The role of intramedullary nailing in treatment of open fractures ...

Eur J Trauma Emerg Surg (2015) 41:39–47 DOI 10.1007/s00068-014-0485-5

REVIEW ARTICLE

The role of intramedullary nailing in treatment of open fractures A. Hofmann · S.‑O. Dietz · P. Pairon · P. M. Rommens

Received: 24 November 2014 / Accepted: 30 November 2014 / Published online: 24 December 2014 © Springer-Verlag Berlin Heidelberg 2014

Abstract The management of open fractures remains one of the greatest challenges to orthopedic trauma surgeons. Damage to the soft tissue envelope together with periosteal stripping are the most important factors making open fractures prone to complications such as nonunion and infection. Urgent and thorough soft tissue debridement, proper surgical fracture stabilization as well as the administration of intravenous and local antibiotics as adjunctive therapy are mandatory to reduce the risk of infection. Intramedullary nail osteosynthesis has become an accepted treatment method of open long bone fractures. Especially at sites of sparse soft tissue coverage like the proximal and distal tibia, early intramedullary stabilization proved advantageous for its superior biomechanical stability, the chance of early soft tissue reconstruction, shorter healing times, and quicker rehabilitation. However, due to a potential risk of deep infection, especially when a reamed technique is applied, nailing of open fractures remains contentious. In this review, we focus on the current evidence of nail osteosynthesis in open fractures and delineate its value with respect to other possible treatment options. Keywords Open fracture · Intramedullary nailing · External fixation · Wound closure · Soft tissue

A. Hofmann (*) · S.‑O. Dietz · P. Pairon · P. M. Rommens Department of Orthopedics and Traumatology, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany e-mail: hofmann.trauma‑[email protected]

Introduction The management of open fractures still remains one of the greatest challenges to orthopedic trauma surgeons. It requires an experienced surgeon with a profound knowledge of different treatment modalities, and a great attitude to insure best possible outcome for the patients. Only few injuries require as much clinical attention and judgment and generate as much controversy as open fractures. The surgeon has to face a difficult situation, in which a complex fracture is associated with a significant open soft tissue damage of skin, muscles, and neurovascular structures. Major factors that affect the prognosis of open long bones fractures include the extent of soft tissue destruction, the severity of wound contamination, the fracture morphology, and localization, the presence and amount of bone defects as well as the general co-morbidities of the patients [1–3]. Damage to the soft tissue envelope together with periosteal stripping make open fractures prone to complications such as nonunion and infection. This is especially true for open tibia fractures. The surgeon must perform an urgent and careful debridement; thereby avoiding additional surgical insults to already compromised viable tissue. Furthermore, a proper surgical technique for fracture stabilization and the administration of intravenous and local antibiotics as an adjuvant therapy are mandatory steps to reduce the risk of infection. A better understanding of the underlying pathology and recent advances in fracture fixation have dramatically changed our view on treatment for open factures [4–7]. After meticulous debridement, primary internal fracture fixation provides many advantages for handling of soft tissue injuries, for nursing and for rehabilitation. In particular, intramedullary nail osteosynthesis became a popular treatment method [8–12]. Especially at sites of sparse soft

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tissue coverage like in the proximal and distal tibia, early stabilization of open fractures using an intramedullary implant proved advantageous for the biomechanical stability, early soft tissue reconstruction, healing times, and rehabilitation. However, due to a potential risk of deep infection, especially when a reamed technique is applied, the use of intramedullary implants in open fractures remains contentious. This technique has been supposed to spread bacteria from the contaminated wound along the medullary canal with the formation of a bacterial biofilm, finally causing deep infection. Moreover, adequate treatment of deep infection is not possible without implant removal. To address these concerns, we focus in this review on the current evidence of nail osteosynthesis in open fractures and delineate its value with respect to other possible treatment options.

