Primary Nailing in the Open Fractures of the Tibia-Is it worth?

Abstract

Context (Background): The tibial shaft is one of the most common sites of open fractures. The specific methods of skeletal stabilization and soft tissue treatment of open fractures continue to be topics of debate in the orthopaedic traumatology.

Aims: To evaluate the results of the intramedullary nailing in the open fractures of the tibia, especially in the Indian scenario.

Settings and design: An observational, descriptive study which was done at a tertiary care hospital from 2006 to 2010.

Material and methods: A prospective study was done on thirty cases which had sustained open fractures of t/hable Gustilo and Anderson grades I, II and III, who were operated for primary intramedullary interlocking nail fixation after thorough debridement and closure of their wounds with suturing, lateral skin release, split thickness skin grafting and muscle pedicle flap, where ever necessary. All the patients were followed up for a minimum of two years.

Statistical analysis: Descriptive statistics and Fisher's Exact test were used.

Results: Of the total thirty cases, ten were of grade I, seven were of grade II, three were of grade IIIA, seven were of grade IIIB and three were of grade IIIC. Dynamization was done in nine cases. The average time to union was 16.0 weeks in the grade I cases, it was 18.3 weeks in the grade II cases, it was 23.6 weeks in the grade III A cases, it was 28.4 weeks in the grade III B cases and it was 32 weeks in the grade III C cases. The mean time to union was 20.7 weeks. Infection occurred in 3 cases. Delayed unions were observed in 4 cases. A non union occurred in 1 case of type IIIC. A mal union was observed in 1 case of type IIIB. 1 case of grade IIIC had the compartmental syndrome. No case had any implant failure (nail / screw breakage), or deep vein thrombosis.

Conclusion: We conclude that the unreamed intramedullary nailing in cases of open fractures of the tibia, with an early soft tissue coverage, results in a faster soft tissue and bony healing, an easier soft tissue coverage, a better biomechanical stability and early rehabilitation and infection rates as comparable to those which are seen with other methods.

Keywords: Functional assessment; Intramedullary nailing; Open fracture; Tibia; Unreamed.

[Table/Fig-4]:

A 26 year male with Gustilo & Anderson grade III C Open fracture in our series. * Post debridement wound showing extensive loss of soft tissues with exposed muscles, tendons and neurovascular structures. † Final wound after soft tissue coverage with muscle pedicle rotation flap with split thickness skin grafting ‡ § Preoperative Skiagram showing transverse fracture both bones leg, lower one third. II ** Skiagram at final follow up at two years, showing good signs of union in both bones leg

[Table/Fig-7]:

A case of Gustilo & Anderson grade III B Open fracture in our series. * Open wound showing skin loss with tethered muscles and loose bony fragments. † Two years follow up status with good flap uptake. ‡ § Skiagram showing comminuted fracture both bones leg (middle one third) extending to upper one third. II ** Two years follow up Skiagram showing fracture well united with