|Year : 2015 | Volume
| Issue : 3 | Page : 262-268
Comparative studies on intramedullary nailing versus ao external fixation in the management of gustilo type II, IIIA, and IIIB tibial shaft fractures
Soudip Sinha1, Soumya Ghosh1, Arunima Chaudhuri2, Soma Datta3, Pradip Kumar Ghosh1, Dhiraj Girish Patil4
1 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, India
3 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, India
4 Department of Orthopedics, IMSR Medical College, Mayani, Satara, India
|Date of Web Publication||2-Sep-2015|
Krishnasayar South, Borehat, Burdwan - 713 102
Background: Tibial diaphyseal injuries with severe open fractures have always been a troublesome concern for treatment. Aims: The aim was to compare results of external fixator and unreamed interlocking nail in treating Gustilo type II, type IIIA, and type IIIB tibial diaphyseal fractures to come to a conclusion to establish their appropriateness in the respective fractures. Materials and Methods: This pilot project was conducted in a tertiary care hospital of eastern India after taking institutional ethical clearance and informed consent of the subjects. Forty-five patients were selected. Results: A total of 23 cases were treated by external fixator and 22 cases were treated by unreamed solid interlocking nail. A total of 14 cases, that is, 31% showed delayed union. Type II injury 3/15 = 20%; Type IIIA injury 6/22 = 27.3%; Type IIIB injury it is -5/8 = 12.5%. For cases treated with unreamed nail it was 22.7%; external fixator it was 39.1% among 45 cases, 05 cases showed nonunion. For cases treated with unreamed nail it was 13.6%; external fixation it was 8.7%. The overall rate of deep infection is 11.1%. The rate in interlocking nail was 13.6%, and external fixation was 8.7%. Reoperation in the form of dynamization and bone graft application after 20 weeks in unreamed nail was 36.4%, whereas in external fixation the rate was high, almost 48%. The average time of union with unreamed interlocking was about 25.4 weeks, wherein external fixation it was 28.6 weeks. Conclusions: Though external fixators are good and reliable method of stabilization of Gustilo type II, type IIIA, and type IIIB tibial diaphyseal fractures, unreamed interlocking intramedullary nail yields better results in treating Gustilo type II and type IIIA tibial shaft fractures.
دراسات مقارنة لعمل مسامير داخل نخاع العظم مقارنة مع التثبيت الخارجي في علاج أنواع غستيلوII, IIIA, IIIB لكسر جذع عظم الساق الأعظم :
الخلفية: تعدّ إصابات الجزء المشاشي لعظم الساق الأعظم في حالة الكسور المفتوحة الشديدة من المشكلات التى يصعب علاجها.
الهدف: مقارنة نتائج التثبيت الخارجي مع مسامير التشبيك غير الثاقبة في علاج أنواع غستيلو II, IIIA, IIIB من كسر مشاش عظم الساق الأعظم للحصول على افضل الطرق المناسبة لأستخدامها قى العلاج فى مثل هذا الكسر.
المواد والطريقة: طبق هذا المشروع الرائد في مستشفى متخصص في شرق الهند بعد عمل الإجراءات الاخلاقية للمؤسسة وموافقة المرضى. وتم اختبار 45 مريضأً .
النتائج: كان مجموع المعالجين باستخدام التثبيت الخارجي 23 حالة و22 حالة بالتشبيك باستخدام مساميرصلبة غير ثاقبة، مجموع 14 حالة والتى تبلغ نسبتها %31 أظهرت تأخرا في الالتئام .
الاصابة من نوع 20%II =3/15 ، والاصابة من نوع IIIA 27.3% = 6/22، والاصابة من نوعIIIB 12.5%=5/8. الحالات التى تم علاجها بواسطة المسامير غير المثقوبة كانت 22.7% والتى تم علاجها بالتثبيت الخارجي كانت 39.1% في ال45 حالة و5 حالات لم تلتئم. الحالات التى تم علاجها بمسامير غير الثاقبة كانت 13.6% والحالات التى تم علاجها بالتثبيت الخارجي 8.7%. المعدل الكلي للالتهابات العميقة هو 11.1%، وبعد التشبيك الداخلي بالمسامير هو .7% الحالات التى خضعت لإعادة الجراحة لإعادة الحركة وترقيع العظم بعد 20 اسبوعا في حالات التشبيك بالمسامير كانت 36.4% بينما كان المعدل أعلى للتثبيت الخارجي بنسبة 48% تقريباً. متوسط الزمن للإلتئام باستخدام التشبيك غير الثاقب كانت 25.4 اسبوعا وللتثبيت الخارجي كانت 28.6 اسبوعا.