Intramedullary nailing versus external fixation External fixation is a well-established method for the provisional stabilization of long bone open fractures in a polytrauma scenario (DCO: damage control orthopedic surgery, [13, 14]), especially in cases of severe soft tissue damage and wound contamination (Fig. 1). But, historically, it was also considered to be the preferred method for primary definitive stabilization because of its virtual simplicity of application, minimal compromise of the blood supply, and low infection rate at the fracture site [15–17]. However, recent studies challenge these advantages by the proof of high incidence of pin-track infection, high risk of malunion, and difficulties relating to soft tissue management [4, 8]. Giannoudis et al. [18] systematically reviewed 13 studies that investigated external fixation in open tibial fractures. A total of 536 fractures treated by external fixation of which 82 % were Gustilo/Anderson grade-III open injuries were included in the analysis. Union had occurred in 94 % at a mean time of 37 weeks. The overall incidence of delayed union after 6 months was 24 % [9–11, 18–21]. Although failure rate occurred only in 2.7 %, the rate of malunion was up to 20 % [9, 11, 17–20]. The incidence of deep infection was 16.2 %, with chronic osteomyelitis developing in 4.2 % [9–11, 17–20]. The most relevant device-associated complication was, however, the high rate of pin-track infections, which occurred in up to 32.2 % of cases [8–10, 17–20]. In the 1990ies, small-diameter, unreamed, interlocked intramedullary nails have been established [8, 10, 22, 23] as an alternative for external fixation, especially in tibial shaft fractures. Different studies advised that unreamed intramedullary nailing was superior to external fixation with regard to fracture healing. Alberts et al. [8] reported

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that the incidence of delayed union was twice as high in the external fixation group compared to the nail group with numbers of surgical procedures performed to promote union being three times higher in the external fixation group. Accordingly, Agrawal et al. found in a consecutive series of thirty patients with open tibia fractures that unreamed intramedullary nailing resulted in a faster fracture healing, a better biomechanical stability and earlier rehabilitation [24]. Infection rates in this study were comparable to those which are found with other methods. Comparisons for re-operation, nonunion, and risks of deep infection between intramedullary nails and external fixators for stabilization of open tibial fractures were conducted in a systematic metaanalysis by Bhandari et al. [25] from randomized trials available until 2001. They found compelling evidence that unreamed nails reduced the incidence of re-operation rates, superficial infections and malunions as compared with external fixators. Six years later, a metaanalysis by Giannoudis et al. [18] showed similar results. They included four prospective randomized clinical trials [9, 11, 21, 26] with 296 fractures. The two treatment methods differed significantly with respect to the rates of malunion, which were significantly higher in external fixation, and to the rates of implant failure, which was higher in the unreamed intramedullary nailing group. In general, clinical experience shows that time to healing is much longer in open fractures than in closed fractures with failure of implants (especially screw breakage and autodynamization of the implant) being quite frequent (Fig. 2). Interestingly, this metaanalysis did not show statistically significant differences with regard to time to union and deep infection and osteomyelitis between the groups. Even in Gustilo/Anderson grade-IIIB open tibial fractures unreamed nailing was not associated with a higher risk of nonunion or deep infections.

Reamed versus unreamed interlocking nailing Experimental studies suggested that the compromise of the cortical blood supply by intramedullary reaming prior to insertion of a interlocked nail may potentially increase the rate of nonunions and infection [27, 28]. Therefore, unreamed interlocked nails, especially for the treatment of tibial fractures, have been recommended as temporary implants in order to reduce the risk of pulmonary embolism in multiply injured patients as well as of the infection in open fractures [29]. Additional benefits of an unreamed nailing procedure include reduced heat production, reduced disturbance of the endosteal blood supply, and reduced associated bone necrosis. As shown by different experimental studies, cortical bone perfusion decreases much higher after reamed nail insertion than after unreamed nail

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Fig. 1 Forty-one-year old hemodynamically unstable polytrauma patient (motorcycle accident) with pulmonary contusion, fracture of the first lumbar vertebral body, unstable pelvic ring fracture, large open fracture of the right femur, a multifragmentary right proximal tibia fracture, and subtotal amputation of the left foot. Following resuscitation and according to the DCO-concept in polytrauma treatment, the open injuries of both lower legs were debrided and fixed using external fixation. The radiological assessment of the open femur fracture on the right site revealed a transverse fracture type with a small area of comminution. The fracture was classified as Gustilo/Anderson grade-IIIa injury due to severe muscle damage of the quadriceps muscle but preserved periosteal cover of the main fracture fragments. a Ap and posteromedial views of the 3D reconstruction of the trauma CT-scan showing the fracture of the right femur. b, c The fracture of the right femur was provisionally fixed with an external fixator and the wound covered with Epigard®. Early definitive reconstruction of the pelvic fracture at day 3 with a second look and repeated debridement of all open injuries of the lower legs. d Conversion of the external fixation and implantation of an interlocked femur nail at day 9. The soft tissues and the fracture ends were debrided. A large vital wedge fragment was carefully reduced and fixed to the proximal main fragment with a lag screw. e Nice bony bridging and callus formation at 3 months after trauma. f Uneventful healing of the soft tissues. The patient is full weight bearing with crutches

insertion [28, 30, 31]. Accordingly, findings of these studies suggest that cortical revascularization is restored by 6 weeks in the unreamed group, but not until 12 weeks in

the reamed group [28]. This may be of particular relevance for severe open fractures where blood supply is already significantly compromised (Figs. 2, 3).

