Reamed Or Unreamed Nailing
In Open Fractures Of Tibia – Current Concepts.
Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut
E-Mail: drpgopinath@yahoo.com
Addresses for Correspondence
Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut
E-Mail: drpgopinath@yahoo.com
JJ.Orthopaedics 2005;2(3)e1
Introduction:
Open fractures of the tibia remain a formidable injury. External
fixation has been the mainstay of treatment for the more severe
fractures. This treatment option, however, is not without
significant complications. Of particular importance is the rate
of infection once the fixator is converted to a reamed
intramedullary nail in cases of delayed union or nonunion. There
is always a controversy regarding whether to use reamed or
unreamed nailing in open tibial fractures. In this review
article an attempt is made to understand the current concepts
regarding whether to use reamed or unreamed nailing in open
tibial fractures.
Review:
Bhandari M et al concluded that there is no difference in out
comes in reamed and unreamed groups. The relative merits of
reamed versus unreamed nails in the treatment of open tibial
fractures remain uncertain.1
Bizot
P et al inferred that the risks of intramedullary tibial
nailing are evaluated. Only one case presented a serious septic
complication leading to nail removal and knee arthrodesis.
Intramedullary nailing may be indicated in grade I and II
non-unions, but should rarely be used in grades III and IV
2
Finkemeier et al were of the opinion that the use of
reamed insertion of IM nails for the treatment of closed tibia
fractures, led to earlier union without increased
complications. In addition, canal reaming did not increase the
risk of complications in open tibia fractures.3
Freedman EL et al inferred that proximal third tibial
fractures may require a neutral or slightly lateral entrance
angle to ensure a more anatomic reduction and centromedullary
nail orientation to offset the tendency for valgus angulation.4
Ketterl R et al concluded that the rate of infection seen in
open fractures was reduced by using an UTN for the tibia (4.5%
using RTN versus 1.3% using UTN in primary implantation; 6.5%
versus 4.3% in case of changing from EF to tibial nailing). The
UTN does not disturb the healing of the fracture and there is no
increased risk of axis deviation.5
Krettek C et al made the final conclusion in their study that
the overall results of AO Unreamemed tibial nail (UTN) was
judged with the Karlstrom-Olerud score, which was applicable in
66 of 75 cases; excellent, n = 2; good, n = 22; satisfactory, n
= 24; fair, n = 9; poor, n = 9. In the remaining nine cases no
scoring was attempted because of severe injuries around the knee
or ankle.6
Krettek C et al were of the opinion that unreamed nailing -which
always relies on interlocking screws and is associated with
function better than and infection rates similar to those with
external fixation, but has an increased incidence of screw
breakage. In contrast to the biological problems in the tibia,
those problems encountered in the femur are more predominantly
mechanical in origin7.
Lang GJ et al opined that Fractures of the proximal third of the
tibial shaft do not appear to respond as favorably to
intramedullary nailing as do fractures in the distal 2/3 of the
tibia. Valgus, apex anterior angulation, and residual
displacement at the fracture site are common after nailing.
Surgical errors of a medialized nail entry point and a
posteriorly and laterally directed nail insertion angle
contributed to malalignment. Based on their findings, the
authors have limited the use of intramedullary nailing for
proximal third tibial shaft fracture and consider alternate
forms of fixation (plate or external fixation).8
Muller
CA concluded that the results show that the same good infection
rates were achieved for the UTN as for the external fixator. The
advantages of the UTN are, however, a lesser need for secondary
intervention and greater patient comfort. Therefore, we find the
UTN to be a good alternative to the external fixator in the
treatment of open fractures with severe soft tissue damage.9
Piccioni L et al concluded that retrospective review of the
records of 20 patients who underwent unreamed, interlocked,
intramedullary nailing for tibial fracture has shown that
unreamed tibial rodding offers an excellent alternative to
external fixation for the management of Grades I and II open
tibial fractures. Additionally, for Grade III open fractures,
this serves as an excellent form of preliminary stabilization,
allowing the soft-tissue injury to heal.10
Runkel
M, et al were of the opinion that the use of unreamed nailing
can be recommended, especially for open fractures and fractures
with severe soft tissue damage.11
Richter D et al concluded that in cases treated with unreamed
tibial nailing the highest rate of complications (22%) was seen
in patients with distal fractures of the fibula without
additional plating (of the fibula). There was no deep infection.