الخلاصة: يعتقد أن التثبيت الخارجي جيد وطريقة موثوق بها لتثبيت أنواع غستيلو II ،IIIA ، IIIB للكسر المشاشي لعظم الساق الاعظم، اما مسامير التشبيك الغير ثاقبة للنخاع فتعطى نتائج افضل في حالة غستيلو II، IIIA من كسر جذع الساق.
Keywords: External fixation, intramedullary nailing, tibial fracture
|How to cite this article:|
Sinha S, Ghosh S, Chaudhuri A, Datta S, Ghosh PK, Patil DG. Comparative studies on intramedullary nailing versus ao external fixation in the management of gustilo type II, IIIA, and IIIB tibial shaft fractures. Saudi J Sports Med 2015;15:262-8
|How to cite this URL:|
Sinha S, Ghosh S, Chaudhuri A, Datta S, Ghosh PK, Patil DG. Comparative studies on intramedullary nailing versus ao external fixation in the management of gustilo type II, IIIA, and IIIB tibial shaft fractures. Saudi J Sports Med [serial online] 2015 [cited 2019 Jul 19];15:262-8. Available from: http://www.sjosm.org/text.asp?2015/15/3/262/164303
| Introduction|| |
Most of the complications of open fractures of the tibia are difficult to handle by any of an established form of treatment. In grade II injuries with adequate soft tissue cover, all methods available may be used to achieve stability. These include intramedullary device; rigid or flexible, reamed or unreamed, internal plating device inserted by biological technique; external fixator and a combination of above. Skeletal traction entails some serious hazards because any traction allows motion at the fracture site, what so ever well-balanced traction may be. For type III fractures, where soft tissue coverage is not possible, only intramedullary device and external fixation are the options. ,,,,,
The use of External fixation in Gustilo type III fractures may offer many advantages. It is the process of manipulating, aligning, and stabilizing bone structures with pins, wires, and screws or other bone fasteners that affix the bone to an external scaffold or frame. The main supporting frame is attached to the ends of pins and therefore leaving room for dressing or procedures such as skin grafting or other soft tissue procedure. It can be used quickly for stabilization in a patient with shock. It is having many advantages like - rigid fixation and good access for wound care, wide space for secondary soft tissue procedure, maintains the limb length, helpful in segmental fractures and any angulation, overlapping, displacement or rotation of fragments can be corrected. No special operation theater or equipment is needed. ,,,,
The use of the unreamed locked intramedullary device for grade II and grade III open fractures has gained prominence in last few years. Several comparative studies conclude that it is at least as effective, if not more so than using an external fixator and has acceptable complication rate. It gives better stability and promises early weight bearing. Therefore, in grade III tibial fractures the decision making is based on the wound condition, the amount of muscle damage, type of fractures, and availability of equipments. ,,,,,
Hence, we performed a comparative study between external fixator and recently popularized unreamed interlocking nail in treating Gustilo type II, type IIIA, and type IIIB tibial diaphyseal fractures to come to a conclusion to establish their appropriateness in the respective fractures.
| Materials and Methods|| |
This pilot project was conducted in a tertiary care hospital of eastern India after taking institutional ethical clearance and informed consent of the subjects. Forty-five patients were selected.
Patients with open diaphyseal fracture of tibia who were skeletally matured were selected.
- Patients with diaphyseal fractures with intraarticular extension
- More than 12 h old injuries
- Associated systemic injuries (e.g., head injury, abdominal injury)
- Associated co-morbid conditions such as diabetes mellitus, ischemic heart disease, chronic obstructive pulmonary disease
- Associated other major fractures (e.g., hip fractures, spine fractures).
Management on admission
Open fractures of the tibia are frequently associated with other major injuries. The standard protocol of the "Advanced Trauma Life Support" program was maintained.