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42 Fig. 2 Primary definitive osteosynthesis of a Gustilo/ Anderson Type IIIB-Fracture of the left tibia. The 24-year-old motorcycle accident victim also sustained a mild pulmonary contusion and Gustilo/Anderson grade-IIIb injuries of the right femur and of the right tibia (a, see also Fig. 4). b Detail photograph of the left lower leg showing severe contusion and loss of the skin especially above the fracture area. c After meticulous debridement, the left tibia fracture was fixed primarily with an unreamed tibial nail (UTN, DePuy-Synthes, Solothurn, CH). Gastrocnemius muscle flap was used to cover the exposed fracture area in the same session in order to prevent drying and secondary infection of the bone. Fractures of the right lower extremity were primarily fixed with an external fixator due to the pulmonary involvement. d The muscle flap was covered with split skin grafts 3 days later e Stable fracture fixation and convenient soft tissue care allowed for an early mobilization under full weight bearing. f Condition of the soft tissues 6 months after surgery g fracture healing at 12 months with failure of the unreamed implant

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Fig. 3 Nail osteosynthesis in a Gustilo/Anderson gradeIIIB fracture of the ulna (a). A 19-year-old motorcycle victim sustained a severely open fracture of the right forearm with loss of some diaphyseal bone fragments of the ulna. A radius fracture has been treated years before with plate osteosynthesis. Meticulous debridement and temporary fixation with a hand joint bridging external fixator. The open wounds of the right forearm could be closed primarily due to acceptable skin and soft tissue conditions (b). At day three, open reduction and angle-stable plate fixation was performed for the midshaft and for the distal radius. The ulna fracture was splinted with an interlocked nail (ForeSight-nail, Smith & Nephew, Memphis, USA) without re-opening the initial wound. Additionally, a transscaphoidal fracture dislocation of the wrist was treated by a closed reduction, Herbertscrew fixation of the scaphoid fracture and temporary K-wire fixation carpal bones (c). The stable fixation of the forearm allowed early rehabilitation of the injured extremity. Fracture union was noticed at 5 months (d). Implant removal (e, f) and functional outcome (g) at 1 year

Interestingly, potential disadvantages of reaming that were found in experimental studies have been mainly outweighed by the fact that reamed interlocked nails provide superior biomechanical stability with more reliable healing results especially under load-bearing conditions. Therefore, reaming remains controversial as part of the treatment of open fractures. In a prospective, randomized clinical study, Finkemeier et al. [32] investigated the differences in healing, complications, or number of procedures required to obtain union among both, open and closed tibia fractures treated with intramedullary nails inserted with and without reaming. A higher percentage of closed fractures healed at 4 months after reamed nail insertion compared with unreamed insertion, but there was no difference at 6 and 12 months. In contrast to closed fractures, no significant differences in the time to union, numbers of additional procedures

performed to obtain union, rates of infection or compartment syndrome were found in patients with reamed versus unreamed nail insertion in open fractures. Unfortunately, severe grades of open fractures (Gustilo grade-IIIB and -IIIC) were not included in this study thereby limiting the value of the conclusions. In the prospective, randomized, multicenter SPRINT trial [33], a composite outcome including the need for bone-grafting, implant exchange or removal, debridement of bone and soft tissue because of deep infection, locking screw removal, screw breakage or loosening, nail breakage, fasciotomy, and hematoma drainage has been investigated for reamed (n = 622) and unreamed (n = 604) nailing of closed and open tibial fractures. The authors found a higher risk for composite outcome events only among patients treated with reamed nailing but not in patients treated with unreamed nailing. Although this study includes very high

