E-ISSN:2349-4166
P-ISSN:2349-4158

Research Article

Fractures

Public Health Review - International Journal of Public Health Research

2015 Volume 2 Number 1 January-March
Publisherwww.medresearch.in

To compare and assess the clinical results of interlocking nailing in closed fractures of shaft of tibia by reamed and unreamead technique

Uppara RM.1*, Jonna N.2
DOI: https://doi.org/10.17511/ijphr.2015.i1.02

1* Uppara RM, Assistant Professor, Department of Orthopedics, Rajiv Gandhi Institute of Medical Sciences, Kadapa, Andhra Pradesh, India.

2 Jonna N, Associate Professor, Department of Orthopedics, Rajiv Gandhi Institute of Medical Sciences, Kadapa, Andhra Pradesh, India.

Introduction: The successful use of unreamed nailing in patients with open tibial fractures has led some investigators to recommend this technique for closed fractures as well. Potential advantages of unreamed nailing over the reamed technique include shorter operative time, less blood loss and less disruption of the endosteal blood supply in patients with severe closed soft tissue injuries. Materials and Methods: This study consists of 34 cases of fracture both bones of leg, tibia treated by internal fixation with interlocking tibia, of which 17 cases are reamed and 17 cases are unreamed from August 2009 to July 2011, and followed upto November 2011. The study was conducted to assess the functional outcome and complications of reamed over unreamed nailing in tibial fractures. Results and Conclusion: In our study group there are no definitive criteria for using reamed and unreamed procedures, age groups are comparable and both procedures are applied randomly. 2 superficial infections are noted in unreamed cases and one deep infection noted in reamed cases. Knee pain complained in two cases of reamed nailing compared to one case of unreamed nailing. Odema of leg noted in one case of unreamed nailing. Earliest union noted in reamed nailing compared to unreamed.

Keywords: Reamed, Undreamed, Tibial Fractures

Corresponding Author How to Cite this Article To Browse
Uppara RM, Assistant Professor, Department of Orthopedics, Rajiv Gandhi Institute of Medical Sciences, Kadapa, Andhra Pradesh, India. Uppara RM, Jonna N. To compare and assess the clinical results of interlocking nailing in closed fractures of shaft of tibia by reamed and unreamead technique. Public Health Rev Int J Public Health Res. 2015;2(1):9-14.
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https://publichealth.medresearch.in/index.php/ijphr/article/view/9

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2015-03-15 2015-03-16 2015-03-29 2015-03-30
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
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© 2015 by Uppara RM, Jonna N and Published by Siddharth Health Research and Social Welfare Society. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Public Health Review - International Journal of Public Health Research 2015;2(1)9
Uppara RM. et al: To compare and assess the clinical results

Introduction

Tibia is the most commonly fractured long bone and the exposed anatomical location makes it vulnerable to direct blow and high-energy trauma as a result of motor vehicle accident [1]. Tibia has precarious blood supply with inadequate muscular envelope. Tibial fractures may be associated with compartment syndrome, vascular or neural injury [2]. The presence of hinge joints at the knee and the ankle, allows no adjustment for rotatory deformity after fracture. Because of high incidence of complications, management is often difficult.

The successful use of unreamed nailing in patients with open tibial fractures has led some investigators to recommend this technique for closed fractures as well. Potential advantages of unreamed nailing over the reamed technique include shorter operative time, less blood loss and less disruption of the endosteal blood supply in patients with severe closed soft tissue injuries. More over there is theoretical lowering of the incidence of fat embolism, by avoiding reaming.

Duwelius et al. [3] 1995 recommended unreamed nailing of closed tibial fractures with severe soft tissue injuries and reamed nailing of those without significant soft tissue injury. Gregory and Sanders [4], 1996 recommended unreamed nailing for polytraumatized patients with closed, unstable tibial fractures but found no advantage over reamed nailing for isolated, closed, unstable tibial fractures.

Materials and Methods

The aim of this prospective study is to compare and assess the clinical results of interlocking nailing in closed fractures of shaft of tibia by reamed and unreamead technique. The results will be tabulated, statistically arranged, and observation will be compared with similar studies published in literature. This is a prospective study done in SVRRGGH, Tirupati, to know the intraoperative, immediate post operative and late complications following closed interlocking intramedullary nailing. In this study, we have also tried to focus on the possible etiological factors for such complications.

Results

This study consists of 34 cases of fracture both bones of leg, tibia treated by internal fixation with interlocking tibia, of which 17 cases are reamed and 17 cases are unreamed from August 2009 to July

2011, and followed upto November 2011.

Age Distribution: The average age was 34.5 years (reamed) and 37.7 years (unreamed) with a range of 22 to 65 years.

Table 1: Age distribution of patients (N=34)

Age group No. of patients Percentage (%)
R UR R UR
20-39 13 8 76 47
40-59 3 8 18 47
60 Above 1 1 6 6
Total 17 17 100.0 100.0

X2=3.46; df = 2; P=0.177; Nil Significant

Table 2: Sex Distribution of Patients (N=34)

Sex No. of patients Percentage
R UR R UR
Male 15 13 88 76
Female 2 4 12 24
Total 17 17 100 100

Fisher exact P value = 0.65 Nil Significant

Table 3: Distribution by side affected

Side No. of patients Percentage
R UR R UR
Right 10 9 59 53
Left 7 8 41 47
Total 17 17 100 100

X2=0.12; P=0.72; Nil Significant

Table 4: Level of Fracture in Patients

Level of fracture No. of patients Percentage
R UR R UR
U/3 0 0 0 0
U/3-M/3 3 4 18 24
M/3 6 3 35 18
M/3-L/3 7 7 41 40
L/3 1 3 6 18
Total 17 17 100 100

Statistics of Surgery: Surgery was done from 5 to 30 days after admission at an average of 15 days. All the cases were operated under spinal anaesthesia. Average duration of surgery was 45 minutes for reamed interlocking and 35 minutes for unreamed interlocking tibia.

