shaft fractures in 94 patients with the Grosse-Kempf locked tibia! nail (Grosse, ... (line. < 45#{176}from the horizontal),. 33 were long oblique or spiral, seven were.
LOCKED
INTRAMEDULLARY
DISPLACED
ANTTI
ALHO,
ARNE
TIBIAL
EKELAND,
KNUT
From
We analysed
six fractures the
tibia.
The
deep
tibia!
shaft
lary
(Charn!ey We report
nailing
fractures
1979
fractures tibia!
They
to 1986,
represented
department, unlocked
was
3.2%.
FRACTURES
GUNNAR
FOLLERAS,
University
of Oslo
treated
BJORN
OLAV
THORESEN
with the Grosse-Kempflocked
nail.
grade
I to II, and 54 were located
outside
There
were
The
treated
conservatively;
only
grade
(Charnley 1961 ; Nico!l but is not suitable for all will require an operative
1961 ; B#{246}stman 1986; Ekeland et a! our experience with locked intramedultibia!
PATIENTS From
rate
are
for displaced
shaft locked
fractures
FOR
two
poor
results.
Twentythird of
the middle use
of this
method
is
and discussed.
this is safe and resource-sparing 1964; Sarmiento et a! 1984), cases. A number of fractures method 1988).
shaft
Hospital,
19 were open
infection
SHAFT
STR#{216}MSOE,
Ullevaal
of 93 tibial
were comminuted,
recommended Most
the results
NAILING
shaft
AND
we treated
were
I or
II (Muller
transverse
horizontal), segmental
least one butterfly fragment circumference of the bone.
We have
Thirty-four
oblique
(line
33 were long oblique and 19 were otherwise
Technique.
fractures.
et a! 1979).
or short
or spiral, comminuted,
larger
described
98 displaced,
recent,
than
the
seven were having at a third
our technique
(Ekeland et a! 1988), but some details The support under the knee should
METHODS
fractures 45#{176} from
15#{176}. partly because of other injuries. assess statistical Half of the fractures were
>
51 were weight-bearing
6
for 37 students, housewives patients did not return to
2 cm,
>
two
amount
the et
significance.
Of the 93 fractures,
5 Fig.
65 (36
and (Ekeland
as shortening
10#{176}, or rotational test was used to
4
(differ-
time was and plaster
re-examined, fair or poor
3
Months
cases) or ca!canea! pin traction was used before the operative treatment. Two cases had failure of another type ofosteosynthesis before they were nailed. The median follow-up was 22 months (12 to 97); all 89 patients (93 fractures) results graded as excellent,
2
22 of
of
II open
union
-
-
Re-operation, nailing
static
grafting and bone and bone
graft graft
THE
JOURNAL
Excellent Poor Poor
fracture
OF BONE
AND
JOINT
SURGERY
LOCKED
INTRAMEDULLARY
NAILING
FOR DISPLACED
Fig.
TIBIAL
SHAFT
FRACTURES
3
An oblique fracture of the right tibia in a 20-year-old man (a). Dynamic distally locked planned, but operative splintering (b), led to the use of static nailing. There was uneventful months (c and d). The proximal screw was removed for local pain, but the nail was retained was excellent.
the result was only fair in one hammer toes and reduced dorsiflexion were
two
superficial
open and was 5.3%.
two
and
closed
three
fractures
neglected ofthe
deep ; the
case, with ankle. There
infections total
in three
infection
rate
Splintering ofthe fracture occurred during operation in two cases. One ofthem healed uneventfully after static nailing (Fig. 3), but the other, after dynamic nailing, had 2.5 cm shortening with operation was necessary
only a fair result. One early for rotatory malalignment.
reIn
one case, distal fixation by only one screw resulted in nonunion (see Fig. 4). There were three cases ofdelayed union or nonunion. Nonunion in two was successfully treated by plate osteosynthesis and cancellous bone grafting. The results were classified as poor due to the failure of the first method, good
though,
and Five
proximal a result The VOL.
after
the
second
fair respectively. nails broke at the
stress
operation, riser
they
produced
end of the slot. One early breakage of significant re-injury and nonunion
others
were
fatigue
72-B, No. 5, SEPTEMBER
fractures 1990
after
were by the
occurred as followed.