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numbers of patients, the results for treatment of open fractures were not further specified with respect to the degree of the open injury and to the type of adverse events that were more frequently observed after reaming. Keating et al. [34] conducted a prospective, randomized clinical trial to compare reamed (n = 50) and unreamed (n = 44) nailing in open tibial fractures. Only a small part of fractures in both groups included high degree open injuries (Gustilo grade-IIIB: n = 7/50 vs. n = 4/44, respectively). No clinically important or statistically significant differences were found between the two groups with regard to early postoperative complications, time to union, nonunion and infection rates, and functional outcomes. In the group treated without reaming, there were significantly more broken screws (29 %) than in the reamed group (9 %). The authors concluded that besides higher frequencies of screw failure in unreamed nailing the clinical and radiographic results of reamed nailing are similar to those of unreamed nailing for fixation of open fractures of the tibia. Xue et al. [35] carried out a systematic review of six eligible randomized controlled studies investigating reamed versus unreamed protocols for intramedullary fixation of open and closed tibial fractures. The authors found significantly lower risks for fracture nonunion and implant failures with reamed nails compared to unreamed nails only in closed tibial fractures. In particular, there were no differences in frequencies of malunion, compartment syndrome, embolism, and infection between the two treatment options in open fractures. On the basis of the available data, the authors concluded that there are no statistical differences in rates of complications evaluated between reamed and unreamed nails in open tibial fractures. In a Cochrane library metaanalysis, Duan et al. [36] also compared results of randomized (n = 9) and quasirandomized (n = 2) controlled clinical studies evaluating reamed and unreamed methods of intramedullary nailing for both closed and open tibial shaft fractures in adults. Primary outcome criteria included health-related quality of life, patient-reported function and re-operation for treatment failure or complications. The data were dominated by the results of the SPRINT study reporting on 1,319 participants out of a total of 2,093 participants included in this review. The authors found a ‘moderate’ quality evidence suggesting that there is no clear difference in the rate of major re-operations and complications between reamed and unreamed intramedullary nailing. Reamed intramedullary nailing showed a lower incidence of implant failure than unreamed nailing. Only a ‘low’ quality evidence has been found for the suggestion that reamed nailing may reduce the incidence of major re-operations related to nonunion in closed fractures rather than in open fractures.

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Although studies available until now did not show relevant differences between reaming and non-reaming in open fractures, the major problem for the translation of those results into daily clinical practice is the lack of differentiation between different grades of open injuries treated by the one or the other method. In a recent review, Papakostidis et al. [37] investigated outcome measures of open tibial fractures with respect to the Gustilo/Anderson grade of open fracture injury and to the method of treatment. They included 32 eligible articles reporting on 3,060 open tibial fractures to analyze rates of union, as well as rates of deep infection, compartment syndrome, and amputation. Interestingly, reamed nailing was associated with significantly higher odds of early union compared with unreamed tibial nails in Gustilo/Anderson grade-IIIB open fractures. No significant differences were documented per grade of open fractures with respect to both delayed and late union rates. Significantly increased deep infection rates were detected in Gustilo/Anderson grade-IIIB open fractures compared with all other grades in both, reamed and unreamed modes of treatment.

General prerequisites for intramedullary osteosynthesis in open fractures There are some very basic prerequisites for fixation of open fractures using intramedullary implants. First, in order to prevent deep infection the surgeon must be sure that the nail is inserted under aseptic conditions into a sterile environment. This implies that the entire success of this enterprise will depend on the quality of the soft tissue debridement as well as on the quality and timing of the soft tissue closure. The decision to perform a primary nailing in an open fracture depends on the quality of debridement by an experienced surgeon where no contaminated or nonviable tissues are left behind. Subsequently, both the fracture site and the implant must be covered with viable tissues to prevent drying and secondary necrosis of the bone leading to secondary colonization and development of deep infection (Figs. 2, 4). To this point, nail osteosynthesis is clearly advantageous in comparison to plates and internal fixators that are more prominent and much more exposed in open fractures, and are more difficult to be covered without tension. In this context, the timing of wound closure also plays a crucial role. At the time of the very first debridement, if done appropriately, the cleanliness and sterility of the wound will be to the highest-possible degree for the next course of healing. If a tension-free primary wound closure can be achieved in the same session, an intramedullary implant will be at the utmost help with no additional compromise of the soft tissues. In a consecutive case series