Size of Nail: It depends upon the procedure with 8 to 9 mm for most of unreamed and 9 to 10 mm nail for reamed nailing. Length depends upon the patient. 10 mm nail was not used for unreamed and one nail of 8 mm size used for reamed nailing.

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Uppara RM. et al: To compare and assess the clinical results

Table 5: Size of Nail

Nail diameter Reamed Unreamed Total
8 1 7 8
9 10 10 20
10 6 0 6
Total 17 17 34

X2=10.5, df=2, P<0.005 Significant

Table 6: Complication by Reamed & Unreamed Category

Complication Reamed Unreamed Total
Infection 1 2 3
Oedema 0 1 1
Knee Pain 2 1 3
Varus 0 1 1

X2=2.31; df =3; P=0.51; Nil Significant

Table 7: Union in months

Union in months No. of patients Percentage
Reamed Unreamed Reamed Unreamed
2 ½ 1 0 6 0
3 14 11 82 65
3 ½ 2 6 12 35
TOTAL 17 17 100 100

X2=3.36, df=2.00; P=0.186, Nil Significant

Table 8: Outcome by Age Group

Age Excellent Good Fair Poor
R UR R UR R UR R UR
20-39 9 4 3 3 0 0 1 1
40-59 2 1 1 4 0 2 0 1
60 and Above 1 0 0 1 0 0 0 0

Table 9: Outcome by level of fractures

Level of fracture Excellent Good Fair Poor
R UR R UR R UR R UR
U/3 0 0 0 0 0 0 0 0
U/3-M/3 3 1 0 3 0 0 0 0
M/3 4 0 2 3 0 0 0 0
M/3-L/3 5 2 1 1 0 2 1 2
L/3 0 2 1 1 0 0 0 0

Table 10: Outcome by Procedure

Outcome Reamed Unreamed
Excellent 12 5
Good 4 8
Fair 0 2
Poor 1 2

X2=6.55;df=3.00; P=0.08; Nil Significant

Overall results were excellent in 17 cases (12 in reamed, 5 in unreamed), Good in 12 cases (4 in reamed, 8 in unreamed), Fair in 2 cases only in unreamed and poor in 3 cases( one reamed and 2 in unreamed ).

Discussion

Total 34 cases of tibia were treated by internal fixation, intra medullary nailing, by reaming and unreaming procedure, each 17 cases. They were followed for a period of 9 months within the study period of August 2009 to July 2011, and followed up to November 2011 . The purpose of the study was to evaluate the end result of treatment in these patients. No definitive criteria selected for reaming and unreaming procedure. They applied randomly.

Level of fracture
Study Proximal third Junction of P/3 and M/3 Middle Third Junction of M/3 and D/3 Distal third Total
Keating et al [5] 3(4%) 9(10%) 36(41%) 31(35%) 9(10%) 88(100%)
Court Brown et al [6] 2(7%) _ 16(55%) _ 11(38%) 29(100%)
Bone and Johnson et al [7] 2(2%) 5(5%) 60(60%) 17(17%) 16(16%) 100(100%)
Present 0 8(23.5%) 8(23.5%) 14(41%) 4(12%) 34(100%)

Size of the diameter of the Nail: The average diameter of the nail in our study was lesser than the keating et al's study as the western population had a better built than ours[5]. In the Whittle's study all patients underwent unreamed nailing which obviously fitted smaller diameter nails [8]. In our study both reamed and unreamed nailing had an average diameter of 8.5 and 9 respectively.
Study Diameter of nail (mm)
9 10 11 Others (8-13) Total Average
Keating et al [5] 23 19 24 28 94 10.4
Whittle et al [8] 18 13 0 16 47 8.9
Present 20 6 - 8 34 8.97

Reamed technique or not: The more recent studies as by Keating et al, Court Brown et al have shown same results with reamed technique with no significant increase in nonunion.

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Uppara RM. et al: To compare and assess the clinical results

Whittle's study had only unreamed ones as they believed that reaming destroys the endosteal supply which was affirmed in the experimental study by Schemitch et al on sheep models. In our study we have done a randomized selection of patients for either technique so that the influence of other factors like fracture pattern, site of fracture, age of patient, etc did not influence the final outcome.

Study Reamed unreamed Total
Present 17 17 34
Keating et al [5] 50 44 94
Whittle et al [8] 0 50 50
Court Brown et al [7] 41 0 41

Conclusion

The study was conducted to assess the functional outcome and complications of reamed over unreamed nailing in tibial fractures. In our study group there are no definitive criteria for using reamed and unreamed procedures, age groups are comparable and both procedures are applied randomly. 2 superficial infections are noted in unreamed cases and one deep infection noted in reamed cases. Knee pain complained in two cases of reamed nailing compared to one case of unreamed nailing. Odema of leg noted in one case of unreamed nailing. Earliest union noted in reamed nailing compared to unreamed.

Reference

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  4. Gregory P, DiCicco J, Karpik K, DiPasquale T, Herscovici D, Sanders R. Ipsilateral fractures of the femur and tibia- treatment with retrograde femoral nailing and unreamed tibial nailing. J Orthop Trauma. 1996;10(5)309-16.
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  2. Gregory P, Sanders R. The treatment of closed, unstable tibial shaft fractures with unreamed interlocking nails. Clin Orthop Relat Res. 1995 Jun;(315)48-55.
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