bone
healing;
807
their
only
effect
was
difficult. Outcome. There 2 cm in two and
to make
nailing was healing by 15 and the result
the removal
ofthe
nail
was shortening of 1 cm in nine 3 cm in two. Varus malalignment
more cases, was 6#{176}
to 10#{176} in four cases and valgus 6#{176} to 10#{176} in six cases. Anterior angulation of6#{176} to 10#{176} occurred in three patients, and recurvatum deformity of 6#{176} to 10#{176} in three. One patient
had
an external Knee patients patients
an internal rotation movement
rotation
deformity
of 15#{176}. was full and
free
of 20#{176} and in all cases,
complained of some anterior had a 10#{176} to 30#{176} loss ofdorsiflexion
knee
pain. ofthe
one
but
14
Nine ankle,
four of them having a similar loss of plantar flexion, and six having a 50% reduction of subtalar movement. Two of the patients with reduced ankle and foot movement also after
had some undetected
had
pain
oedema. reduced. activities
at
pain including compartment the
fracture
the short syndrome. site
and
The working capacity Nine other patients had and five had not returned
In 44 patients
the
nail
had
foot syndrome Nine patients
12 had
some
distal
of 12 patients was reduced their sporting to sport.
been
removed
and
10
A. ALHO,
808
A. EKELAND,
K. STR#{216}MS#{216}E, G. FOLLERAS,
Fig.
4
An oblique tibial fracture in a 50-year-old man (a), nailed dynamically the most distal screw is not in the hole of the nail (c). The instability upper screw (d). Although able to work, he had a warm painful osteosynthesis with bone chips from the iliac crest (e).
patients
had
had
dynamisation. planned for
one
or several
screws
removed
after
the
Removal of the nail because of pain was 14 other patients and because of their young
age
for another The result
fair not
in 1 1 and affect the
1 1. was excellent
in 58 fractures,
poor in two. The timing course or result and the
good
in 22,
of operation did results in the 19
open fractures did not differ from those for closed fractures. The median time for radiographic healing was 16 weeks (10 to 52) for comminuted and 14 weeks (9 to 40) for the others (difference not significant). The median time for full weight-bearing was 55 days for comminuted and 37 days for non-comminuted fractures (not significant),
but
the end
results
were
no different.
DISCUSSION During the study period, we treated most tibia! shaft fractures conservatively ; intramedullary nailing was the only primary operative method for closed fractures. Very few fractures were nailed without locking, and there was an increasing tendency for static locking during the period under review. This resulted from the shortening and occasional rotational instability seen after dynamic nailing. A fresh wound, less than eight hours old, was not considered to be a contra-indication for locked intramedullary nailing. There were more infections in the open
B. 0. THORESEN
with distal locking (b). The resulted in varus malignment fracture site. The nonunion
than
in the closed
fractures,
lateral view shows that and loosening of the was treated by plate
but they
all resolved
well
and
did
not affect the end result. There was a delay in the radiographic healing of statically nailed fractures, but this seemed to have no clinical consequences, since the patients could bear weight early even when callus formation was delayed. Dynamisation could possibly have accelerated the healing
in some
cases
(Grosse
some adverse experiences resulting in malalignment 1985). when
et a! 1978),
but
with early and shortening
we
have
had
dynamisation (Thoresen et al
We therefore recommend that dynamisation, necessary, should be delayed until the fourth
month. Merianos, Cambouridis favourable results in a series treated nailing stability.
and Smyrnis(1985) of 143 tibia! shaft
reported fractures
with two Ender nails, but it seems that locked may provide more rotational and longitudinal Good results have also been achieved by plate
fixation (Christensen, this carries a greater
Greiff and Rosendahi risk of wound infection
1982), but and its
consequences. As in other reported series of intramedullary nailing (Puno et a! 1986), we obtained satisfactory control of shortening and angular and rotatory deformities to give a 3% rate of malunion. This is significantly less than those reported for displaced, conservatively treated fractures, those treated by miniosteosynthesis with Rush THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
LOCKED
pin,
cerclage
or screws,
1978; Puno Sarmiento reported.