Rapid primary survey with simultaneous resuscitation
On admission, a rapid survey was done. Emergency measures are taken to combat pain, hemorrhage, and shock with proper sedation, analgesic, intravenous infusion or transfusion of blood when required.
Detailed secondary survey
- History and thorough clinical examination
- Assessment of soft tissue injury.
The examination includes determination of the extent and type of soft tissue wound and the existence of any vascular and neurological damage. Vascular injury or compartment syndrome was treated promptly for limb salvage and to avoid tissue ischemia, which, if present for 8 h or more can cause irreversible muscle and nerve damage.
Two swabs were taken from the wound (one from superficial and other from deep part) and sent for culture sensitivity. An high dose of broad spectrum bactericidal antibiotics was administered.
Swabs for the culture of the wounds were taken prior to any irrigation and administration of antibiotics. Shaving was done surrounding the wound and a preliminary skin preparation with savlon and povidone-iodine was carried out. All foreign materials embedded within wounds were removed meticulously, and the wound was thoroughly irrigated with copious amount of normal saline. Considerable efforts were made to minimize soft tissue trauma.
We had done thorough debridement under general anesthesia within 6 h of admission.
We initiated a methodical, layer by layer debridement beginning from skin and subcutaneous tissue. A margin of healthy skin, as minimum as less from the contaminated and contused skin border was excised. Debridement continued until all the devitalized tissue had been removed layer by layer to the depth of the wound but respecting the integrity of important structures such as blood vessels, nerves, and tendons. All foreign materials were removed either by washing or by excision of the tissue.
Antibiotics were started intravenously before surgery, and continued for 2 weeks of postoperative period routinely and further extended depending upon the status of the wound and culture sensitivity report.
Following debridement, the wound were covered with sterile dressing soaked with normal saline and pressure bandages were applied. The fractures splinted by a temporary POP back slab with the achievement of reduction as much as possible and planning done for operation.
Except for the selection of the fixation device, open fracture care was similar in the two treatment groups. All patients underwent emergency irrigation and debridement along with swab for culture sensitivity with concomitant skeletal stabilization. Patients were randomly allocated into one of the two treatment groups.
Tibial unreamed intramedullary interlocking nailing
It has smooth 11° bend in the anteroposterior direction located at the junction of upper one-third and lower two-third length. The only angled nail can accommodate in angled access of medullary canal.
To achieve early mobility and early weight bearing.
- Screw insertion at two ends of the nail, which will interlock the proximal and distal fracture fragments. This prevents sliding of the fracture fragments along the nail, and it is called static locking
- Interlocking controls the bone length and rotation of fracture fragment and improves the rotational stability
- It is used in segmental fracture, comminuted fracture, long oblique or spiral fractures.
- When screws are inserted only at one end of the nail, it is called dynamic locking
- Distal locking screw resists axial and torsional loading and prevent toggling of the nail in the anteroposterior direction in the medullary canal.
- If healing is normally progressing, then there is no need to dynamize
- One side screw is removed which weaken the interlocking phenomenon
- It is indicated when there is a risk of development of nonunion or in established pseudoarthrosis, the screw is then removed from the longer fragment and maintaining adequate control on shorter fragment.
It is a method of stabilizing a fracture through remotely placed, percutaneously inserted pins, connected to an assembly outside.
Alignment of the fracture was usually accomplished under direct visualization either through the wound or by giving small incisions overlying the fracture. By traction and manipulation the fracture was reduced, the fragments were carefully placed into position. After reducing the fracture, these were held with self-retaining bone holding forceps. Following reduction, the bone should resemble its prefracture state. Then the injured limb was compared with other limb whether there was any rotational mal-alignment or shortening.