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Fig. 4 Same patient as shown in Fig. 2. The fracture of the right tibia was accompanied by a small skin defect only (a), but a 4 × 3 cm piece of the ventral cortex at the fracture site was missing. The periosteum at the fracture margins was severely damaged. After the first debridement, the fracture was fixed together with the femur fracture using an external fixator (b). At day three, a second look debridement of the open wound was performed together with the removal of the external fixator, implantation of a reamed interlocked nail and wound closure (c). In the further course, an infection and fistula developed at the fracture site (d) due to an insufficient soft tissue cover of the bone surface and the defect. The wound was radically debrided (e) and reconstructed using a local fasciocutaneous flap and local antibiotic foams (f). No recurrence of infection was noticed and the soft tissues recovered well. Status of the soft tissues 6 weeks after the flap surgery (g). Six weeks later, the flap was carefully mobilized (h) followed by decortication of the fracture ends. A reameraspirator-irrigator (RIA) graft from the contralateral femur (i) was used for reconstruction of the bone defect. Again, healing of soft tissues was uneventful after this procedure (j). The stable fixation of the fracture with an interlocked nail allowed for early mobilization and weight bearing. A complete healing of the bone defect was noticed at 6 months (k). Status after implant removal at 12 months (l)

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of 557 open fractures, Rajasekaran et al. [38] performed a primary wound closure in 173 patients with Gustilo/ Anderson grade-IIIA and grade-IIIB open fractures. The authors applied very strict criteria for primary wound closure and fracture fixation for these types of injuries [2, 38]. In this study, fractures of the lower limb were mainly treated by locked intramedullary nails. At a mean followup of 6.2 years they found excellent and good outcomes in 93.1 % of cases. Deep infection occurred in five patients only and only six patients developed a fracture nonunion. In case of secondary wound closure, however, the debrided wound will become colonized by bacteria that are typically acquired in the hospital, e.g., gram-negative organisms that are very difficult to treat with antibiotics only. In a prospective, randomized, double-blinded study in a level-one trauma center, Patzakis et al. [39] found that only a minority (18 %) of infections were caused by the same organism initially isolated from the wound. A delayed closure of the wound may therefore increase the risk of the implant colonization and development of deep infection. Second, the surgeon must carefully analyze not only the fracture type and the grade of open injury, but also the type of the contamination. In case of wound contamination with organic material (farmyard injuries), sewage or feces, the surgeon should be aware of a high risk of infection even after a meticulous debridement. In such cases, a staged protocol with external fixation, repeated wound debridement, local and systemic antibiotics, and secondary wound closure should be applied independently from the degree of the open injury. Third, the use of different protocols for wound closure and fracture fixation, strongly depend on the available infrastructure and the condition of the patient at arrival. In developing countries, open fractures mostly occur especially in young, healthy, male patients, who are exposed to road traffic accidents and other high energy trauma mechanisms. Although fracture and soft tissue healing are likely not disturbed in this age group by different co-morbidities to the same extent like in the elderly, problems of infrastructure and primary care may be decisive for the later outcome. In particular, patients may present too late for early definitive treatment of open fractures and primary wound closure. The risk for deep infection in open wounds increases exponentially over time, though, definitive fracture fixation beyond the golden window of the first 8 h (empiric recommendation) will increase the risk for deep infection, especially when intramedullary implants are used.

Conclusion Intramedullary nail osteosynthesis is one of the most powerful tools for fixation of open long bone fractures. Current

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evidence shows that intramedullary nails are superior with respect to healing times and incidences of complications like malunion, nonunion and infection as compared to external fixators for definitive fixation of open long bone fractures. Up to date, different studies also show that open fractures are no contraindication for reamed nailing suggesting that rates of implant failures can be reduced by the use of thicker (reamed) and more stable implants. However, there is no evidence showing clear significant differences between reamed and unreamed nails for the treatment of open fractures. General prerequisites including radical debridement, soft tissue reconstruction, full, tension-free coverage of the implant and appropriate use of local and systemic antibiotics must be respected for the successful treatment of open long bone fractures with intramedullary implants. Meeting these criteria, intramedullary nailing of open long bone fractures provides many advantages for the rehabilitation of the patient and for achieving best possible functional outcomes. Conflict of interest Alexander Hofmann, Sven-Oliver Dietz, Philip Pairon, and Pol M. Rommens declare that they have no conflict of interest. Compliance with ethics guidelines This article does not contain any studies with human or animal subjects performed by any of the authors.

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