% CI of 0.27-2.06 making the association statistically
insignificant at p=0.891(table2). Sample size did not allow
comparison of complication rate like malunion and deep
infection. No evidence of greater residual deformity at ankle
and knee. Greater number of surgery required in the external
fixator groups.
Table –1
Comparing IM nailing with external fixator
Parameter |
IM Nailing (10 cases) |
Ext. Fixation (20 cases) |
Average time to union |
31.3333±7.6594 |
26.1538±5.6250 |
Malunion |
Nil |
10°(1
case) |
Shortening |
Nil |
2 cm 1(cases) |
No. of surgery |
60%-1,
25%-3 |
45%-1,
25%-3, 20%-2,
10%-3 |
ROM-Ankle |
Full |
Full |
ROM-Knee |
Full |
Full |
Deep infection |
1 case (osreomyelitis) |
0 |
Non-union |
4 cases (40%) |
6 cases (30%) |
Table-2
Comparing risk 0f non –union in the two group
Treatment |
Non-union |
Union |
Total |
Ext.fix. |
06 |
14 |
20 |
IM nail |
04 |
06 |
10 |
Total |
10 |
20 |
30 |
Relative Risk
=0.75,95%CI0.27<RR<2.06,P=0.891
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