Stabilization of the fractures
Intramedullary interlocking nailing:
- Position - supine. A pad placed under the popliteal fossa, the knee bent to at least 90°
- Reduction of the fracture
- Incision - 5 cm longitudinal incision along the medial border of the patellar tendon, extending from the tibial tubercle in a proximal direction. It might be necessary to extend the incision further proximally if required
- Entry point - insertion of curved awl through the metaphysis done. The tip of the awl was placed proximal to the tibial tubercle at the level of the tip of the fibular head (approximately 1.5 cm distal to knee joint)
- The awl was directed nearly perpendicular to the shaft when it first penetrates the cortex, but gradually brought it down to a position more parallel to the shaft as it was inserted more deeply to prevent violation of the posterior cortex
- Reduction attempted and checked by image
- Nail insertion - attachment of insertion device and proximal locking screw guide to the nail was done. The solid interlocking nail was inserted with the knee in flexion. Rotational alignment by aligning the iliac crest, patella, and a second ray of the foot. If the nail did not advance, a small diameter nail is used
- Distal locking screw applied under image intensifier
- Reduction checked by image. Before interlocking, the fracture site was inspected for any distraction
- Proximal locking screw - proximal locking was done using the jig attached to the nail insertion device
- Removal of insertion device was done
- Top screw applied
- Wound closed in layers.
AO external fixation
After proper open reduction and holding the fracture, the most distal Schanz screw was introduced near to the ankle joint through the "Safe Soft Tissue corridor" which lies anteromedially and varies in size from an arc 220° close to the tibial plateau to 120° just above the ankle joint. By insertion of pins through this safe corridor, injury to the main vessels, nerves, and musculotendinous units were avoided.
Clamps and tube attachment
After inserting the Schanz screw, drill sleeve was removed, and a universal clamp was attached to the Schanz screw and was fixed to it approximately 40 mm from the surface of the tibia.
Now, an 11 mm tube of appropriate length was attached to these clamps so that it was posterior to the Schanz screw. Three universal clamps were slided into this tube and were fixed to the tube at predetermined sites of Schanz screw insertion.
Most proximal Schanz screw was then introduced below the knee joint through the most proximal clamps using the technique as described before, after ensuring that it was parallel to the first screw in both planes and then it was fixed to the clamp.
Construction of mirror image or delta frame
The construction of mirror image, that is, uniplanar and unilateral frame or delta frame (biplanar) was done according to the requirements. Now along the anteromedial aspect of the tibia a second single tube unilateral frame was constructed at an angle of 60-90° to the first frame. Preload was applied to the Schanz screw of each frame. Two subframes were connected with a pair of short tubes using Tube to Tube clamps. Using universal clamps and connecting rods or Steinmann pin could also connect this. This connection enhances the rotational stability of the assembly.
Non-adherent dressing like Vaseline gauze or Sofra-Tulle, which one was available, covered the raw wound surface. Local irrigation of the wound was carried out. The patient was monitored for the presence of infection by evaluation of his/her temperature, as well as white blood cell count and wound inspection. Regular dressing of the wound was carried out. If there foul smelled discharge from the wound, swab sent for culture and sensitivity. Antibiotics were changed according to the sensitivity report. Postoperatively check X-ray was done and accordingly adjustment in the frame tried if necessary in external fixation.
Active and passive movements of the ankle and knee joint and quadriceps strengthening exercise started immediately on the day following the surgery. As soon as tolerated by the patient, he/she was encouraged to do partial weight bearing.
The fractures stabilized with an external fixator or intramedullary nail consolidated by the secondary bony union. Progressive force transmission across the healing fracture site appears to stimulate bone formation. After healing of the soft tissues, patients were encouraged to walk with partial and then full weight bearing.
The patients were followed up with serial X-ray at 4 weeks interval and dynamization and/or bone grafting was done after 20 weeks when there was delay in union or there was a gap in between the fracture in X-ray or any nonunion anticipated.
The patients were followed up at every 4 weeks interval. They were examined clinically and radiologically.
Patients were advised to do quadriceps exercises, active straight leg raise and knee bending exercises since 1 st postoperative day. If, after good healing of the soft tissues, check X-ray showed sufficient callus for union and the patient walked without support having no pain, we thought regarding the removal of external fixation.
If the patient had knee or ankle stiffness, local ultrasonic therapy with wax bath was advised for 10-14 days to avoid muscle spasm. After 3-6 months external fixator was removed followed by PTB cast for 4-8 weeks and weight bearing was progressively increased in the customized manner. As usual patients were regularly checked both clinically and radiologically till complete union is achieved in the follow-up period. Then the plaster was removed, and the patients were rehabilitated to normal activities gradually.
The arbitrary standard considered for the time of union, delayed union, and nonunion were as follows:
- Normal union - union occurring before 30 weeks
- Delayed union - union occurring after 30 weeks
- Nonunion - no union even after 9 months.