or by external
Gregg
intramedullary
of locked
to ear!yjoint
of early weight-bearing. work than after plaster
reported
Donald
Crease
(Donald
to or and
to the patient not only to but also to achieve it as
The
operative but,
technical
difficulties
using a operative
method technique
adequately carefully
treatment
of
as in otherfields should
trained selected
not
which must
tibia!
orthopaedics,
deter
surgeon
the
gives superior be meticulously
surgeons, for each
and
type
fractures
of modern
the
cases
be
Charnley etc:
VOL.
fractures stability
J. The c/osed treatment E & S Livingstone,
72-B, No. 5, SEPTEMBER
of of
the shaft of the tibia : initial reduction. J Bone Joint Surg [Br]
ofcommonfractures. 1961.
1990
BO, Albo A, Str#{246}ms#{246}e K, Follers
C, Haukeb#{246} A. the treatment of tibial C/in Orthop 1988; 231 :205-15.
intramedullary a report of4S cases.
nailing
in
143
tibial
J Bone
Nicoll
EA. Fractures Joint Surg [Br]
Oni
of the
tibial
shaft
: a survey
Onnerfalt
R. Fracture
tion and 7-63.
early
RM,
Teynor
Puno
of 705
J Bone
cases.
1964; 46-B :373-87.
OOA, Hui A, Cregg PJ. The healing the natural history of union with Surg[BrJ 1988; 70-B :787-90. of the weight-bearing.
JT,
results of treatment 212:113-21.
tibial
Nagano of 201
ofclosed tibial closed treatment. shaft
treated
Acta Orthop J, Custilo tibial
shaft
RB.
shaft
fractures:
J Bone
by
Scand
analysis
C/in Orthop
A, Sobol PA, Sew Hoy AL, Ross SDK, Prefabricated functional braces for the tures of the tibial diaphysis. J Bone Joint Surg 1328-39.
Racette treatment
RR.
Joint
primary opera1978; Suppl. 171:
Critical
fractures.
Sarmiento
Skjeldal Spiral and :462-6.
the shaft of the Injury 1982 ; 13:
[Am]
of 1986;
WL,
Tan
of
frac66-A:
1984;
Sarmiento A, Cersten LM, Sobol PA, Shankwiler JA, Vanganess CI. Tibial shaft fractures treated with functional braces : experience with 780 fractures. J Bone Joint Surg [Br] 1989; 71-B :602-9.
REFERENCES Boatman OM. displacement 1986; 68-B
of
ME, Allg#{246}werM,Schneider R, WiHeneggerH. Manual of interna/ fixation .‘ techniques recommended by the AO Group. 2nd ed. Berlin, etc : Springer-Verlag, 1979.
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Although none of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit institution with which one or more of the authors is associated.
Fractures osteosynthesis.
P, Cambouridis P, Smyrnis P. The treatment of fractures by Ender’s nailing and early weight-bearing. Surg [Br] 1985 ; 67-B :576-580.
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The by
must
AO-compression
Miller
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as possible.
demanding,
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FRACTURES
D. Treatment of tibial shaft fractures by percutanailing : technical difficulties and a review of SO C/inOrthop 1983; 178:64-73.
A, Thoresen
Interlocking fractures:
return 1978)
SHAFT
C, Seligson neous KOntscher consecutivecases.
Ekeland
the possibility
locking
TIBIAL
Christensen J, Creiff tibia treated with 307-14.
intramedu!!ary
motion,
without
Seligson 1983). It is important have a satisfactory end result,
DISPLACED
by
(1978).
This allows earlier fixation (Onnerfalt
nailing
1988;
6% to 12% malunion was normal ankle movement
advantage
is, in addition
FOR
(nnerfalt
and
(90%), as compared with the 75% et al (1984) and 78% by Onnerfalt
A significant
soon
NAILING
fixation
et a! 1986; Oni, Hui
et a! 1989), where We found practically
in 84 cases Sarmiento nailing
INTRAMEDULLARY
3rd ed. Edinburgh,
distal
Thoresen
5, Backe targeting.
S. Interlocking
Arch Orthop
BO, Albo A, Ekeland
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intramedullary forty-eight cases.
medullary
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nails
Surg
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-
radiation
doses
in
106:179-81.
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nailing
