locked intramedullary nailing for displaced tibial shaft fractures 1

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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.

of treatment.

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.

Joint

The by

must

AO-compression

Miller

is from

results. performed

S.

J, ROseDdahi

A, Kempf I, Lafforgue D. Le traitement des fracas, pertes de substance osseuse et pseudarthroses du femur et du tibia par l’enclouage verrouill#{233}. A propos des 40 cas. Rev Chir Orthop 1978; 64 (Suppl. II) :33-35.

Merianos shaft

as possible.

demanding,

809

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

Interlocking report of A :1313-20.

intramedullary forty-eight cases.

medullary

Trauma A, Stremsee

nails

Surg

1987;

-

radiation

doses

in

106:179-81.

K, FOHeIIS C, Hau.keba A. in femoral shaft fractures. A J Bone Joint Surg [Am] 1985; 67-

nailing