The fracture was considered healed when:
- It was clinically stable
- The roentgenogram showed sufficient callus for weight bearing
- The patient was able to walk without discomfort and support.
| Results|| |
In this series of 45 cases of open tibial diaphyseal fractures (Gustilo type II, IIIA, IIIB) had been studied. Of 45 cases, 23 cases were treated by external fixator and 22 cases were treated by a unreamed solid interlocking nail. The choice of the fixator was selected randomly for an approximate equal distribution in each group of cases. [Table 1] shows overall results.
For type II and type IIIA injury - unreamed interlocking nail yielded a better result.
For type IIIB injury, no implant showed superior to the other as far as the union is concerned.
The rate of union in type IIIA fractures with unreamed interlocking nail was higher, probably due to more stable fixation and early weight bearing.
A total of 14 cases, that is, 31% showed delayed union. Type II injury 3/15 = 20%; Type IIIA injury 6/22 = 27.3%; Type IIIB injury it is -5/8 = 12.5%. For cases treated with unreamed nail it was 22.7%; external fixator it was 39.1%.
Among 45 cases, 05 cases showed nonunion. For cases treated with unreamed nail it was 13.6%; external fixation it was 8.7%. The overall rate of deep infection is 11.1%. The rate in interlocking nail was 13.6%, and external fixation was 8.7%. About 17.8% patients developed ankle stiffness. The rate of ankle stiffness in unreamed nails is 9.1%, and external fixation is 26.1%. The overall rate of malunion with a unreamed nail is 13.6%, and external fixation is 26.1%. Reoperation in the form of dynamization and bone graft application after 20 weeks in unreamed nail was 36.4%, whereas in external fixation the rate was high, almost 48%. The average time of union with unreamed interlocking was about 25.4 weeks, wherein external fixation it was 28.6 weeks. In our series only in 17 cases, wounds healed by secondary intention and 12 cases needed delayed primary closure. In the rest of the cases (16), we have to perform different late reconstructive procedures such as split-thickness skin grafting, gastrocnemius myocutaneous flap, and soleus flap application.
Six (13.3%) patients had necrosis of the margins noticed when the dressing was opened for the 1 st time. All healed by secondary intention with usual treatment within 3-4 weeks time.
Twelve (26.6%) cases required delayed primary suture for wound closure. Wounds were covered with gauze soaked in saline to prevent drying of the tissues. Dressing was changed on every alternate day till delayed stitches done on 4-5 th postoperative day. The wound healed without further complications. Twelve (26.7%) had serious discharge from the wound. Four cases had a negative culture. The culture mostly showed Staphylococcus aureus and only two cases showed positive Pseudomonas infection. They were treated by antibiotics according to sensitivity and regular dressing. Only two cases continued to drain through a small sinus, but later that discharge was culture negative. Ten patients (22.2%) developed a superficial infection (mostly culture positive S. aureus). With unreamed nail, it was 18.2% and with external fixator -26.1%.
Five patients (11.1%) developed deep wound infection. The culture showed mostly S. aureus or Pseudomonas. One case was Klebsiella culture positive.
Of 45 patients, one patient developed weakness of dorsiflexion of the ankle on the next postoperative day. The Schanz screw was taken out and again reintroduced in the separate site. The neurological deficit gradually recovered.
Three patients showed gross restriction of ankle movements during the postoperative days. In two cases of the interlocking nail, there was avulsion fracture of the tibial tuberosity. Seven (30%) out of twenty-three patients who had undergone external fixator developed pin tract infections. Ankle stiffness developed in 8 (17.8%) cases. Of these 5 cases, there were <25% and in other 3 cases there were more than 25% stiffness. The patients are having <25% of stiffness had no difficulty in walking but squatting was slightly difficult for them.
Nine (20%) developed malunion more with external fixation. Six patients developed angulation in various directions varying from 5° to 10°. Five patients had 10-15° rotational deformity. Six (13.3%) patients showed shortening varying from 0.5 cm to 2 cm in those severely comminuted and unstable fractures. None had any serious problem due to this shortening.