Tibial fractures close to the ankle joint can be managed by
unreamed nailing. Distal fractures of the fibula should be
stabilized by additional plating. Because of the unreamed
technique of implantation this procedure can also be used in
grade II or III open fractures.12
Vecsei
V et al opined that because of the success rate observed in the
treatment of borderline indications for locked intramedullary
nailing of femoral and tibial fractures and the improvement in
equipment, training and techniques, we have expanded the
indications for treatment of these fractures by intramedullary
nailing.13
Weckbach A et al concluded that with primary data (type of
fracture and grade of soft tissue injury) being comparable, we
found an almost identical rate of infection for both techniques.
Finally, unreamed nailing has been established as monorail
procedure treating defect fractures by means of segmental
transport.14
Zelle
BA concluded that exchange reamed nailing for nonunions of the
tibia results in a high union rate and is associated with a low
complication rate. This technique is recommended as a standard
procedure for aseptic tibial nonunions after initial unreamed
intramedullary nailing.15
The
author’s preferred method is to use unreamed tibial nailing in
all open tibial fractures regardless of the severity of soft
tissue injury provided stability can be achieved by this method5
Conclusion:
Open fractures of the tibia
remain an unsolved problem even in modern orthopedic practice
External fixation has been the mainstay of treatment for the
more severe injuries. But considering the post external fixation
complication unreamed intramedullary nailing is viable option as
a primary procedure. Many of the articles are in favour of
unreamed tibial nailing as a primary procedure with lesser
compilcations
References:
1.
Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment
of open fractures of the shaft of the tibia. J Bone Joint Surg
Br. 2001 Jan;83(1):62-8.
2.Bizot P, Zucman J. Secondary nailing of the tibia in
non-unions with septic risk. Indications and results Rev Chir
Orthop Reparatrice Appar Mot. 1991;77(4):241
3.Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF A
prospective, randomized study of intramedullary nails inserted
with and without reaming for the treatment of open and closed
fractures of the tibial shaft. J Orthop Trauma. 2000
Mar-Apr;14(3):187-93.
4.Freedman EL, Johnson EE Radiographic analysis of tibial
fracture malalignment following intramedullary nailing. Clin
Orthop Relat Res. 1995 Jun;(315):25-33.
5.Gopinathan p et al Short term follow up of un reamed
interlocking nailing in compound fractures of tibia journal of
calicut Ortho alumni association 2003 oct-dec 1(3)43-46.
6.Ketterl R, Leitner A, Wittwer W.Reducing the risk of infection
by use of an unreamed intramedullary nail in open tibial
fractures Zentralbl Chir. 1994;119(8):549-55.
7.Krettek C, Schandelmaier P, Rudolf J, Tscherne H. Current
status of surgical technique for unreamed nailing of tibial
shaft fractures with the UTN (unreamed tibia nail)] :
Unfallchirurg. 1994 Nov;97(11):575-99.
8.Krettek C, Gluer S, Schandelmaier P, Tscherne H Intramedullary
nailing of open fractures. Orthopade. 1996 Jun;25(3):223-33.
9. Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial
shaft fractures. Should they be nailed? : Clin Orthop Relat Res.
1995 Jun;(315):64-74
10. Muller CA, Dietrich M, Morakis P, Pfister U. Clinical
results of primary intramedullary osteosynthesis with the
unreamed AO/ASIF tibial intramedullary nail of open tibial shaft
fractures Unfallchirurg. 1998 Nov;101(11):830-7.
11.Piccioni L, Guanche CA. Clinical experience with unreamed
locked nails for open tibial fractures. : Orthop Rev. 1992
Oct;21(10):1213-9.
12.Runkel M, Wenda K, Stelzig A, Rahn BA, Storkel S, Ritter G
Bone remodeling after reamed and unreamed intramedullary
nailing. A histomorphometric study] Unfallchirurg. 1994
Aug;97(8):385-90.
13.Richter D, Hahn MP, Laun RA, Ekkernkamp A, Muhr G, Ostermann
PA. Ankle para-articular tibial fracture. Is osteosynthesis with
the unreamed intramedullary nail adequate? Chirurg. 1998
May;69(5):563-70.
14.Vecsei V, Seitz H, Greitbauer M, Heinz T. Borderline
indications for locked intramedullary nailing of femur and tibia
: Orthopade. 1996 Jun;25(3):234-46.
15. Weckbach A,
Blattert TR, Kunz E. Differential indications for intramedullary
nailing of the tibia with the reamed and unreamed technique]
Zentralbl Chir. 1994;119(8):556-63.
16.Zelle BA, Gruen GS, Klatt B, Haemmerle MJ, Rosenblum WJ,
Prayson MJ Exchange reamed nailing for aseptic nonunion of the
tibia. : J Trauma. 2004 Nov;57(5):1053-9
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