Ten patients out of 22 cases of interlocking nail developed anterior knee pain. Nine patients (20%) developed knee stiffness in the postoperative days. Totally, 25 patients (56%) out of 45 showed thigh muscle wasting from 1 cm to 4 cm in comparison to the healthy side. More wasting was seen in cases of external fixation. Screw breakage occurred in 3 cases (13.6%) out of 32 unreamed interlocking nail.
| Discussion|| |
In the present series, a comparative study was done to evaluate the role of external fixation and unreamed interlocking nail in the treatment of open fractures tibia (Gustilo type II, type IIIA, and type IIIB) and to compare the results obtained after treating these cases by the respective methods considering different parameters.
Fang et al. in 2012  retrieved original publications of comparative studies from medical literature databases and selected 9 of them for a meta-analysis. Observation items included malunion and deep infection rate, nonunion, and comparison of time to union. The analysis showed a lower malunion rate using unreamed intramedullary nailing than external fixation.
A study by Xue et al. in 2014  aimed to investigate: (1) Which fixation, IMN or plating, was better in the clinical outcomes and in the complications for the treatment of DTF and (2) which modifying variables affected the comparative results between the two modalities. Fourteen of 6620 studies with 842 patients were included. IMN was probably preferential to plating for DTF given its higher functional score (P = 0.01), lower risk of infection (P = 0.02), and comparable pain score (P = 0.33), total complication rate (P = 0.53), and time to union (P = 0.86). However, plating had a lower malunion rate than IMN (P < 0.0001).
Mohseni et al. in 2011  compared the outcome and consequences of OA tubular external fixation versus unreamed intramedullary nailing in open grade IIIA-IIIB tibial shaft fractures. The time of union was 3, 4, 5, and 6< or = weeks after operation in 28, 12, 32, and 28% of the cases in unreamed intramedullary group versus 4, 12, 48, and 36% of the cases in external fixation group, respectively. Postoperative infection, soft tissue injury, malunion, and nonunion were documented in 16, 8, 0, and 4% of the cases in unreamed intramedullary group versus 32, 12, 24, and 8% of the cases in external fixation group, respectively (P = 0.19, 0.50, 0.02, and 0.50, respectively). The mean ambulation time after the operation was 2.92 ± 2.43 weeks in the unreamed intramedullary nailing group vs. 2.68 ± 2.14 weeks in the external fixation group (P = 0.71).
Totally, 486 tibial shaft fractures were enrolled in the study by Metsemakers et al.  Univariate regression analysis revealed similar risk factors for delayed union and nonunion, including fracture type, open fractures, and Gustilo type. Factors affecting the occurrence of deep infection in this model were primary EF, a prolonged TTN, open fractures, and Gustilo type. Multiple logistic regression analysis revealed polytrauma as the single risk factor for nonunion.
In studies by Papakostidis et al.  reamed tibial nails (RTNs) were associated with significantly higher odds of early union compared with unreamed tibial nails (UTNs) in IIIB open fractures. Significantly increased deep infection rates of IIIB open fractures compared with all other grades were documented for both modes of treatment (RTN, UTN). Lower deep infection rates for IIIA open fractures treated with RTNs were recorded compared with grades I and II.
Forty-two open tibial fractures were treated with secondary IMN after EF by Yokoyama et al.  Seven (16.7%) of the 42 open tibia fractures developed deep infections. All deep infections occurred in Gustilo type III (22.6%, 7/31). Only the skin closure time was a significant factor affecting the occurrence of deep infection on the present analysis (P = 0.006).
Noumi et al. in 2005 examined 89 open femoral fractures treated with immediate or delayed locked IMN in a static fashion. Multivariate analysis revealed that only Gustilo type significantly correlated with the occurrence of deep infection (P < 0.05); only fracture grade by AO type significantly correlated with the occurrence of nonunion (P < 0.02). 
Results of the present study suggests that though external fixators are good and reliable method of stabilization of Gustilo type II, type IIIA, and type IIIB tibial diaphyseal fractures, unreamed interlocking intramedullary nail yields better results in treating Gustilo type II and type IIIA tibial shaft fractures.
| Conclusions|| |
Results suggest that though external fixators are good and reliable method of stabilization of Gustilo type II, type IIIA, and type IIIB tibial diaphyseal fractures, unreamed interlocking intramedullary nail yields better results in treating Gustilo type II and type IIIA tibial shaft fractures.
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